INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 14, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital 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 an interview with the facility director, the facility failed to document an overall plan for addressing assessment of staff training needs and an annual evaluation of the overall training plan.
The findings include:
On November 14, 2013, the Licensing asked to see the facility's overall plan for addressing assessment of staff training needs and an annual evaluation of the overall training plan. An overall plan for addressing assessment of staff training needs and an annual evaluation of the overall training plan was not presented for review.
The findings were confirmed during an interview with the facility director on November 14, 2013 at approximately 2:30 P.M.
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Plan of Correction
Kensington Hospital's overall plan for addressing assessment of staff training needs, as well as, an annual evaluation of the overall training plan will be done every January for the previous year's activities. This will be completed by January 30th each year and will be the responsibility of the Director of Behavioral Health Services. The Chief Executive Officer will assure compliance is maintained by receiving and maintaining a copy of the Plan for addressing staff training assessments, as well as, the Annual Evaluation of the overall Training Plan by January 30th each year. |
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 a personnel record, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of STD/TB training and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff from a Department approved curriculum in one of one personnel record reviewed.
The findings include:
On November 14, 2013, one personnel record was reviewed to verify that employees had received a minimum of 6 hours of HIV/AIDS and at least 4 hours of STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff using a Department approved curriculum. The facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff from a Department approved curriculum in one of one personnel record reviewed, specifically, personnel record # 3.
Employee # 3 is a counselor and was hired September 4, 2012. Employee # 3 was due to complete a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training from a Department approved curriculum by September 4, 2013. Personnel record # 3 included documentation of HIV/AIDS and STD/TB training for employee # 3. However, the HIV/AIDS and STD/TB training for employee # 3 was not from a Department approved curriculum.
The findings were confirmed during an interview with the facility director on November 14, 2013 at approximately 2:30 P.M.
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Plan of Correction
All Clinical Staff will receive a minimum of 6 hours of HIV/AIDS training and at least 4 hours of STD/TB training and other health related topics with in the first year of employment and within 2 years of employment for non-clinical staff. Therefore, an educational training for both trainings will be scheduled by 12/30/13 for staff members needing the training. The Director of Behavioral Health will be responsible to assure continued compliance by reviewing each staff member's educational profile in order to determine if they lack this particular training. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that a project director and facility director completed 12 clock hours of required training in one of two personnel records reviewed.
The findings include:
On November 14, 2013, two personnel records requiring documentation of 12 clock hours of training were reviewed. The facility failed to provide documentation of 12 clock hours of training in one of two personnel records reviewed, specifically, personnel record # 2.
Employee # 2 is the facility director and was hired in 2011. Employee # 2 was required to complete 12 clock hours of annual training hours by December 31, 2012. However, personnel record # 2 only had documentation of 6 clock hours of annual training for the January 1, 2012 to December 31, 2012 training year as of November 14, 2013.
The findings were confirmed during an interview with the facility director on November 14, 2013 at approximately 2:30 P.M.
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Plan of Correction
A meeting was held on 11/27/13 between the CEO and the Director of Behavioral Health Services to review the Director's annual training plan hours. Arrangements have been made for the Director to complete the required training hours (12) by the end of the year. The Chief Executive Officer is responsible for continued compliance by reviewing the Director of Behavioral Health's training hours quarterly to assure continued compliance. |
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 25 clock hours of required training in one of one personnel record reviewed.
The findings include:
On November 14, 2013, one personnel record requiring documentation of 25 clock hours of training was reviewed. The facility failed to provide documentation of 25 clock hours of training in one of one personnel record reviewed, specifically, personnel record # 4.
Employee # 4 is a counselor and was hired January 3, 2007. Employee # 4 was required to complete 25 clock hours of annual training hours by December 31, 2012. However, personnel record # 4 did not include documentation of annual training hours for the January 1, 2012 to December 31, 2012 training year as of November 14, 2013.
The findings were confirmed during an interview with the facility director on November 14, 2013 at approximately 2:30 P.M.
This is a repeat citation. The facility was cited on September 25, 2012 for noncompliance with this standard.
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Plan of Correction
The Director of Behavioral Health Services will meet with each Counselor quarterly in order to determine the number of hours completed thus far from their Training Plan in order to assure they are on target to complete the required number of training hours (25) by the end of year. The Director of Behavioral Health will be responsible to assure continued compliance by conducting these monthly meetings with each Counselor. |
711.14(b)(5) LICENSURE Subchapter B.Approval Procedures.Restrictions
711.14. Restrictions on certificate of compliance.
(b) Utilizing appropriate Department forms, the holder of a certificate shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on observations on November 14, 2013, the facility failed to notify the Department within 90 days of the occurrence of a change in the authorized maximum capacity of beds for the clients.
The findings include:
A physical plant inspection was conducted on November 14, 2013. The facility's authorized maximum capacity for Inpatient Hospital Detoxification beds to the number of clients is 29. Therefore, the facility was required to have 29 beds for Inpatient Hospital Detoxification patients. However, based on observations from approximately 3:16 P.M. to 3:45 P.M., the total number of beds for Inpatient Hospital Detoxification clients was 28. The facility decreased their authorized maximum capacity for the Inpatient Hospital Detoxification licensed activity by 1 bed.
The findings were confirmed during an interview with the medical staff and maintenance staff on November 14, 2013 at approximately 3:45 P.M.
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Plan of Correction
One (1) bed was off the floor for repair. The bed will be back in service by 1/30/14. |