INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 5, 2011 and October 6, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Diakon Lutheran Social Ministries was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records and the facility's policy and procedures, the facility failed to document feedback on completed training in three of nine records.
The findings include:
Nine personnel records were reviewed on October 6, 2011. Of the nine, six were reviewed for training and documentation of feedback forms after the completion of training, #1, 2, 3, 4, 5 and 7. The following records failed to show documentation of feedback forms in records, #1 and 2. The training year reviewed was January 1, 2010 through December 31, 2010. The facility director and clinical supervisor was interviewed on October 6, 2011 and confirmed the findings.
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Plan of Correction
Preparation and submission of this plan of correction is required by state and federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
Employee #1 and #2 will complete the required Staff Training feedback form following the completion of all required trainings. Completed trainings for 2011 will be reviewed and corresponding feedback forms completed.
Random audits will be completed by Clinical Director/designee to ensure the completion of the training feedback forms.
Any identified issues will be addressed by the Executive Director as appropriate.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure and document that project director completed at least 12 hours of training for the 2010 training year in one of nine personnel record.
The findings include:
Nine personnel records were reviewed on October 6, 2011. Two employee records represented the project director and facility director who were required to have obtained 12 hours of training for the 2010 training year based on the hire dates, #1 and 2. A discussion with the facility director and clinical supervisor on October 6, 2011 confirmed that the required training hours was obtained for training year 2010 but could not provide documentation.
Employee #1 was hired to this position on January 1, 2010 and was required to have obtained 12 hours of training for the 2010 training year. Employee #1 provided no training documentation for training year 2010.
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Plan of Correction
The project director and facility director have completed the 12 clock hours required. Copies of the project director's training were obtained and are maintained in the Mechanicsburg office.
Random chart audits will be conducted by the Clinical Director/designee to ensure compliance.
Any identified issues will be addressed by the Executive Director as appropriate.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record, the facility failed to document alternate exit routes to be used during fire drills, as required by regulation.
The findings include:
A review of the fire drill record was conducted on October 5, 2011. The fire drills conducted from September 2010 through September 2011 were reviewed. Per regulation, a nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility did not document alternate exits used during fire drills for the following months; September 2010, October 2010, January 2011, February 2011, March 2011, April 2011, May 2011, June 2011, July 2011, August 2011 and September 2011. The exit routes documented for those months was front and side exits with no alternatives identified.
An interview with the clinical supervisor on October 5, 2011 confirmed the findings.
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Plan of Correction
The Clinical Director has identified alternative exit routes, which will be included in the monthly fire drills.
Random audits will be completed by the Clinical Director/designee to ensure compliance.
Any identified issues will be addressed by the Executive Director as appropriate. |
709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
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Observations
Based on the review of the facilities policy and procedure for letter of agreements, the facility failed to obtain updated letters of agreement with referral sources.
The findings include:
The facility's policy and procedures were reviewed on October 5, 2011. The policy for letter of agreements was reviewed and the letters of agreements, besides the 24 hour medical and psychiatric coverage, was outdated and needed to be updated. The letters of agreements read "the agreement expires one year from the date of the signature and can be terminated with a 30 days notice by either party." The dates of the letter of agreements were signed on August 2010 and expired August 2011.
The clinical supervisor was interviewed on October 5, 2011 and confirmed the findings.
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Plan of Correction
Letters of Agreement from the primary referral sources have been obtained for a 2 year period and are on file.
Random audits will be completed by the Clinical Director to ensure ongoing compliance.
Any identified issues will be addressed by the Executive Director as appropriate. |
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 the review of client records, the facility failed to document case consultations within the ninety day time frame in two of five client records reviewed.
The findings include:
Eight client records were reviewed on October 6, 2011. Per agency policy, case consultations shall be completed every 90 days. Case consultations were required in five discharge records, #3, 5, 6, 7 and 8. The facility did not document a case consultation within the ninety day time frame in client records # 5 and 7. A discussion with the clinical supervisor on October 6, 2011 confirmed the findings
Client #5 was admitted on March 8, 2011 and discharged on July 1, 2011. The case consultation was due by June 8, 2011 and the case consultation was documented on June 18, 2011, 10 days past the 90 day timeframe.
Client # 7 was admitted on March 29, 2011 and discharged on July 18, 2011. The case consultation was due by June 29, 2011 and the case consultation was documented on July 18, 2011, 19 days past the 90 day timeframe.
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Plan of Correction
The Clinical Director will re-educate clinicians on the policy and procedure regarding timely completion of case consultations. The Clinical Director will meet individually with each clinician.
Random chart audits will be conducted by the Clinical Director/Designee to ensure compliance.
Any identified issues will be addressed by the Executive Director as appropriate. |