INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 17, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Creative Health Services 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of a personnel record, the facility failed to ensure that clinical supervisors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision in one of one personnel record reviewed. The findings include:On March 17, 2014, one personnel record was reviewed for documentation that a core curriculum in clinical supervision was completed for a clinical supervisor who has not functioned for 2 years as a supervisor in the provision of clinical services. The facility failed to ensure that a clinical supervisor completed a core curriculum in clinical supervision in one of one personnel record reviewed, specifically, personnel record # 3.Employee # 3 is a clinical supervisor and was hired June 17, 2013. Based on employee # 3's resume, she does not have experience functioning as a supervisor in the provision of clinical services. Personnel record # 3 did not include documentation that employee # 3 completed a core curriculum in clinical supervision as of March 17, 2014.The findings were confirmed during an interview with the facility director on March 18, 2014 at approximately 3:00 P.M.
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Plan of Correction
By 06/09/2014 Employee 3# will begin the core supervision training which is offered by DDAP. She will attend this training from 06/09/2014-06/13/2014. The facility director will ensure that employee attends the training and will document the attendance as well as maintain a certificate of completion. Moving forward the facility director will utilize a training grid to ensure all mandated trainings are completed and documented within the required time period. |
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
Based on a review of a personnel record, the facility failed to document an individual training plan annually for each employee in four of eight personnel records reviewed. The findings include:On March 17, 2014, eight personnel records requiring documentation of an individual training plan were reviewed. The facility failed to document an individual training plan in four of eight personnel records reviewed, specifically, personnel records # 1, 14, 15, and 16.Employee # 1 is the project director and was hired August 1, 2006. The individual training plan for employee # 1 was due January 31, 2014. However, personnel record # 1 did not include documentation of an individual training plan as of March 17, 2014.Employee # 14 is the medical director and was hired August 1, 2011. The individual training plan for employee # 14 was due January 31, 2014. However, personnel record # 14 did not include documentation of an individual training plan as of March 17, 2014. Employee # 15 is a psychiatrist and was hired November 1, 2010. The individual training plan for employee # 15 was due January 31, 2014. However, personnel record # 15 did not include documentation of an individual training plan as of March 17, 2014. Employee # 16 is a psychiatrist and was hired September 16, 2013. The individual training plan for employee # 16 was due January 31, 2014. However, personnel record # 16 did not include documentation of an individual training plan as of March 17, 2014. The findings were confirmed during an interview with the facility director on March 18, 2014 at approximately 3:00 P.M.
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Plan of Correction
By 04/25/2014 the facility director in conjunction with the project director, (employee #1), the medical director (employee #14), and psychiatrists
(employees #15 and 16) will develop and document individual training plans for the year 2014.
The facility director will have staff meetings to monitor all staffs individual training plans to ensure all staff have completed an individual training plan on time every year. |
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 a personnel record, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of STD/TB training and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff in one of one personnel record reviewed.The findings include:On March 17, 2014, one personnel record was reviewed to verify that an employee had HIV/AIDS and STD/TB training. The facility failed to ensure that persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of STD/TB training in one of one personnel record reviewed, specifically, personnel record # 13.Employee # 13 is a counselor and was hired for her current position November 30, 2012. Employee # 13 was due to complete a minimum of 6 hours of HIV/AIDS training and at least 4 hours STD/TB training by November 30, 2013. However, personnel record # 13 did not include documentation of HIV/AIDS and STD/TB training as of March 17, 2014.The findings were confirmed during an interview with the facility director on March 18, 2014 at approximately 3:00 P.M.
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Plan of Correction
By 5/02/2014 the facility director will ensure that employee #13 is in full compliance with HIV/AIDS, STD/TB training. Employee #13 is scheduled to attend HIV/AIDS training 5/2/2014.
Facility director will review on a monthly basis at staff meetings up comong trainings, and training availablities.
Facility director will track through use of DDAP grid, attendance at mandated trainings to ensure all staff receive their trainings within their training period for employment compliance. |
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 that a project director and facility director completed 12 clock hours of required training in one of two personnel records reviewed.The findings include:On March 17, 2014, two personnel records requiring documentation of 12 clock hours of training were reviewed. The facility failed to provide documentation of 12 clock hours of training in one of two personnel records reviewed, specifically, personnel record # 1.Employee # 1 is the project director and was hired August 1, 2006. Employee # 1 was required to complete 12 clock hours of annual training hours by December 31, 2013. However, personnel record # 1 did not include documentation of annual training hours for the January 1, 2013 to December 31, 2013 training year as of March 17, 2014.The findings were confirmed during an interview with the facility director on March 18, 2014 at approximately 10:15 A.M.
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Plan of Correction
By 04/15/2014 facility director will obtain documentation of 12 clock hours of training completed by project director (employee #1) for year 2013.
Facility director will monitor trainings attended by project director to ensure that there is a minimum of 12 clock hours of training attended for January 1st 2014 to December 31st every year. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on review of administrative documentation, the facility failed to make available to the public an annual report at the end of their fiscal year.The findings include:The administrative documentation was reviewed on March 14, 2014. The facility was required to make available to the public an annual report at the end of their fiscal year. The facility's 2012 through 2013 fiscal year ended on June 30, 2013. However, the facility's annual report was not made available to the public until February 27, 2014. The findings were confirmed during an interview with the facility director on March 18, 2014 at approximately 3:00 P.M.This is a repeat citation. The facility was cited on April 8, 2013 for noncompliance with this standard.
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Plan of Correction
The facility director will orient the board of directors to the required public notification of the projects's annual report availablity.
The facility director will ensure that the annual report for the fiscal year 2013-2014 is avaialable for public review prior to December 31st 2014.
The facility director will request a proof of publication announcing the availability of the projects 2013-2014 report. The facility director will be responsible for ensuring that the annual report is made available to the public on time annually. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on the facility's census of active and discharged clients, the facility failed to develop a data collection and record-keeping system that allowed for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.The findings include:Upon the Licensing Specialist arrival at the facility, the facility presented a list of clients on March 17, 2014 that was supposed to reflect the facility's current census of active clients. Some of the clients on the list were actually discharged clients. Also, the facility was unable to accurately tell the Licensing Specialist which clients on the list were active clients and was unable to provide the actual number of active clients. The facility did not present an accurate census of active clients until 3:00 P.M.The findings were confirmed during an interview with the facility director on May 17, 2014 at approximately 3:05 P.M.
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Plan of Correction
By 6/01/2014 a program will be developed by network adminstator, and implemented by staff that will create a report utilizing our inplace system, which will separate our acitive clients from our inactive clients. The system will be updated as clients are either opened or closed,to maintain an up to date listing.
Moving forward the utilization of this new system will enable the facility to produce and present a current and accurate census of active clients and discharged clients in a timely manner. Moving forward the office manager will be responsible for maintaining an up to date list of all current active clients and inactive closed clients. |