INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 24, 2006 and July 25, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on August 16, 2006.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
The project director does not possess a degree in chemical dependency, psychology, social work, counseling, nursing, public administration, business management or other related fields.
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Plan of Correction
On 8/10/06, the Governing Body of White Deer Run, Inc appointed an Acting Project Director/Acting Executive Director, during the interim in which a permanent Project Director/Executive Director is identified. |
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
Individual training plans are incomplete, failed to defined time frames and resources.
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Plan of Correction
The "Individual Training Plan" will be modified to include a checklist of potential trainings to be offered in the upcoming year. The QI/Staff Development Department will note on the checklist the proposed resource for training (for example, Ethics-BDAP Trainer), and the proposed time frame in which the training will be offered (for example, Summer 2007). The "Individual Training Plan" will then provide documentation of:
1. Training needs assessment
2. Identified resources in which to meet training needs
3. Proposed timeframes in which to meet those training needs
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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
The organization failed to provide documentation of the general training requirements for five support staff.
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Plan of Correction
Step 1: In an effort to resolve the deficiencies immediately the required trainings (6 hours of HIV, 4 hours of TB/STD), will be held on 3 consecutive Saturdays so that all staff and volunteers who are delinquent in completing this training will become current.
Step 2: The White Deer Run-Allenwood nurse educator, who is approved to provide trainings on CPR, First Aid, TB and other communicable diseases, HIV and Aids, will quarterly schedule through the Quality Improvement Department and facilitate trainings for staff at White Deer Run-Allenwood. Training evaluation forms will be completed and forwarded to the Quality Improvement Department by the nurse educator. Training certificates will be completed by the nurse educator and provided to all participants that complete the training. A copy of all certificates will be forwarded to both the Quality Improvement and Human Resources Departments.
Step 3: Every employee is to be provided an evaluation at the end of their first 90 days of employment at White Deer Run-Allenwood. At the time of this evaluation the training plan will be reviewed and will include documentation of the completion of all mandatory trainings. Where an exception exists, mandatory trainings will be scheduled during this evaluation session to be completed within the next 90 days. This will ensure that all mandatory trainings are completed on every employee within the first 180 days of employment.
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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
Two unit supervisors, counselors, failed to provide documentation of twenty-five hours of training for the calender year 2005.
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Plan of Correction
The 2 unit supervisors who had failed to submit transcripts to the facility management have provided the documentation necessary to prove that they have completed the required 25 hours of annual training through graduate school attendance. The following steps will be taken to ensure that such documentation is in all personnel records as required:
Step 1: At the time of the initial evaluation (90 days) the supervisor will review with the employee a list of the proposed trainings for the duration of the year. As trainings are completed, copies of certificates will be mailed to Quality Improvement and Human Resources departments. The Quality Improvement department does maintain an aggregate listing of all trainings which supervisors will consult quarterly to ensure adherence to the existing staff development policy. Supervisors will document in quarterly supervision notes the completion of trainings for the year as verified through Quality Improvement and any need for resubmission of documentation.
Step 2: At WDR, the WDR HR P&P number 501 is followed: It is the responsibility of each employee and their immediate supervisor to complete a Training Needs Assessment form upon hire and annually thereafter, and to return the documents to the QI department. The WDR/CFBHS Staff Development Technician compiles a master list of all recommended trainings to prioritize the needs of the overall training program offered by WDR/CFBHS. For those in an educational process i.e. graduate school a review of the policy for completion verification of course work will occur.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
The facility failed to provide documentation of hot food preparation at the required temperature of 140 degrees Fahrenheit.
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Plan of Correction
Immediately after the survey the director of dietary services at White Deer Run-Allenwood began documenting and maintaining records of an already existing practice, that of measuring temperature of hot foods. This information is documented at every meal and maintained in a binder in the dietary department. The documentation of cold and frozen temperatures is kept separately on cards due to requirements of other regulatory bodies. This information will be forwarded to the risk management and safety director at monthly safety committee meetings. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
There was no handrail located on the sidesteps of building #6 . Outside stairs exceeding two steps must have a secured handrail.
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Plan of Correction
The installation of a well-secured handrail was completed on Friday, July 28, 2006.
A regular monthly surveillance is completed on all 26 buildings at White Deer Run-Allenwood.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to provide and document fire extinguisher training for staff within seven days of the date of employment.
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Plan of Correction
The deficiency in this area is in part due to an omission on the orientation checklist for housekeeping, maintenance, transportation and administration. The WDR/CFBHS Forms Committee has been notified of this error. The Forms Committee is scheduled to meet on August 30, 2006, at which time the corrections will be made. The corrections will then be reviewed by the Senior Leadership and Quality Improvement Committee on September 13, 2006, and either modified, or approved for implementation. Revised forms will be distributed for use on later than September 15, 2006. Until that time all new employees will be provided fire extinguisher training by our coordinator of risk management and safety within the 7 days from the date of employment as scheduled by the facility administrative assistant. Until the actual form is revised, a handwritten entry will be made on the orientation checklist by the supervisor or designee, documenting the date the training was provided. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to provide documentation of emergency procedures training within seven days of the date of employment.
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Plan of Correction
The deficiency in this area is in part due to an omission on the orientation checklist for housekeeping, maintenance, transportation and administration. The WDR/CFBHC Forms Committee has been notified of this error. The Forms Committee is scheduled to meet on August 30, 2006, at which time the corrections will be made. The corrections will then be reviewed by the Senior Leadership and Quality Improvement Committee on September 13, 2006, and either modified, or approved for implementation. Revised forms will be distributed for use on later than September 15, 2006. Until that time all new employees will be provided emergency procedures training by our coordinator of risk management and safety within the first 7 days of employment as scheduled by the facility administrative assistant. Until the actual form is revised, a handwritten entry will be made on the orientation checklist by the supervisor or designee, documenting the date the training was provided. |