INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 9 - 10, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northeast Treatment Centers, 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.
|
Plan of Correction
|
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.
|
Observations
Based on a review of employee training files, the facility failed to ensure that staff persons received at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum within the required timeframe.
The findings include:
One employee training file from the inpatient facility was reviewed on September 9, 2015, for documentation that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training.
The facility failed to ensure that employee # 3 received the required 4 hours of TB/STD training within the first year of employment.
Employee # 3 was hired as a counselor on February 24, 2014 and was required to receive 4 hours of TB/STD training by February 24, 2015. There was no documentation of this training at the time of review on September 9, 2015.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Residential Program Director will coordinate a scheduled TB/STD training to be conducted where Employees #3 will attend. The TB/STD training is scheduled for November 12, 2015. The Residential Program Director will review and monitor personnel files monthly to ensure all employees receive TB/STD and HIV/AIDS training within one year of hire date to avoid future infractions regarding licensure standard 704.11.
TB/STD and HIV/AIDS trainings will be scheduled accordingly, by the Residential Program Director to meet the training requirements for this standard. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
|
Observations
Based on a physical plant inspection, the facility failed to keep frozen food at or below 0 degrees Fahrenheit.
The findings include:
A physical plant inspection was conducted on September 9, 2015. The facility failed to keep frozen food at or below 0 degrees Fahrenheit.
The thermometer in the kitchen freezer displayed a temperature of 10 degrees Fahrenheit. In addition, the freezer temperature log for the month of September 2015 documented that the freezer was 10 degrees Fahrenheit for each day in September. The temperature log also documented 8 degrees Fahrenheit on August 8, 2015 and 10 degrees Fahrenheit on August 31, 2015.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Residential Program Director contacted the Refrigeration Company to inspect and fix the walk in freezer to ensure that it can keep frozen food at or below O degrees. The walk in freezer was fixed on 9/10/15 and is now working properly.
The Residential Program Director also conducted a Food Safety training on 9/17/15 to ensure that all food is handled properly and stored at the correct temperatures to avoid future infractions regarding licensure standard 705.7. Also, the assigned Resident Manager will keep a daily log of all refrigerator and freezer temperatures and report any problems to the Residential Program Director so that the units can be inspected and fixed immediately. |
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. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on a review of client records, the facility failed to adhere to 4 Pa. Code 255.5 in one of seven client records reviewed from the inpatient facility.
The findings include:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Seven client records requiring documentation of informed and voluntary consents were reviewed on September 9, 2015. The facility failed to adhere to 4 Pa. Code 255.5 when obtaining an informed and voluntary consent to release in client record # 4.
Client # 4 was admitted to the facility on July 28, 2015. On July 28, 2015, client # 4 signed a consent to release form which did not adhere to 4 Pa. Code 255.5, as the facility documented the release of client # 4's urinalysis to a governmental entity, or treatment court.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Residential Program Director reviewed client record #4 and corrected the consent to ensure that it adheres to PA 255.5
The Residential Program Director also conducted a Confidentiality training with staff on 9/30/15 in order to ensure that all consents are completed properly and included all of the required information to avoid future infractions regarding licensure standard 709.28. In addition the Clinical Supervisor and the Residential Program Director will train all new staff within 30 days as well as conduct annual staff training to ensure that all staff understands the importance of client confidentiality, proper consents and compliance with the regulations. |