INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17-18, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Resources for Human Development 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(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of the facility's policy manual, the facility failed to develop a comprehensive staff development program for agency personnel.
The findings include:
The facility's policy manual was reviewed on July 17, 2012, for documentation of a comprehensive staff development program. The facility did not document a staff development program that included policies and procedures with time frames for completion of the following components:
(1) An overall plan for addressing staff training needs
(2) An annual evaluation of the overall training plan
An interview with the facility director on July 17, 2012 confirmed the findings.
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Plan of Correction
A comprehensive training plan will be developed for the overall program by the Program Director each spring. This plan will be annually evaluated by the program director each spring prior to the new training year's plan creation. The plan will address areas of concentration for training of staff at the program and include the specific mode/method by which the training will occur. The annual evaluation will outline how the goals of the training plan were achieved and how/when they occurred. To correct the citation from this year's inspection, a Training Plan for the 2012-2013 training year will be completed by August 31st by the Program Director. The Program Director will be responsible to ensure this standard continues to be met. The policy manual will be updated to reflect these procedures and the governing body will sign-off and approve all changes to the policy manual July 1st of 2013 when they convine to review the policy and procedure manaual. |
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 the review of personnel records, the facility failed to document an individual training plan for each employee.
The findings include:
Six personnel records requiring documentation an individual training plan were reviewed on July 17, 2012, specifically records # 1, 2, 3, 4, 5 and 6. The facility failed to document an individual training plan for personnel #s 2, 4 and 5.
Employee # 2 was hired on 12/1/10. Employee # 2's personnel record did not contain a training plan for the 2012-2013 training year.
Employee # 4 was hired on 1/3/11. Employee # 4's personnel record did not contain a training plan for the 2012-2013 training year.
Employee # 5 was hired on 1/3/11. Employee # 5's personnel record did not contain a training plan for the 2012-2013 training year.
An interview with the facility director on July 17, 2012 confirmed the findings.
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Plan of Correction
A written individual training plan will be developed for each employee as a part of their annual review with their supervisor to take place in the spring. The plan will include areas of training needed to address the needs of the employee in their role. The plan will be developed with input from the employee and the supervisor. It will include specific areas of training, the mode/method by which the training will take place and the resources available for obtaining the training. To correct the citation from this year's inspection, an individual training plan will be created by each employee and supervisor by September 30th. The Program Director will be responsible to ensure this takes place by the date indicated. The Program Director will be responsible to ensure this standard continues to be met. |
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 the review of personnel records, the facility failed to document that all personnel were trained to perform assigned task during emergencies.
The findings include:
Nine personnel records were reviewed on July 17, 2012 for documentation of emergency training. The facility did not document that emergency training was provided to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. Seven out of nine records reviewed contained documentation where the employee had not been trained anywhere form one month to seven months following their start of employment, specifically, personnel records # 2, 3, 4, 5, 6, 7, 8, 9 and 10.
Employee # 2 was hired on 12/1/10, but verification of emergency training was not documented at the time of review on 7/17/12.
Employee # 3 was hired on 1/3/11, but verification of emergency training was not documented until 7/11/12.
Employee # 4 was hired on 1/3/11, but verification of emergency training was not documented until 7/11/12.
Employee # 5 was hired on 1/3/11, but verification of emergency training was not documented until 7/11/12.
Employee # 6 was hired on 2/17/11, but verification of emergency training was not documented until 7/11/12.
Employee # 7 was hired on 4/18/11, but verification of emergency training was not documented until 7/11/12.
Employee # 8 was hired on 4/11/12, but verification of emergency training was not documented until 7/11/12.
Employee # 9 was hired on 6/6/12, but verification of emergency training was not documented at the time of review on 7/17/12.
Employee # 10 was hired on 4/4/11, but verification of emergency training was not documented until 7/11/12.
An interview with the facility director on July 18, 2012 confirmed the findings.
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Plan of Correction
Fire Safety training will take place at new-hire orientation and documented. The training will include a fire safety video, training on the program's emergency policy/procedures as well as training on how to operate a fire extinguisher and the locations at the program. The Assistant Director will be responsible to ensuring this training takes place at new-hire orientation. The change in this policy was made on 7/22/12. On-going confirmation this policy is carried out will be the responsibility of the Assistant Director. All current staff have received this training to ensure they are aware of the programs policy and procedures. This occurred by 7/31/12 and was overseen by the Program Director. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client records and the client handbook, the facility failed to inform clients of their rights.
The findings include:
The client handbook and seven client records were reviewed on July 18, 2012. The facility did not document a complete list of client rights in the client handbook or on the client rights sign-off form in records # 2, 3, 4, 5 and 6.
The facility did not inform the clients of the following rights:
(1) A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
(2) The client has the right to appeal a decision limiting access to his records to the project director.
(3) The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
(4) The client has the right to submit rebuttal data or memoranda to his own records.
An interview with the facility director on July 18, 2012 confirmed the findings.
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Plan of Correction
The client handbook will be updated by Program Director to include the following rights of clients: the right to inspect his/her own record, the right to appeal a decision limiting access to his/her record, the right to request the correction of inaccurate, irrelevant, outdated or incomplete information, and the right to submit rebuttal data. This information will be added to the client handbook by the Program Director by August 31st. The Program Director will be responsible to ensure this standard continues to be met. |
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 the review of client records, the facility failed to document an individual treatment and rehabilitation plan within 30 days from intake.
The findings include:
Five client records requiring a treatment and rehabilitation plan were reviewed on July 18, 2012, specifically records # 2, 3, 4, 5 and 6. The facility did not document an individual treatment and rehabilitation plan within 30 days from intake, as per facility policy in records # 2, 4, 5 and 6.
Client # 2 was admitted on 4/16/12, but the treatment and rehabilitation plan in client # 2 ' s record was dated 5/31/12.
Client # 4 was admitted on 1/10/12, but the treatment and rehabilitation plan in client # 4 ' s record was dated 2/14/12.
Client # 5 was admitted on 1/10/12, but the treatment and rehabilitation plan in client # 5 ' s record was dated 3/6/12.
Client # 6 was admitted on 1/12/12, but the treatment and rehabilitation plan in client # 6 ' s record was dated 3/7/12.
An interview with the facility director on July 18, 2012 confirmed the findings.
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Plan of Correction
An individual treatment plan will be created within the first 30 days of treatment or by the 4th session attended by the client (whichever comes first). The individual treatment plan will be created by the client and the assigned therapist. The Assistant Director will be responsible for ensuring this standard is met by conducting random audits of client charts on a weekly basis. Specifically, 3 charts will be selected from each therapist's case load by the Assistant Director who will review the treatment planning and ensure that the policy and procedure is being met. This correction will take place as of August 31st as confirmed by the Assistant Director. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document treatment plans that included type and frequency of treatment and rehabilitation services.
The findings include:
On July 18, 2012, treatment plans in five client records were reviewed for documentation type and frequency of treatment and rehabilitation services, specifically in records # 2, 3, 4, 5 and 6. The facility did not document treatment plans to include type and frequency of treatment and rehabilitation services in client records # 2, 3, 4, 5 and 6.
Client # 2 was admitted on 4/16/12. The treatment and rehabilitation plan in client # 2 ' s record dated 5/31/12 did not include type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on 3/26/12. The treatment and rehabilitation plan in client # 3 ' s record dated 4/25/12 did not include type and frequency of treatment and rehabilitation services.
Client # 4 was admitted on 1/10/12. The treatment and rehabilitation plan in client # 4 ' s record dated 2/14/12 did not include type and frequency of treatment and rehabilitation services.
Client # 5 was admitted on 1/10/12. The treatment and rehabilitation plan in client # 5 ' s record dated 3/6/12 did not include type and frequency of treatment and rehabilitation services.
Client # 6 was admitted on 1/12/12. The treatment and rehabilitation plan in client # 6 ' s record dated 3/7/12 did not include type and frequency of treatment and rehabilitation services.
An interview with the facility director on July 18, 2012 confirmed the findings.
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Plan of Correction
Documentation included in treatment plans will include type and frequency of treatment and rehabilitation services in client. These will be listed with specificity. The correction will be made by August 31st by the Program Director. Training will occur with all staff by this date. Training will be led by both Program Director and Assistant Director. Continued oversight by the Assistant Director will ensure compliance by conducting random audits of client charts on a weekly basis. Specifically, 3 charts will be selected from each therapist's case load by the Assistant Director who will review the treatment planning and ensure that the policy and procedure is being met. |