INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 11, 2011 through April 12, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Colonial House Inc. 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 and a plan of correction is due on May 12, 2011.
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Plan of Correction
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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
Based on a review of personnel records, staffing requirements facility summary report and a staff interview, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Nine personnel records were reviewed on April 11, 2011 through April 12, 2011. There was no documentation of HIV/AIDS or TB/STD training in one employee records and one documentation of both trainings that was completed late. Of the two, one was to have HIV/AIDS and TB/STD training within the first year of employment and the second was required to have HIV/AIDS and TB/STD training within the first two years of employment. An interview with the Project Director and Facility Director on April 12, 2011 confirmed the findings.
Employee #7 was hired March 24, 2009 and was required to have HIV/AIDS & TB/STD training by March 24, 2010. There was documentation of TB/STD being completed January 26, 2011 and HIV/AIDS completed January 25, 2011 making them 10 months late from the required completion date of March 24, 2010.
Employee #8 was hired October 1, 2008 and was required to have HIV/AIDS & TB/STD training by October 1, 2010. There was no documentation of TB/STD training in the employee's record as of April 11, 2011.
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Plan of Correction
The Director of Residential Services and CEO met to discuss findings from site visit on 4/26/11. Individual training plans were discussed paying close attention to required training topics for staff and timely completion. The Director of Residential Services will create a training needs spread sheet to track needed trainings for all staff and update immediate needs monthly. Employee #8 will be registered for the next scheduled TB/STD training that we can find. I spoke with York/Adams D&A and they are planning this training in either July or August. Colonial House will continue to look for this training to completed at an earlier date if possible. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of facility staff CPR/first aid certification cards and a interview with the Project Director and Facility Director, the facility failed to ensure that at least one person trained in CPR skills onsite during the project's hours of operation.
Findings:
Based on a review of staff schedules and staff CPR/first aid certification cards, the facility failed to ensure that the driver had an updated CPR certification card. An interview with the Project Director on April 11, 2011 confirmed that employee #9 did not have current CPR certification card.
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Plan of Correction
On 4/12/11, the CEO advised employee #9 that he was not able to drive for Colonial House until he received his CPR and 1st Aid certification. A class has been scheduled for 5/13/11. In addition, all staff who schedule client transportation were advised that no one may drive a client anywhere unless they have current CPR certification and have attended at least one 1st Aid class. The Director of Residential Services will provide an approved driver list to those staff who schedule transportation and copy will be posted in the main office. List will be reviewed monthly and updated as needed by Dir of Res Services. |
705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant inspection and a interview with the Project Director and Facility Director, the facility failed to provide bunk beds to clients that are equipped with securely attached railings.
The findings include:
The physical plant inspection took place on April 12, 2011 at around 10:30 am. During the physical plant tour it was observed that the bunk beds did not have securely attached railings. An interview with the Facility Director on April 12, 2011 at around 11 am confirmed that none of the bunk beds had railings as required. During the exit interview on April 12, 2011 the Project Director confirmed that they did not have railings attached to the bunk beds.
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Plan of Correction
The CEO ordered bed rails for the five beds that are bunked. The rails were delivered to Colonial House on 5/4/11. The maintenance manager was directed to install them immediately. In addition, the CEO communicated to the maintenance manager that only beds with rails can be bunked. The maintenance manager will monitor for compliance during his daily room checks. The CEO and Director of Residential Services will meet with the weekend staff to insure that only beds with rails are bunked. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection and an interview with the Facility Director, the facility failed to provide slip resistant surfaces in all of the bathtubs and showers.
The findings include:
A physical plant inspection was conducted on April 12, 2011. All bathtubs/showers are required to have slip resistant flooring. The facility did not provide slip resistant flooring in the showers located in the men's restroom and the women's restroom. An interview with the Facility Director on April 12, 2011 confirmed the findings.
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Plan of Correction
The CEO met with the Maintenance Manager after the inspection to advise him that shower stalls in both the men's and women's bathrooms were lacking a sufficient non skid surface. The maintenance manager installed non skid material in the showers on 4/27/11. He will monitor the showers during his regular facility inspections and has been directed to replace as needed. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 and a discussion with the Project Director and Facility Director, the facility failed to document comprehensive treatment plans after the completion of the clients' assessments in three of six client records.
The findings include:
Eight client records were reviewed on April 12, 2011. Comprehensive treatment plans can not be documented until the clients' psychosocial and psychosocial evaluations are completed. Treatment plans were required in eight client records. Client records #1, 4 and 6 contained comprehensive treatment plans that were completed before the client's psychosocial evaluations were completed. A discussion with the Project Director and Facility Director on April 12, 2011, confirmed that they were completed before the completion of the psychosocial and psychosocial evaluations.
Client #1's comprehensive treatment plan was completed on 1/18/11 and the psychosocial history and evaluation was completed on 1/21/11.
Client #4's comprehensive treatment plan was completed on 2/14/11 and the psychosocial history and evaluation was completed on 2/15/11.
Client #6's comprehensive treatment plan was completed on 12/2/10 and their psychosocial evaluation was completed on 12/3/10.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the April 5, 2010 through April 6, 2010 Licensing inspection. The facility's plan of correction submitted on May 4, 2010 and approved on May 7, 2010 stated the following:
"On 4/22/2010, the clinical supervisor conducted a staff meeting with clinical team to address the findings from site inspection. She went over the timeline for completion of paperwork. She paid particular attention to when the Biopsychosocial evaluations and treatment plans are to be completed. Treatment plans cannot predate biopsychosocial. The team must pay close attention to the dates being documented in the client records. No treatment plans are to be prepared prior to completion of the biopsych and counselor impression. The clinical supervisor will be responsible for on-going monitoring of compliance of this standard. She will continue to review all treatment plans and check to make sure the treatment is completing paperwork in the correct order and address the clinical team as needed."
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Plan of Correction
The clinical supervisor responsible for providing training to the clinical staff and insuring compliance of this standard from the previous visit was terminated from Colonial House on 4/18/11. In preparation for the site visit, it had become evident that the clinical supervisor had not been providing adequate training to her staff, as well as, supervision consistant with their experience and skill level. In addition, upon review of last year's report she had agreed to monitor compliance of this standard through review of all treatment plans. She was also the person responsible quality assurance and had indicated that all the charts current and closed were ready for inspection. Staff hired after 4/22/10, were interviwed by the Director of Residential Services to evaluate their training needs paying close attention to their understanding of how the chart is ordered and how each task needs to be completed in a certain order. She found that they were lacking sufficient knowledge to see how how each part of the chart relates back to each other.
On April 27, 2011 and again on 5/4/11, the Director of Residential Services held clinical staff meetings. Addressed at these meetings were findings from the site visit. An explanation was given to the clinical staff on how the comprehensive treatment plan goals are developed directly from the biopsychsocial evaluation and that a comprehensive treatment plan can never be developed prior to the completion of the biopsychsocial. The clinical team was also advised to date their work correctly to avoid an accidental inaccurate documentation in the client record.
The Director of Residential Services will monitor for compliance during weekly staff meetings and review of all treatment plans. |