INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 23, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Penndel Mental Health Center 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to provide documentation of an individual training plan for the current training year developed with input from both the employee and the supervisor, each personnel record reviewed.
Employee # 1 was hired as the Project Director on August 24, 2018. The individual training plan signed by the employee was not developed with input from the supervisor.
Employee # 2 was hired as the Facility Director on August 24, 2018. The individual training plan signed by the employee was not developed with input from the supervisor.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
All staff that work within the D&A program licensed #097117 will create a training plan with their supervisor. We will have on file, an annual written individual training plan that is reviewed and signed by respective supervisors.
At time of audit, there were two employees of the project identified (Project Director and Facilities Director) and no other hires. Though plans were developed with supervisors, we neglected to sign off at the time. As of 7/30/2019, both the Project Director and the Facilities Director did review again with, and obtain signatures from, respective supervisors.
Both the Project Director and Facilities Director were considered "hired" August 24, 2018 and training plans will be consistently formatted annually from that date.
Both Project and Facility Director will ensure training plans are completed and signed annually via personnel chart audits.
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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
The project failed to have and implement a written policy and procedure regarding all medications used by client which shall include, but not be limited to:
(1)Administration of medication, including the documentation of the administration of medication when self -administered by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/30/19 the Project Director has revised our medication administration policy (CL 403.01). It has been changed to reflect documentation of administration of medication by staff and/or client.
This will be reviewed with all staff by Facilities Director or designate for ongoing future implementation.
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709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
The project failed to have and implement a written policy and procedure regarding all medications used by client which shall include, but not be limited to:
(5)Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/30/19 the Project Director has revised the medication administration policy (CL 403.01). It has been changed to reflect protocol for security, loss, theft and misuse of drugs/ medications on sight.
This will be reviewed with all staff by Facilities Director or designate for ongoing future implementation.
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