INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6 - 7, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mercy House of Meadville, Inc. was found not to be 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)(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 personnel records, CPR and first aid certification cards, the facility failed to ensure that a sufficient number of staff persons were trained in CPR.The findings include:Five personnel records and employee CPR and first aid certification cards were reviewed on March 6 - 7, 2012. Only one full-time employee has CPR certification. If this employee is unavailable to work, the facility does not have any other employees with CPR certification to provide coverage. The facility failed to ensure that a sufficient number of staff persons were trained in CPR.The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Two staff members are registered for The American Red Cross, which will make a total of 3 staff members certified in CPR. CPR/AED/Pediatrics certification class will be held April 21 at New Beginnings Church of God, Meadville, Pa 16335. Facility Director will confirm that classes are taken by personally paying registration fees and getting copies of CPR cards of participants. Facility director will perform a semi-auunal audit of presonnel records to insure that sufficient staff have CPR training. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to document the number of persons in the facility at the time of the drill.The findings include:On March 6, 2012, fire drill records were reviewed from March 2011 through February 2012. The facility failed to document the number of persons in the facility during the following fire drills: May 19, August 30 and September 29, 2011.The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Facility director will insure that firedrill numbers are documented by highlighting in yellow the number of people in the building. Office manager will counter sign to make sure record is complete. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on a physical plant inspection, the facility failed to post a fee schedule in a prominent place. The findings include:At approximately 11:15 AM on March 6, 2012, a physical plant inspection was conducted. During this inspection, a fee schedule was not observed in a prominent place. At approximately 8:30 AM on March 7, 2012, another review of the physical plant was conducted. A fee schedule was not posted at this time. The project/facility director was interviewed and confirmed a fee schedule was not posted in the facility.
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Plan of Correction
Facility director had office manger make a fee schedule that is now placed in the intake room in a prominent place. Correction has already occured. The Office Manager will conduct an inspection of the intake room monthly to ensure the fee schedule remains posted.
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709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on a review of the employee handbook, personnel records and a physical plant inspection, the facility failed to demonstrate efforts toward informing staff of employee rights in one of one personnel record.The findings include:Five personnel records were reviewed on March 6, 2012. One personnel record pertained to a newly hired employee and was reviewed for documentation of employee rights. A review of the facility's employee handbook documented an employee rights policy. New employees are provided an employee handbook during orientation. The employee then signs off that they received a copy of this handbook. The facility failed to inform employee # 5 of their employee rights.Employee # 5 was hired on February 9, 2012. Employee record # 5 did not include documentation that employee # 5 received a copy of the handbook containing employee rights.A physical plant inspection was conducted on March 6, 2012. During this inspection, employee rights were not observed to be posted in the facility.The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The facility director had the employee that had the omitted handbook on employee rights signature page missing, sighn one. The documentation of employee signature is now in personnnel record. The facility director will ensure all new staff hired receive a copy of the employee rights and will review personnel records quarterly to ensure compliance.
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of one client records. The findings include:Seven client records were reviewed on March 6 - 7, 2012. Four client records were reviewed for documentation of informed and voluntary consents to the funding entity. One client record required documentation of an informed and voluntary consent to the funding entity. Three clients were private pay and did not require consents. Prior to releasing client information to the funding entity, the facility failed to document an informed and voluntary consent from the client in client record # 3The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The project/facility director will have client # 3 sign a consent to release information for the funding entity. Also, all clients with insurance will sign a consent to release information prior to the facility releasing informaton to the insurance company. The case manager will ensure the deficiency does not recur by completing monthly chart audits to ensure compliance. Office manger, with facility director approval also created a new form for this particular release. |
709.93(a)(3) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document the provider of counseling sessions on the record of services provided in three of four client records. In addition, the facility failed to document the duration of the service provided in four of four outpatient client recordsThe findings include: Seven client records were reviewed on March 6 - 7, 2012. Four client records were reviewed for a record of services provided. The facility failed to document the provider of counseling sessions on the record of services provided in client records # 1, 3 and 4. The facility failed to document the duration of the service provided in client records # 1, 2, 3 and 4.Client # 1 was admitted into treatment on January 12, 2012. The client was receiving group and individual counseling sessions. The record of services provided failed to document the provider of group counseling sessions and the duration of the service.Client # 2 was admitted into treatment on November 16, 2011. The client was receiving individual counseling sessions. The record of services provided failed to document the duration of the service.Client # 3 was admitted into treatment on December 15, 2011. The client was receiving group and individual counseling sessions. The record of services provided failed to document the provider of individual/group counseling sessions and the duration of the service.Client # 4 was admitted into treatment on November 7, 2011. The client was receiving group and individual counseling sessions. The record of services provided failed to document the provider of group counseling sessions and the duration of the service.The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Under supervision of facility director, office manager made new forms that reflect specifically the duration of service and the provider's name for that group. To insure that providers document individual sessions training will occur at next treatment team meeting to make sure clinicians initial their individual counseling services and duration of those services. Case manager will also conduct monthly chart audits to ensure compliance. |