INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 8-9, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, treatment Trends Inc.-Keenan House was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report, the facility failed to ensure that employees #9 and 10 received the required trainings.
Employee #9 was hired as a Clinical Tech on 6/9/2014; HIV/AIDS and TB/STD trainings were due by 6/9/2016 but were not documented as completed at the time of the inspection.
Employee #10 was hired as an Assistant Service Coordinator on 10/1/14; HIV/AIDS training was due by 10/1/2016 but were not documented as completed at the time of the inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
To correct the violation of standard 704.11(b)(1), the Clinical Director will review each employee training record twice yearly before the spring and fall training session. Each new staff member will be registered for upcoming seasonal trainings as they become available.
on February 22, 2017 Employee #9 and #10 are signed up the HIV/AIDS seasonal trainings for April 5th and 12th respectively to complete the required trainings. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report and staff schedules, the facility failed to have CPR coverage on January 15, 2017 from 10 p.m. until 12 p.m.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
To correct the failure of the facility to provide CPR coverage as occurred during a 2 hour period on January 15th 2017,The Tech supervisor of Contracts and Clinical Support Staff will begin to review each schedule by February 25, 2017 to ensure appropriate staff are available on each shift. This will address Licensure CPR Certification requirement 704.11(c)(2). Further the supervisor will oversee the training of new staff who are not yet CPR certified to ensure there are enough staff to cover all shifts. All staff are scheduled to complete CPR training by March 15, 2017. Scheduling as it pertains to requirement 704.11(c)(2) will be reviewed in staff education seminar to be conducted in staff meeting scheduled for Monday March 6, 2017 by the clinical director. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection conducted on February 8, 2017, the facility failed to ensure privacy by allowing unobstructed visual access from the hallway during counseling sessions in the main counselor's office located on the 4th floor.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To ameliorate the violation of standard 705.4(3) Counseling areas, the Clinical Director will instruct the Maintenance Department to hang blinds in the 12" X 20" glass panel in the 4th floor staff office thus obstructing visual access from the hallway during counseling sessions by April 20, 2017.
During the staff meeting scheduled for Monday March 6,2017 Clinical supervisor will review confidentiality regulations with clinical staff specifically as it pertains to visual access. Staff will be reminded to close the blinds during counseling sessions. In addition a new white noise machine was placed in that location on Monday February 27th to ensure auditory confidentiality. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
During a physical plant inspection conducted on February 8, 2017, it was observed that the facility was storing boxed discharged client records in the storage room located on the 5th floor. Although the door to this area was locked it was confirmed that non-clinical staff have keys to this area.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Keenan House failed to ensure limited key entry for records intended for shredding thus violating standard 709.28(b). The clinical Director will work with the Operations Director and Maintenance to ensure the doors (2) are re-keyed to allow clinical staff entry only to storage area which are utilized to store clinical records until shredding by March 15, 2017. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records on February 8-9, 2017, the facility failed document treatment plan updates in client records, #5, 6 and 7.
Client #5 was admitted on 7/20/16 and discharged on 12/13/2016. A comprehensive treatment plan was documented on 7/28/16; a treatment plan update was due by 8/28/16 but was documented on 8/31/16. Another update was due by 10/1/16 but was not documented until 10/3/16. Lastly another update was due by 11/2/16 but was not documented until 11/4/16.
Client #6 was admitted on 8/10/16 and discharged on 12/12/2016. A treatment plan update was documented on 9/14/16; a treatment plant update was due by 10/14/16 but was documented on 10/20/16.
Client #7 was admitted on 6/20/16 and discharged on 8/22/2016. A comprehensive treatment plan was documented on 6/26/16; a treatment plan update was due by 7/26/16 but was documented on 8/1/16.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Five records failed to contain a Treatment Plan update at least every 30 days which violates standard 709.52(b). The following occurred during the staff meeting scheduled for Monday February 27, 2017. The Clinical Supervisor reviewed the Treatment Plan update policy and standard with staff. Clinical Supervisor reviewed the grid which highlights Treatment Plans due. Charts will be audited weekly by the clinical supervisor and/or director beginning 3/9/2017 |