INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15, 2016 through June 16, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Libertae Family House Liberate, 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)(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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that all staff persons received at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in three of eight personnel records reviewed.Employee #5 was hired as a treatment tech on March 11, 2010 and was due to complete the TB/STD training no later than March 11, 2012. Only two hours of training was completed as of the date of inspection.Employee #6 was hired as a treatment tech on July 3, 2012 and due to complete the required TB/STD training no later than July 3, 2014. Only two hours of training was completed as of the date of inspection.Employee#7 was hired as a treatment tech on June 7, 2005 and was due to complete the TB/STD training no later than June 7, 2007. Only two hours of training was completed as of the date of inspection. These findings were reviewd with facility staff during the licensing process.
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Plan of Correction
Employees #5, #6 & #7 will be enrolled in TB/STD training upon the next available training date to complete 2 additional hours of training. It is the responsibility of the Director of Operations to ensure that treatment techs receive mandatory trainings within required timeframes. Director of Operations will review current employee files to ensure that all trainings are up-to-date. Any employee who has not completed trainings will be scheduled for next available trainings by Director of Operations. |
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
All employee CPR/First Aid certification cards were reviewed on June 15, 2016 through June 16, 2016. A four week work schedule was reviewed and the work schedule showed several days where staff worked and there was no CPR coverage. The facility is open 24 hours Sunday through Saturday. The following dates and times reflect a lack of CPR coverage: 4 PM to 12 AM shift May 2016: 15, 28, 29.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
One staff person on schedule for those dates did have CPR training completed on June 4, 2016. However she did not provide agency with copy of CPR card. This card is now on file. Director of Operations will review staff files to determine that all covering staff have completed CPR/First Aid training.
The Director of Operations has a schedule when all staff are required to update CPR/First Aid certification. The Director of Operations will notify same staff in advance of date when credential expires. No staff will be scheduled to work who has not submitted updated certification card. The Director of Operations will cross-check this when preparing the monthly schedule. This will ensure that the deficiency does not recur.
The Director of Operations is responsible for ensuring the corrective action is implemented. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 the fire drill record, the facility failed to document whether there were problems encountered during fire drills.A review of the May 2015 through May 2016 fire drill record was reviewed during the annual licensing inspection. During the months of May 2015, July 2015 and November 2015 the facility failed to document whether there were problems encountered during the fire drill. These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The fire drill form used has been revised so that the item in question "whether there were problems encountered during the fire drill" is highlighted. Fire drill protocols were reviewed with staff at a regularly scheduled staff meeting on July 11, 2016. The procedures were also noted in the staff shift log as a reminder to complete this section of the record. Director of Operations is responsible for this requirement. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document annual staff work performance evaluations in one of eight personnel records reviewed on June 15, 2016 through June 16, 2016.Employee #1 was hired as the project director on May 4, 2015. There was no documentation of an annual work performance evaluation, signed and dated by the employee, in the personnel record as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director has notified the board of directors of this deficiency and the requirement to complete the performance evaluation. The board of directors will complete the evaluation and review with the project director, who will date the evaluation. The evaluation will be filed in the personnel record of the project director.
Board of Directors will schedule annual evaluation for project director to occur before the end of May each year to satisfy this requirement. This will ensure that deficient does not recur. |
709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The facility failed to obtain an informed and voluntary consent to release in three of ten client records reviewed during the course of the annual licensing inspection on June 15, 2016 through June 16, 2016.Client #5- The facility failed to document the purpose of the release in two consent to release forms dated March 30, 2016 to the client's family member and a government agency. Client#6- The facility failed to document the purpose of the release in one consent to release forms dated October 1, 2015 to a specific person. In addition, the facilty failed to obtain the signature of a witness on a consent to release form signed by the client on October 1, 2015, disclosing to a drug and alcohol treatment facility.Client #10- The facility failed to document the purpose of the release in two consent to release forms dated January 7, 2016 to a specific person and an organization. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Social Services will review the three consents to release information for the respective clients and amend them according to specifications. Director of Social Services will update social service staff at next staff meeting on informed and voluntary consent to release information as it relates to regulations. Records clerk will audit charts on a weekly basis to ensure that consents to release information are detailed in their purpose of the release and specificity as to whom the release is granted, and that all releases are signed by clients. This will ensure that deficiency does not recur.
The Director of Social Services is responsible for ensuring the corrective action is implemented. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Client #10 was admitted to the facility on January 16, 2016 and was administratively discharged on March 8, 2016. The facility failed to inform the client in writing the decision to involuntarily terminate treatment.These findings were reviewed with facility staff during the licening process.
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Plan of Correction
Written notification of agency's decision to involuntarily terminate treatment has been filed in client's chart. Records are available to former clients upon request.
It is the project director's responsibility notify clients in writing of any decision to involuntarily terminate treatment. When a client is being involuntarily terminated the Director of Clinical Services will ensure that the written notification has been obtained from the project director and given to the client before the client's departure from the program. This will ensure that the deficiency does not recur. |