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.This report is a result of Part 1, an abbreviated off-site inspection, conducted on August 19, 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, Kensington Hospital Outpatient Treatment Program, 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on an administrative review of the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that a full-time clinical supervisor was employed for every eight full-time counselors. The facility's counselor Full Time Equivalent (FTE) equated to 9.4 counselors. The FTE calculation for the number of clinical supervisors needed is as follows:The total # of hours project-wide devoted to D&A clients divided by the project's standard workweek, or 353.5 hours / 37.5 hours = 9.4 FTEBased on the calculation, the project is required to have at least one full-time clinical supervisor on staff and based on the facility-submitted SRFSR, the facility does not employ a full-time clinical supervisor.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective, 9/20/2020, Kensington Hospital's Nursing Supervisor has been assigned the duties of the Facility Director of the Outpatient Treatment Program on a part-time basis.
The Nursing Supervisor is a BSN graduating from the College of Saint Francis in December 1996 and has 36 years experience in the Behavioral Health field. A Job Description has been developed and signed by the employee for the position of Facilities Director.
The current full-time Clinical Supervisor will remain in her position to ensure supervision for eight full-time counselors.
In order to assure continued compliance with the proper Staffing Requirements the Executive Assistant is responsible for the proper completion of the Staffing Requirement Summary Report at time of all future DDAP inspections. The Staffing Requirement Facility Summary Report (SRFSR) form, will be reviewed by the Hospital's CEO prior to submission to DDAP for all future surveys.
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704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's comprehensive staff development program, the facility failed to document an overall plan for addressing the staff training needs for the 2020 training year.The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
A comprehensive Overall Training Plan has since been developed by the Hospital's Employee Educator on 8/26/2020. The Overall Training Plan now addresses the Agency staff's training needs for the 2020 Training Year.
The Overall Training Plan now includes:
1) New Hire Training (for all employees, including Department specific Policies & Procedures, 2) New Hire Training (for the Nursing Staff) 3) Annual Mandatory Training (for all employees including updates/revision to any Department specific Policies & Procedures & 4)
On-going Performance Improvement Education and Re-Education.
The Overall Training Plan will now be used by the Employee Educator for all new hires, mandated annual trainings, as well as on-going Performance Improvement Education and Re-Education.
In order to assure continued compliance of a comprehensive Overall Training Plan, the Overall Training Plan will be reviewed by the Hospital's Employee Educator on a yearly basis by 1/31 of the new year to assure the Overall Training Plan has been updated/revised with any added trainings. The Executive Assistant will be responsible to assure the Overall Training Plan has been updated/revised each year by 1/31.
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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 a review of personnel records, the facility failed to document an annual written individual training plan, with input from both the employee and the supervisor in one of four personnel records reviewed. Employee #1 was hired on November 8, 2016 and was still employed at the time of the inspection. A training plan for this employee was completed on January 23, 2020; however, there was no documentation that this training plan was developed with input from both the employee and supervisor as plan was only signed by the employee.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1's Training Plan was developed with input from both the employee and supervisor, however, Supervisor was off site and did not sign the Training Plan. On 8/20/2020, the Training Plan was signed by Employee #1's Supervisor.
In order to assure continued compliance, the Executive Assistant will be responsible to assure that the Training Plans submitted for the new Training Year (by 1/31) are complete with Employee's Signature and Date and the Supervisor's Signature and Date before they are filed.
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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 November 2019 through July 2020 fire drill logs, the facility failed to include the exit route used on every fire drill log conducted. These findings were reviewed with facility staff during the licensing processThis is a repeat citation from the November 5, 2019 licensing inspection.
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Plan of Correction
The Fire Drill log has been revised to include the exit route used. The form was revised on 8/20/2020 by the Executive Assistant and was forwarded to the Hospital's Fire Drill representative for use.
In order to assure continued compliance, the Safety Officer, will monitor that the submitted monthly fire drill log is completed on the proper form (which now includes the exit route used by staff). This review will be reported to the Safety Committee on a bi-monthly basis for the next six (6) months to assure continued compliance.
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