INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
report is a result of Part 1, an abbreviated off-site inspection, conducted on July 8, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, RHD Lower Merion Counseling Services 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training during the facility's July 1, 2018 through June 30, 2019 training year in one of two applicable personnel records.
Employee #4 was hired as a counselor on June 5, 2017. The personnel record documented 20.5 hours of training.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 will remain in their current position as counselor.
Employee #4 will make sure going forward to submit all completed training certificates to the Clinical Director and Quality Assurance Manager to document that training was completed.
To prevent this issue going forward, the Project Director and Quality Assurance Manager will standardized Employee Performance Evaluation Procedures and require that all Supervisors complete their direct reports annual evaluation by July 1ST.
Included in the Performance Evaluation will be an Individual Staff Development Plan that outlines the annual training goals for each employee. For Counselors, this will include the required DDAP 25 hours of training.
The Clinical Director will provide monthly supervision to Counselors and review the individual's training goals. The Clinical Director will be responsible for ensuring that the employee submits training completion certificates following the completion of training.
The Quality Assurance Manager and Assistant Regional Director will complete Quarterly Personnel File Audits to monitor training plans are being maintained.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document that all staff were instructed in the use of fire extinguishers upon employment in three of four applicable personnel records reviewed.
Employee #2 was hired as the facility director on May 26, 2020.
Employee #3 was hired as the clinical supervisor on May 4, 2020.
Employee #5 was hired as a counselor on March 23, 2020.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #2 will complete the Fire Safety and Fire Extinguisher training by July 30, 2020.
Employees #3 and #5 will complete the Fire Safety and Fire Extinguisher training by August 15, 2020.
To prevent this issue from reoccurring, all new hires will be required to take the Fire Safety Training during Week One of New Hire On-boarding Training Schedule.
The Clinical Director and Office Manager will be responsible for scheduling and monitoring that the Fire Safety training is completed within the first week of employment.
The Project Director and/or Quality Assurance Manager will be required to sign-off on all completed new hire packets and completed on-boarding training checklist.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in three of four applicable personnel records reviewed.
Employee #2 was hired as the facility director on May 26, 2020.
Employee #3 was hired as the clinical supervisor on May 4, 2020.
Employee #5 was hired as a counselor on March 23, 2020.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #2 will complete the Fire Safety training by July 30, 2020.
Employees #3 and #5 will complete the Fire Safety training by August 15, 2020.
During the Fire Safety training staff will learn how fire spreads, how to plan ahead and what steps to take in a fire emergency
Employee #2, #3, and #5 will also receive a copy of the Fire Drill Policy by August 15TH. The Fire Drill Policy provides detailed instruction on staff roles and responsibilities during fire drills.
To ensure that this doesn't occur again, all new hires will be required to take the Fire Safety Training during Week One of New Hire On-boarding Training Schedule. The Fire Drill Policy will also be included in the New Hire Employee Packet given during the first week of on-boarding.
The Project Director and/or Quality Assurance Manager will be required to sign-off on all completed new hire packets and completed on-boarding training checklist.
The Quality Assurance Manager and Assistant Regional Director will complete Quarterly Personnel File Audits to monitor required on-boarding training is being maintained.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on an administrative review of the February 2019 through June 2020 fire drill logs, the facility failed to document on the November 2019 log, the time the fire drill was conducted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On July 31, 2020 the Administrative Assistant responsible for maintaining the Fire Drill Log, updated the November 2019 to document that the fire drill was conducted at 12:00pm.
To prevent this type of deficiency from occurring again, the Project Director will be required to sign-off on the Fire Drill Log after each Drill to ensure adherence to policy procedures.
The Quality Assurance Manager will complete Quarterly Audits of the Fire Drill Log. These audits will monitor that fire drills logs contain date, time, length of drill, exit route used, number of staff and clients in the building and any problems that occurred.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document annual written individual staff performance evaluations, which shall be reviewed and signed by the employee, in two of two applicable personnel records.
Employee #4 was hired as a counselor on June 5, 2017. There was no annual performance evaluation documented in the personnel record.
Employee #7 was hired as a counselor on September 26, 2017. There was no annual performance evaluation documented in the personnel record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employees # 4 and #7 will remain in their current positions.
The Clinical Director will complete their Annual Performance Evaluation by August 31, 2020. Performance Evaluations will be collaboratively reviewed by the employee and Clinical Director. Both the Employee and Clinical Director will be required to sign the written performance evaluation. Once signed, a copy will be given to the employee and the original shall be maintained in their personnel file.
To ensure that this deficiency doesn't occur again, the Quality Assurance Manager and Project Director will standardize Employee Performance Evaluation Procedures. All Supervisors will be required to complete 90-day and 6 months performance evaluations for all newly hired employees.
Supervisors will be required to complete annual performance evaluations for their direct reports by July 1ST annually.
All supervisors will receive training on the Performance Evaluations Procedures by August 14, 2020.
A sample of personnel files will be audited quarterly by the Quality Assurance Manager to monitor the process and to alert the Project Director and Supervisors prior to employee performance evaluation due dates.
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