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 6-7, 2013 licensure renewal inspection. The follow-up inspection was conducted on January 7, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, The Consortium 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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704.11(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 and training records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in tweleve personnel and training records reviewed.
The findings include:
Personnel records were reviewed January 7, 2014.
Employee # 5 was hired July 19, 2011. This employee was required to obtain four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 6 was hired December 9, 2004. This employee was required to obtain four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 7 was hired May 15, 2008. This employee was required to obtain four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 8 was hired July 28, 1983. This employee was required to obtain four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 9 was hired December 8, 2008. This employee was required to obtain six hours of HIV/AIDS and four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 10 was hired May 28, 1996. This employee was required to obtain six hours of HIV/AIDS and four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 11 was hired April 15, 2007. This employee was required to obtain four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 12 was hired August 14, 2009. This employee was required to obtain four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 13 was hired September 1, 2009. This employee was required to obtain six hours of HIV/AIDS and four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 14 was hired September 14, 2009. This employee was required to obtain six hours of HIV/AIDS and four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 15 was hired September 14, 2009. This employee was required to obtain six hours of HIV/AIDS and four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 16 was hired September 14, 2009. This employee was required to obtain four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
This is a repeat citation. The facility was cited on August 7, 2013 and April 3, 2013, for noncompliance with this regulation.
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Plan of Correction
Responsible Party(s): The assigned Supervisor is responsible for ensuring that their corresponding staff receive TB/STD and HIV/AIDS training within the required timeframes.
Employees 5,6,7,8,11,12,and 16 will be scheduled for the next available TB/STD training.
Employees 9,10,13,14,and 15 will be scheduled for the next TB/STD and HIV/AIDS trainings.
Due to high number of persons in need of the training, the Director will also attempt to schedule on site trainings for both HIV/AIDS and TB/STD training to ensure compliance with this standard.
Timeframe for completion: Staff in need of the training will be scheduled for trainings by 3/31/14.
On site training will be requested by 3/31/14.
Monitoring: Supervisors will review each employee's annual training plans with their respective staff once per month, to ensure that all staff receive trainings within the required timeframes. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to provide fire extinguisher training upon employment for three new staff.
The findings include:
Personnel records were reviewed January 7, 2014 for verification that staff had been instructed in the use of a fire extinguisher upon employment..
Three employees were hired since August 2013 and required fire extinguisher training upon hire. Training was documented as completed but not upon hire as designated by regulation.
This is a repeat citation. The facility was cited on August 7, 2013, April 3, 2013, November 16, 2012, December 14, 2011, June 6, 2012 and October 15, 2010 for noncompliance with this regulation.
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Plan of Correction
Responsible Party(s):
Supervisors, in collaboration with the Training Department is responsible for ensuring that all staff receives training in the use of fire extinguishers upon employment.
Timeframe:
Any staff hired, who has not received fire extinguisher training, will receive training by 3/31/14.
Monitoring:
The Training Department will ensure that all new staff receive the fire extinguisher training during the first week of onsite orientation training. Acknowledgment of receipt of the training will be filed in the personnel record.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed to document emergency task performance training upon employment for three new staff.
The findings include:
Personnel records were reviewed January 7, 2014 for verification that staff had been instructed for emergency task performance upon employment..
Three employees were hired since August 2013 and required emergency task performance training upon hire. Both received the training but not upon hire as designated by regulation.
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Plan of Correction
Responsible Party(s): Supervisors, in collaboration with the Training Department is responsible for ensuring that all staff receives training in emergency task performance upon employment.
Timeframe: Any staff hired, who has not received emergency task performance training, will receive training by 3/31/14.
Monitoring: The Training Department will ensure that all new staff receive the emergency task performance training during the first week of onsite orientation training.
Acknowledgment of receipt of the training will be filed in the personnel record. |
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 failed to ensure a psychosocial evaluation was documented as required in ten of ten client records.
The findings include:
Ten client records were reviewed for psychosocial evaluations January 7, 2014.
Client records # 2, 4,5, 6, 8, 9 and 10 did not contain a documented psychosocial evaluation.
Client records # 1, 3 and 7 failed to evaluate and assess the historical data collected.
This is a repeat citation. The facility was cited on August 7, 2013, April 3, 2013, November 16, 2012, June 6, 2012, December 14, 2011, August 29, 2011, October 15, 2010, November 18, 2009 and November 7, 2008 for noncompliance with this regulation.
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Plan of Correction
Responsible Party:
The Clinical Counseling staff is responsible for ensuring that patient records include a comprehensive psychosocial history and evaluation within 30 days of treatment that satisfies all components identified in the agency's policy.
Timeframe: Records # 2, 4,5, 6, 8, 9 and 10 will have a completed psychosocial evaluation in the record by 4/15/14.
Records 1,3 and 7 will have an updated evaluation completed to include an evaluation and assessment of the historical data collected by 4/15/14.
Monitoring: Clinical Supervisors will provide bi-weekly supervision notating review of psychosocial evaluation completion within the required 30 day time frame, as well as ensuring all required components of the bio psycho social are present and are evaluative.
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