INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 29-31, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Drug and Alcohol Rehabilitation Services- Manos House 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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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
During a licensing inspection conducted on October 29-31, 2019, the facility failed to provide documentation of counselor assistants being supervised by a full-time clinical supervisor or counselor in two of three records reviewed. The facility employed three counselors ' assistants concurrently and was providing supervision with only one Clinical Supervisor.
Employee # 6 was admitted on March 4, 2019 as a counselor assistant and was still in this position at the time of the inspection.
Employee # 8 was hired on June 3, 2019 as a counselor assistant and was still in this position at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will disseminate the supervision of counselor assistants between the Clinical Supervisor and other qualified counselors. This will ensure that each Counselor Assistant receives supervision on a one-to-one basis.
These changes will take effect on November 19, 2019.
The Program Director will meet quarterly with the Clinical Supervisor to ensure that this policy is being followed. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
During a licensing inspection conducted on October 29-31, 2019, the facility failed to provide documentation of a counselor assistant being under close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
Employee # 8 was hired a s a counselor assistant on June 3, 2019 and was still in this position at the time of the inspection. There was no documentation of supervision in the personnel record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the identification of this deficiency, the Clinical Supervisor determined a qualified counselor to provide formal, documented case review and an additional hour of direct observation by a supervising counselor once per week to focus on the development on the Counselor Assitant's clinical skills. Weekly supervision notes will demonstrate that close supervision is occurring. Weekly notes will also provide reference to charts and will demonstrate that at least one hour per week of direct observation is being completed.
These changes took effect on October 31, 2019.
The Facility Director will meet with the Clinical Supervisor quarterly to ensure this policy is followed. |
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
During a licensing inspection conducted on October 29-31, 2019, the facility failed to provide documentation of instructing all staff in the use of the fire extinguishers upon staff employment.
Employee #8 did not have documentation of being instructed in the use of the fire extinguishers upon employment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new employees of DARS, Inc. are required to complete internal trainings to ensure each employee's ability to respond appropriately to any emergency.
An Internal Training Checklist is completed within the initial 14 days of employment and is placed in the employee's training file. The staff member identified as employee #8 was missing this document from the training file. However, this checklist was completed, signed, and dated June 10, 2019. A scanned copy of this document will be submitted to DDAP for review.
The Internal Training Checklist includes "Fire Evacuation and Fire Extinguisher Procedures" Employee #8 did successfully complete the required new hire training.
Effective Nov. 12, 2019,all supervisors will ensure that the appropriate trainings have been completed and filed by reviewing each new employee's training file prior to the end of their 3 month probationary period |
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
During a licensing inspection conducted on October 29-31, 2019, the facility failed to provide documentation of ensuring that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee #8 did not have documentation of are trained to perform assigned tasks during emergencies.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new employees of DARS, Inc. are required to complete internal trainings to ensure each employee's ability to respond appropriately to any emergency.
An Internal Training Checklist is completed within the initial 14 days of employment and is placed in the employee's training file. The staff member identified as employee #8 was missing this document from the training file. However, this checklist was completed, signed, and dated June 10, 2019. A scanned copy of this document will be submitted to DDAP for review.
Effective Nov. 12, 2019,all supervisors will ensure that the appropriate trainings have been completed and filed by reviewing each new employee's training file prior to the end of their 3 month probationary period. |
709.26 (a) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(3) Supervision of staff.
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Observations
During a licensing inspection and review of policies and procedures conducted on October 29-31, 2019, the facility was unable to provide policies and procedures implementing the utilization of supervision of staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a policy and procedure pertaining to the organizational division of supervision for all staff.
This policy will indicate all DARS, Inc. employee positions and to whom each position reports as their direct supervisor. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
During a licensing inspection conducted on October 29-31, 2019, the project failed to develop and implement policies and procedures for responding to a physical assault or sexual assault by staff or a client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The following policy will be added to SOPs to reflect the procedures for addressing an incident pertaining to SOP 709.34 (a)1.
Physical Assault or Sexual Assault by Staff or Client
Incidents of physical or sexual assault by staff members or clients are regarded with the utmost importance and DARS Inc. follows a zero-tolerance policy for such incidents.
If a physical or sexual assault occurs by a staff member on a client, or an accusation of an assault is reported, the following actions will take place:
- Immediate notification, by telephone to West Hempfield Police Department
- Medical Assessment by Lancaster General Hospital
- Childline Report will be filed within 24 hours. During this time, all available information will be collected to assist with making a full report.
- Notification of the parent/guardian of the child.
- Notification of the Referring Agency (Juvenile Probation or Children and Youth Services)
- Review of all CCTV video footage to identify information related to the alleged incident. This video footage will be made available to all investigating agencies.
DARS, Inc. will fully cooperate with any investigation conducted by law enforcement, Department of Human Services, Office of Juvenile Probation, or Children and Youth Services.
Since an initial investigation may involve clear evidence of an assault, or simply an allegation of an assault, the personnel response by DARS, Inc. may include any of the following:
- Immediate termination of the employee.
- Suspension of the employee while the investigation is conducted. Based on the outcome of the investigation, the staff member may be terminated or reinstated.
- Re-assignment of the employee to a role that does not require contact with the client while the investigation is conducted.
- If the accusation made by the client is determined to have been fabricated, the staff member(s) implicated in the accusation will have the support of DARS, Inc. if they choose to file a charge against the client.
If a physical or sexual assault occurs by a client on a staff member, or an accusation of an assault is reported, the following actions will take place:
- Immediate notification, by telephone to West Hempfield Police Department
- A medical assessment provided by Lancaster General Hospital.
- Notification of the Referring Agency (Juvenile Probation and Children and Youth Services)
- Review of all CCTY video footage to identify information related to the alleged incident. This video footage will be made available to law enforcement upon request.
- The Executive Director, Treatment Director, and Clinical Supervisor will interview all staff and clients who were potential witnesses to the alleged assault.
Following an investigation by DARS, Inc. and local law enforcement, the following may occur:
If the investigation concludes that an assault did occur
- Removal of the client from the program, with coordination from JPO or CYS, and returning the client to a secure detention setting. All appropriate legal charges filed by the police dept, victim of the assault, or DARS, Inc. will ne submitted to the police and referring agency.
- Notification of the Parent/Guardian that the client will be removed from our treatment program, the child's new location, and the reasons for the removal.
If the investigation concludes that the accusation is fraudulent
- Immediate Termination of the employee who made the accusation.
- Notification of the Parent/Guardian of the outcome of the investigation and the termination of the staff member.
- A Childline report will be made to identify the Department of Human Services to inform the agency of the incident and the fraudulent nature of the staff member's accusation.
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709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
During a licensing inspection conducted on October 29-31, 2019 the project failed to develop and implement policies and procedures in responding to selling or use of illicit drugs on the premises.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A Policy and Procedure was developed by the Program Director to address SOP 709.34 (a) 2 "Selling or Use of Illicit Drugs on the Premises"
This policy is available upon request. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
During a licensing inspection conducted on October 29-31, 2019, the project failed to develop and implement policies and procedures in responding to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A policy and procedure was developed by the Program Director to address SOP 709.34 (a) 3 "Death or Serious Injury...while in Residential Treatment.
This policy is available upon request. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
During a licensing inspection conducted on October 29-31, 2019, the project failed to develop and implement policies and procedures in responding to theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A policy and procedure was developed bye the Program Director to address SOP 709.34 (a) 4 "Significant Disruption of Service...Which closes the facility for more than 1 day.
This policy is available upon request. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a licensing inspection conducted on October 29-30, 2019, the project failed to develop and implement policies and procedures in responding to an event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A policy and procedure was developed by the program Director to address SOP 709.34 (a) 6 "Emergency at the Facility Requiring the Presence of Police, Fire, or Ambulance Personnel"
This policy is available upon request. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
During a licensing inspection conducted on October 29-31, 2019, the project failed to develop and implement policies and procedures in responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A policy and procedure was developed by the Program Director to address SOP 709.34 (a) 8 "Outbreak of a Contagious Disease Requiring Centers for Disease Control (CDC) Notification".
This policy is available upon request. |