INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 8 - 9, 2008 and December 15 - 16, 2008, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, the PA Organization for Women in Early Recovery 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 and a plan of correction is due on January 19, 2009.
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Plan of Correction
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709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based on a review of the policy and procedure manual, the facility failed to provide complete documentation of employee rights.
The findings include:
The policy and procedure manual was reviewed on December 8 - 9, 2008. The facility did not document the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from his or her records.
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Plan of Correction
While both the Employee Manual and the Program Policy & Procedure Manual describe employee rights and responsibilities, the policies were revised to more specifically address (2) "employee"s right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information" from her/his personnel file.
The Employee Manual and Program Policy & Procedure Manual were revised on 1/15/09 by the Executive Director. The HR Director will address the revision with Managers at a meeting on 1/8/09 and the revised pages will be distributed to all staff by 1/15/09. All staff will be required to sign offon a new Manual Receipt form that will be filed in their personnel record. |
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.
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Observations
Based on observation of the facility's kitchen freezer, the facility failed to store food at or below 0 degrees Fahrenheit.
The findings include:
An inspection of the facility's kitchen was conducted on December 16, 2008. The temperature of the freezer was 23 degrees Fahrenheit. The facility did not have documentation of the freezer temperature being monitored on a regular basis.
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Plan of Correction
Since the inspection of the Halfway House on 12/16/08, the freezer in the kitchen is not being used; it will not be used until it can be repaired or replaced. The facility has a commercial walk-in freezer in the basement that is being utilized.
On 1/6/09, a log was created to document monitoring of all freezers and refrigerators. The log was provided to the Halfway House Manager and the Residential Coordinator. It will be the responsibility of the Manager to train staff on proper monitoring and documentation. The logs are located by each freezer and refrigerator. The Halfway House Manager will include a review of these logs during a monthly walk-through. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
Based on a client record review, the facility failed to document timely individual treatment and rehabilitation plans in two of five client records.
The findings include:
Six client records were reviewed on December 15, 2008. Individual treatment and rehabilitation plans were required in five client records. The individual treatment and rehabilitation plan is due within 30 days of the client's admission as stated in the project's policy. The individual treatment and rehabilitation plans were completed late in client records # 3 and 4.
In client record # 3, the individual treatment and rehabilitation plan was due on November 5, 2008 based on the admission date of October 6, 2008. The individual treatment and rehabilitation plan was completed on November 12, 2008.
In client record # 4, the individual treatment and rehabilitation plan was due on July 18, 2008 based on the admission date of June 18, 2008. The individual treatment and rehabilitation plan was completed on July 22, 2008.
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Plan of Correction
Aas follow up to the exit interview 12/16/08, which was attended by the Halfway House Manager, the Associate & Clinical Director reminded the Manager that Individual Treatment Plans are to be completed within 30 days of admission. A written memo was also sent to all Therapist/Counselors. The Associate & Clinical Director will randomly review clients records at least twice each year as a way to monitor compliance and assure quality. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on the review of client records , the facility failed to document follow-up information in two of two client records.
The findings include:
Six client records were reviewed on December 15, 2008. Follow-up information was required in two client records. The facility did not document follow-up information in client records # 2 and 4.
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Plan of Correction
As follow up to the exit interview 12/16/08, which was attended by the Halfway House Manager, the Associate & Clinical Director reminded the Managers that Follow Up information is to be included in the client record. A written memo was also sent to all Therapists/Counselors. The Associate & Clinical Director will randomly review client records at least twice each year as a way to monitor compliance and assure quality. |
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 staff record review, the facility failed to document HIV/AIDS and TB/STD training in one of 5 staff records.
The findings include:
Seven staff records were reviewed on December 8 - 9, 2008. HIV/AIDS and TB/STD training were required in five records. The facility failed to document completion of HIV/AIDS and TB/STD training for employee # 6.
Employee # 6 is support staff and was hired on November 1, 2006. HIV/AIDS and TB/STD training was due to be completed by November 1, 2008.
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Plan of Correction
The employee attended HIV/AIDS training at Clarion at at a BDAP Regional Training on January 15, 2009. She is registered for TB/STDs through an approved trainer from Family Links, on February 27, 2009. The employee was registered by the Halfway House Program Manager. The Halfway House Program Manager will ensure that the employee completes an evaluation of each training; the Executive Assistant will file the evaluations with the training certificates; and the Associate & Clinical Director will inspect the record to ensure proper documentation by 2/2/09. |
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 cards and an interview with the Facility Director, the facility failed to ensure that at least one person trained in CPR skills was onsite during the project's hours of operation.
The findings include:
CPR cards were reviewed on December 8, 2008 and December 15, 2008. Staff schedules covering November 9 through December 6, 2008 were reviewed on December 15 - 16, 2008.
There were no staff with current CPR certification onsite for the following dates: November 9, 2008, November 11 - 14, 2008, November 16, 2008, November 18 - 23, 2008, November 25 - 28, 2008, November 30, 2008, and December 2 - 4, 2008.
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Plan of Correction
This issue has been resolved. The following steps were taken:
1) Employees without current CPR and First Aid certifications were immediately removed from the schedule for any shifts in which they would have been working with other staff who were not certified. 2)Employees whose CPR and /or First Aid certifications had expired have been trained as of 12/ 17/2008 and 12/19/2008.
3)Documentation of completed trainings have been filed in each employee"s personnel file. 4)New training procedures have been developed which include a schedule for registering employee's prior to the expiration of the necessary certifications. 5)On 12/30/08, the Executive Director and the Associate & Clinical Director met with the Halfway House Manager to discuss the seriousness of the matter and to train her on the new procedures; the meeting was documented. 6)The Associate & Clinical Director will review training files at least quarterly to ensure compliance. |