INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on September 10 and 11, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Northern Tier Counseling, 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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704.11(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 three personnel records and an interview with the Clinical Supervisor it was determined that the facility failed to ensure that staff members completed a feedback form on all training in two of two client records
The findings include:
A review of personnel records revealed that employees #1 #2 attended training for the 2010-2011 training year. Both employees failed to complete feedback forms after each training attended.
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Plan of Correction
All staff on the Drug and Alcohol staff roster are required to complete a feedback form for all training hours received after their completion. NTC's Human Resources department along with NTC's Compliance Committee will review staff training's quarterly to ensure the feedback form is completed for all training hours, and the form will be placed in their respective HR file. |
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 agency training files the facility failed to provide documentation of an assessment of staff training needs for the current training year.
The findings include:
Based on a review of the manual and staff records on September 10, 2012, the facility failed to complete a needs assessment training plan for staff #1 and #2 for the 2011-2012 training year. Staff # 3 was hired on April 23, 2012 and received a late training plan on August 21, 2012.
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Plan of Correction
Policy revisions were made through NTC's compliance committee to ensure each employee has an individual training plan; all new employees of NTC will have a training plan completed after their initial 30 day, 60 day and 90 day employment periods, and annually thereafter. This Policy was revised through NTC's Compliance Committee and incorporated into the Policy manual; the Program Director sits on the Compliance Committee and will ensure the plans are completed and reviewed for all employees quarterly.
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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 did not have sufficient staff trained in these skills on duty.
One employee had CPR/first aid certification. A second employee had been certified but this expired on June 9, 2011.
A third employee had been certified but left employenment with the facility on September 7, 2012, leaving only one staff certified in FirstAid /CPR training at this facility.
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Plan of Correction
Currently NTC only has one person certified in CPR and First Aid; the plan of corrective action will require NTC's Compliance Committee, which meets monthly, to designate 2 staff members to obtain and maintain CPR and First Aid Certification, and review quarterly for continued compliance. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records and an interview with the clinical supervisor, the facility failed to document annual performance evaluations as required by agency policy and regulation in one of four personnel records.
The findings include:
Three personnel records were reviewed on September 10, 2012 Three personnel record required to include documentation of annual performance evaluations. Per agency policy, performance evaluations are conducted at three months following hire and annually thereafter. There were no annual performance evaluations documented in personnel record #2 since September 2009.
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Plan of Correction
Policy revisions were made through NTC's compliance committee to ensure each employee has a work performance evaluation completed annually. For new employees, if there are issues/concerns with their work performance they will receive an evaluation on their 30, 60 and 90 day employment periods, and if they successfully complete these evaluations they will receive an annual evaluation thereafter. This Policy was revised through NTC's Compliance Committee and incorporated into the Policy manual; the Program Director sits on the Compliance Committee and will ensure the plans are completed and reviewed for all employees quarterly. |
709.30(1) LICENSURE Client Rights
709.30. Client rights.
(1) A person receiving care or treatment under section 7 of the act (71 P. S. 1690.107), shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on review of client records, the facility failed to ensure that a client was notified of that
every individual admitted to the client was entitled to the retention of their civil rights and liberties.
The findings include:
Four client records were reviewed on September 10, 2012. Clients #2, 3, and 4 had failed to have documentation in the client record pertaining to the client receiving client rights upon entry to the program for treatment.
The clinical supervisor confirmed these findings on September 10, 2012.
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Plan of Correction
Client Rights are reviewed during their intake process, prior to the evaluation; this is signed by the client and placed into their chart record. The Program Director has developed an intake checklist for all staff to review during intakes to ensure each client acknowledges and understands their rights as a client of services at NTC. This checklist will be discussed and reviewed quarterly during individual supervisions as well. The Program Director sits in on the monthly Compliance Committee meetings and will review the program for compliance quarterly.
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709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on review of client records, the facility failed to have documentation that clients received orientation to the project upon admission in three of three client records.
The findings include;
Four client records were reviewed on September 10, 2012. Three client records required clients to receive orientation. Three client records, # 2, 3, and 4, did not contain documentation of orientation.
Confirmation of these findings were made by the clinical supervisor on September 10, 2012.
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Plan of Correction
A Client Orientation is reviewed with each client during their intake process, prior to the evaluation; this is signed by the client and placed into their chart. The Program Director has developed an intake checklist for all staff to review during intakes to ensure each client is oriented to the policies and procedures of Northern Tier Counseling. This checklist will be discussed and reviewed quarterly during individual supervisions as well. The Program Director sits in on the monthly Compliance Committee meetings and will review the program for compliance quarterly. |