INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the August 18-20, 2009 licensure renewal inspection. The follow-up inspection was conducted on March 17, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Addiction Medicine and Health Advocate, 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 April 13, 2010.
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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, the facility failed to document a minimum of 6 hours of HIV/AIDS training in one of six personnel records.
The findings include:
Six personnel records were reviewed on March 17, 2010. Of those six, three were required to have documentation of 6 hours HIV/AIDS training. The facility failed to document 6 hours of HIV/AIDS training in personnel record #6. The Clinical Supervisor was interviewed and it was reported that employee #6 would be scheduled for training April 2010.
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Plan of Correction
Employee #6 has been scheduled for the required HIV/AIDS training on 4/8/2010. Documentation of the completed training will be placed in his personnel file by the Staff Development Coordinator. The Staff Development Coordinator will develop an annual training plan for each employee. This plan will include the required HIV/AIDS and TB/STD training for all new counselors and counselor assistants during their first year of employment at AMHA and within the first 2 years of employment for all other staff. The Clinical Coordinator will be responsible for overall staff compliance with the training plans. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant tour on March 17, 2010, the storage room included a heater that was not permanently mounted or installed.
The findings include:
While conducting the facility plant tour on March 17, 2010, a heater that was not permanently mounted or installed was observed in the storage room of the facility.
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Plan of Correction
The portable space heater has been removed from the facility. Supervisory staff will monitor all offices and storage areas in the clinic and report findings to the Health and Safety Committee. The Clinical Coordinator will be responsible for monitoring future compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility completed the documentation of psychosocial evaluations before completing the historical information relative to the clients ' personal histories, medical histories and drug and alcohol use/abuse histories in three of eight client records.
The findings include:
Eight client records were reviewed on March 10, 2010. Psychosocial evaluations; which are to be based in part on the collected historical information in order to identify possible relationships, conditions and causes leading to the client ' s current situation; were completed prior to obtaining and documenting that historical information in nine of the client records reviewed.
Client record # 1 - The client was admitted on 1/27/10. The psychosocial evaluation was completed on 2/21/10. The personal history, medical history and drug and alcohol use/abuse history was not completed until 2/24/10.
Client record # 3 - The client was admitted on 11/24/09. The psychosocial evaluation was completed on 12/14/09. The personal history, medical history and drug and alcohol use/abuse history was not completed until 12/31/09.
Client record # 4 - The client was admitted on 12/7/09. The psychosocial evaluation was completed on 12/22/09. The personal history, medical history and drug and alcohol use/abuse history was not completed until 12/28/09.
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Plan of Correction
A staff meeting/training has been scheduled for 4/1/2010 to address the findings identified. The facility policy and procedure related to proper and timely completion of the biopsychosocial history and subsequent biopsychosocial evaluation will be reviewed. New patient records will be reviewed during individual supervision sessions with counselors and during monthly quality record reviews to monitor compliance. The two clinical supervisors, including the Clinical Coordinator, will be responsible for monitoring compliance with AMHA's policy and procedure. |