INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 20 through 21, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Nuestra Clinica Rehabilitacion 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 September 24, 2007.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of employee records, the facility failed to document an assessment of training needs in six of six records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
The Project Director and SACA's new Director of Behavioral Health Services will assess the training needs of the staff. Each staff file will have a record of the training needs assessment. This assessment will be completed by November 15, 2007. |
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 employee records, the facility failed to collect feedback for training in three of six records reviewed, #1, 2 and 3. Based on an August 20 and 22, 2007 review training feedback forms were not completed for these three employees.
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Plan of Correction
The Project Director and the Director of Behavioral Health Services will require that all staff submit the training feedback form within five working days of the staff returning from training. |
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 employee records, the facility failed to complete training plans in six of six records reviewed, # 1, 2, 3, 4, 5 and 6.
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Plan of Correction
At initial employment and at each quarter a Drug and Alcohol Staff Training Needs Survey will be provided to each employee in which the employee will indicate areas of need and/or training desired. Using the employee's Staff Training Needs Survey an individual training plan will be developed for the employee outlining the training for the entire fiscal year. A separate section of the employee file will track the trainings attended and the Training Feedback forms. The Project Director and Director of Behavioral Services will perform this task. |
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 employee records, the facility failed to document the mandatory HIV/AIDS and TB/STD training in six of six client records reviewed, # 1, 2, 3, 4, 5 and 6.
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Plan of Correction
Each staff member requiring the HIV/AIDS and TB/STD training will receive the training by 1/15/2008. Training will be provided by SACA's HIV/AIDS and TB/STD Education and Prevention Program. This program if funded and certified by the PA Department of Health. The Project Director and Director of Behavioral Health will oversee the implementation. |
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 an August 20 - 21, 2007 review of facility documentation, the facility failed to provide CPR/first aid coverage for the hours of 4:30 PM through 11:30 PM, Monday through Friday and during all weekend shifts from July 9, 2007 through August 12, 2007.
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Plan of Correction
On October 4, 2007 NCR held a Red Cross training for CPR/First Aid certification. A total of eight staff members took the training and became certified. Two staff members were already cerified and two more are taking their renewal certification. As of October 4, 2007 all shifts on all days have at least one staff member certified for CPR/First Aid. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on an August 20 and 22, 2007 review of employee records, the facility failed to document the required twelve hours of training for employee # 2.
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Plan of Correction
The Project Director will insure that all staff attend the required training and that the trainings are documentd in the staff files. This will be an on-going process. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill documentation, the facility failed to conduct unannounced monthly fire drills from March 2007 through July 2007.
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Plan of Correction
The Project Director has instituted a fire drill calendar for the new fiscal year. The first unannounced fire drill was conducted for September, 2007. Subsequent fire drills will occur on a monthly basis. The Project Director will insure that monthly fire drills are performed and properly recorded |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill documentation on August 20, 2007, the facility failed to conduct a fire drill during sleeping hours during the last six months.
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Plan of Correction
The Project Director made a new monthly fire drill calendar that includes fire drills on all three shifts. This will insure that staff and clients can be evacuated safely regardles of time of day. The Project Director will insure that fire drills are conducted on all shifts. |
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 August 22, 2007 review of employee records, the facility failed to document a work performance evaluation for employee # 2 within the past year.
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Plan of Correction
The Project Director will check all personnel records and all employee work performance evaluations to bring all evaluations up to date. That is to insure that all annual evaluations have been made during the past twelve months. Those not current will be brought up to date. This will be completed by December 15, 2007 |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records on August 21, 2007, the facility failed to document a discharge summary in one of two client records, #5.
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Plan of Correction
The Director of Behavioral Health Services will examine all discharge records to insure that all discharge plans including the after care plans are properly completed. The Project Director will routinely sample a number of discharge plans to confirm that the procedure is been followed. |