INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on December 7, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Community Service Foundation, Inc. of Sellersville 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 facility staff CPR/first aid certification cards, the facility failed to ensure that at least one person trained in CPR skills onsite during the project's hours of operation. Findings: Based on a review of staff schedules and staff CPR/first aid certification cards, the facility failed to ensure sufficient number of staff trained in these skills were available. An interview with the program coordinator acknowledged that only one person had CPR/first aid qualifications.
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Plan of Correction
Each facility has one CPR/first aid current certified person trained. By April 1, 2012 the executive director and clinical supervisor will ensure that additional staff are certified to ensure that at lease two staff are certifed at the facility for each day, in case of a staff absence another staff person is certified. The executive director has already scheduled the CPR/first aid training and will continue certification trainings annually to keep certifications current. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log, the facility failed to document at least monthly fire drills. The findings include: The fire drill record log was reviewed on December 12, 2011. The log was reviewed from December 2010 to December 2011. The facility failed to provide documentation for fire drills the months of July 2011 and August 2011. This finding was confirmed with the program coordinator on December 12, 2011 at 10:00 A.M.
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Plan of Correction
During the summer months when the outpatient program is operating, fire drills will be conducted and recorded. The project director and clinical supervisor will train summer program staff by 5/15/12 how to implement and document fire drills. All facilities will conduct monthly fire drills throughout the year. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to follow their own policy pertaining to the signing of the case consults.The findings include:A review of the facility's policy and procedures indicated a policy that required case consultations to include clinical supervisor involvement, to include the supervisor's signature on the case consultation documentation. Client records # 1,2,4,6, and 7 failed to have the signature of the supervisor included on the case consult. Only the counselor signed the case consults.Client # 1 was admitted on 11-5-2010 and was discharged on 6-6-2011. The case consultation was completed by the counselor on 5-5-2011. The counselor's supervisor did not sign the case consultation.Client #2 was admitted on 11-30-2010 and was discharged on 2-25-2011. The case consult was completed by the counselor on 2-26-2011. The counselor's supervisor did not sign the case consultation.Client # 4 was admitted on 8-21-2011. The case consult was completed on by the counselor on 12-02-2011. The counselor's supervisor did not sign the case consultationClient # 6 was admitted on 11-10-2010 and was discharged on 4-11-11. The counselor completed the case consult on 3-10-2011. The counselor's supervisor did not sign the case consultationClient # 7 was admitted on 11-15-10 and was discharged on 6-22-2011. The case consult was completed by the counselor on 3-15-2011. The counselor's supervisor did not sign the case consultation Client records # 1,2,4,6, and 7 failed to have the signature of the supervisor included on the case consult. Only the counselor signed the case consults.
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Plan of Correction
By 3/15/12, our policy and procedure manual will match our practice. The project director will ensure that the changes are made to the policy and procedure manual to accurately describe the case consultation process and signature. |