INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 14 through May 16, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A. R. S. of Lancaster, LP, 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(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 personnel and training records, the facility failed to provide documentation of HIV/AIDS training in one of ten records reviewed.
The findings include:
Ten personnel records were reviewed on May 14, 2012. Per regulation, staff persons shall receive a minimum of four hours of TB/STD training and six hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first two years of employment.
Employee # 10 was 4/17/2010 as a part-time receptionist. This position is considered a support staff position and was required to obtain six hours of HIV/AIDS training by 4/17/2012. Employee # 10 failed to obtain the training as of the date of the inspection.
This finding was confirmed by the facility director and was not disputed.
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Plan of Correction
All staff person will complete the required HIV/AIDS training and the TB/STD training in the first two years of employment. This requirement will be included in and monitored through the individual training plan for each staff who have not yet completed the required HIV/AIDS and TB/STD training. It is noted, that employee #10, was terminated on June 3, 2012, prior to this individual completing the training requirments under this regulation. The executive director will audit personnel records on a yearly basis to ensure compliance with this requirement. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs, the facility failed to activate a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on May 14, 2012. Per regulation, the nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The fire drill log was reviewed for documentation of fire drills from the time period of May 2011 to May 2012. The facility failed set off the smoke detector or fire alarm during the fire drills. The documentation indicated the alarm was announced. The facility director was interviewed on May 14, 2012 at 12:55 p.m. She confirmed that the alarm was not being activated during fire drills. The facility staff would announce that a fire drill was taking place over the public announcement system.
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Plan of Correction
On May 14, 2012 the executive director and CEO submitted a letter to the PA Department of Health requesting an exception from activating the fire alarm during each monthly drill. If the exception is approved, then the facility will conduct its monthly drill and once a year activate the alarm to ensure it is in working order. Additionally, ARS will follow all other requirments listed within the exception, if granted. Effective in June 2012, ARS will be activating the fire alarm during monthly drills until notification is received from the PA Department of Health regarding the exception. The Health and Safety Staff Designee and Executive Director will ensure compliance with this requirement. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 review of patient records, the facility failed to document an individual treatment and rehabilitation plan as per agency policy in three of six patient records.
The findings include:
Twenty-two patient records were reviewed on May 15 through May 16, 2012. Individual treatment and rehabilitation plans were reviewed in six patient records. Per agency policy, the individualized treatment plan shall be completed within thirty days. Individualized treatment and rehabilitation plans were documented late in patient records # 2, 4, and 6.
Client # 2 was admitted to outpatient treatment on February 21, 2012. The individualized treatment and rehabilitation plan was to be completed by March 21, 2012. The individualized treatment and rehabilitation plan was completed on March 29, 2012.
Client # 4 was admitted to outpatient treatment on April 5, 2012. The individualized treatment and rehabilitation plan was to be completed by March 5, 2012. The individualized treatment and rehabilitation plan was completed on May 8, 2012
Client #6 was admitted to outpatient treatment on February 20, 2012. The individualized treatment and rehabilitation plan was to be completed by March 20, 2012. The individualized treatment and rehabilitation plan was completed on April 5, 2012
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Plan of Correction
The facility experienced some confusion with interpreting its policy regarding the 30 days completion deadline due to the date fields included on the treatment plans. The date fields included on the treatment plan include "print date", "create date", and "signature date". ARS Project Director and Facility Director will revise the policy to clarify the interpretation of these dates and timing for counselor and patient sign off as well as physician and clinical supervisor review and sign off. This policy revision will be completed prior to June 30, 2012 and submitted to the Division for review. Facility policy will be amended and interpreted to mean that treatment plans are only considered complete within the 30 day timeline after admission once they have been printed and signed by the counselor and patient prior to the 30th day after patient admission. Create date will be interpreted to be the date that the counselor started the treatment plan. Print date will continue to be interpreted as the day that the treatment plan was printed, which should be on or before the plan was signed by the patient and counselor. The clinical supervisor will maintain a spreadsheet of all new admissions in order to send reminders of due dates on a weekly basis to the clinical team. Clinical team members will be required to submit the signed treatment plan to the clinical supervisor by the due date or two days prior in order to monitor compliance. If the treatment plan is not received by the clinical supervisor by the deadline, the clinical supervisor will follow up with the counselor by giving them a notification of the chart deficiency. Treatment plan updates shall be reviewed at least every 60 days from the date the comprehensive treatment plan was executed.
The clinical supervisor will ensure continued compliance and compliance with the new policy once implemented through incorporation into the current chart audit process and through monthly reviews in supervision.
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