INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 2, 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, WES Corporation 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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704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
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Observations
The facility was unable to provide a policy addressing relapse of recovering personnel or a policy addressing the discipline of nonrecovering employees who abuse alcohol and other drugs.
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Plan of Correction
A drug and alcohol policy in reference to employees was not requested during the review; however WES has an established Drug and Alcohol Free Workplace Policy that addresses the discipline of all employees and procedure or all employees suspected of actively using. This can be forwarded along with our response separately.
To assure this does not occur again, the director of quality management and program director has reviewed the DDAP regulations and identified all other polices that are missing from the manual as well as identified all other policies that are in need of development to insure they are present and being implemented.
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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
The facility failed to provide a policy and procedure for a mechanism to collect feedback on completed trainings by staff.
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Plan of Correction
A comprehensive staff development policy will be developed and implemented by February 9, 2019.
Going forward this will be the mechanism for WES to distribute and monitor feedback for staff that completed training.
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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
The facility failed to provide 12 clock hours of training for employee # 1.
Employee # 1 was hired on July 16, 2011 and promoted to the current position on May 1, 2011. There were only 6 hours of trainings documented in the personnel file.
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Plan of Correction
WES will develop an individualized training plan for each of its employees.
Program director and Quality Compliance team will review staff training needs on a quarterly basis and either provide, schedule, or assigned recommended and required training throughout the calendar year.
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
The facility failed to ensure the fire extinguishers were inspected and approved annually. The last inspection of the fire extinguishers was in December 2017.
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Plan of Correction
Fire Extinguishers were inspected and approved on 1/8/2019.
To insure this does not occur again, Inspector will be scheduled to come out 30 days before expiration to avoid a lapse in the future.
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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
The facility failed to perform fire drills at least once a month. The facility only documented fire drill for the month of August and September 2018.
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Plan of Correction
Director of facilities will insure fire drills are exercised once a month.
Adherence that fire drills are completed monthly will be monitored at WES Operations Management meetings biweekly to insure this instance is not repeated.
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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.
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Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 1, 3, and 4.
Client # 1 was admitted on September 12, 2018 and was still an active client at the time of the inspection. There was a consent to release form dated September 5, 2018 allowing the release of a physical exam to a funding source.
Client # 3 was admitted on June 15, 2018 and was still an active client at the time of the inspection. There was a consent to release form dated June 12, 2018 with verbiage allowing "relevant records" released to a funding source. In the same record there was also a consent to release report card transcripts, attendance, and disciplinary documentation to a lab.
Client # 4 was admitted on September 27, 2018 and was still an active client at the time of the inspection. There was a consent to release form dated September 20, 2018 with verbiage allowing "relevant records" released to a funding source.
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Plan of Correction
All staff associated to the program will be trained within 30 days to make releases specific and relevant to the source they are being provide. The State code has been provided and the limitations have been noted.
Release to funding sources will only include prognosis, discharge, and services billed, and a short statement of progress.
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to document type and frequency of treatment and individual rehabilitation services within the comprehensive treatment plans developed with the client in 6 of 7 client records reviewed.
Client # 1 was admitted on September 12, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on September 19, 2018 that did not include type and frequency of services.
Client # 2 was admitted on August 14, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on September 5, 2018 that did not include type and frequency of services.
Client # 3 was admitted on June 15, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on June 27, 2018 that did not include type and frequency of services.
Client # 5 was admitted on August 30, 2018 and was discharged on November 21, 2018. A comprehensive treatment plan was developed with the client on August 30, 2018 that did not include type and frequency of services.
Client # 6 was admitted on August 7, 2018 and was discharged on December 5, 2018. A comprehensive treatment plan was developed with the client on April 23, 2018 and last updated on November 9, 2018 that did not include type and frequency of services.
Client # 7 was admitted on May 11, 2018 and was discharged on July 10, 2018. A comprehensive treatment plan was developed with the client on May 11, 2018 that did not include type and frequency of services.
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Plan of Correction
Treatment plans will be revised to include an indicator of service frequency and type.
To insure this does not occur again, staff will be trained on the update and the use of the new treatment plan within 30 days
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709.93(a) 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:
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Observations
The facility failed to provide a complete client record, which is to include aftercare plans, case consultations, and follow-up information in client records # 1, 5, and 7.
Client #1 was admitted on September 12, 2018 and was still an active client at the time of the inspection. There was no case consultation in the client record documenting non-compliance with treatment.
Client # 5 was admitted on August 30, 2018 and was discharged on November 21, 2018. There was no documentation of a case consultation prior to discharge. There was an aftercare plan that was developed upon admission but not updated at discharge to reflect aftercare for the future.
Client # 7 was admitted on May 11, 2018 and was discharged on July 10, 2018. There was no documentation of a case consultation prior to discharge. There was an aftercare plan that was developed upon admission but not updated at discharge to reflect aftercare for the future and there was no documentation of follow-up.
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Plan of Correction
An initial Aftercare Plan will be established and a separate discharge Aftercare Plan will be established. Staff will be trained on implementing their use within 45 days.
Case consultations will be done for each non-compliant client prior to discharge. Director will monitor discharges monthly and participate in case consultations and sign-off in addition to the team attendees.
Follow up is completed for each client within 30 days after discharge and is currently present in all clients' medical record charts. An email can be sent via secure network providing this documentation.
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