INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 13, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CORA Services, 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:
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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 the facility-submitted Staffing Requirement Facility Report and the employee personnel files, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one of five personnel records reviewed.
Employee #5 was hired as a case manager on April 23, 2019. The personnel record did not contain documentation that the HIV/AIDS training was completed at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
HIV/AIDs training has been included as part of mandatory training during new hire orientation.
Employee #5 is registered for a HIV/AIDS training for 11/18/2021.
Training plans will be reviewed with all staff quarterly and annually to ensure that mandatory trainings are completed.
The Program Administrator shall ensure that all newly hired staff receive HIV/AIDS training upon hire. The Program Administrator shall ensure that training plans are reviewed with staff quarterly and annually to ensure compliance.
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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 a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in one of four personnel records reviewed.
Employee #1 was hired as the Project Director/Facility Director on February 12, 2020. The fire extinguisher training was not completed and documented in the record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire safety training has been added to mandatory new hire training and will be implemented during orientation
Employee #1 completed fire safety training on 10/23/2021.
The Program Administrator will ensure that all newly hired staff receive fire safety training as part of their mandatory training during orientation.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's March 2020 through September 2021 fire drill logs, the facility failed to conduct an unannounced fire drill for the month of December 2020.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The maintenance and Facilities director has been made aware of DDAP findings and have adjusted their policy to include unannounced fire drill
Facility staff will also be re-trained by the Maintenance & Facility Director, with guidance from the SUD Program Administrator on DDAP regulation 705.28 (d) (1) and conducting Fire Drills once monthly.
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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 a review of the facility's March 2020 through September 2021 fire drill logs, the facility failed to identify, on their log, which exit route was used during the drills conducted in August 2020, January 2021, February 2021, and July 2021. Additionally, the facility failed to indicate on their log whether the fire alarm or smoke detector was operative during the fire drill conducted in March 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has been made aware of DDAP finding by the SUD Program Administrator and have adjusted our policy to include exit-route taken during the drill
The Facilities department also adjusted our policy to include a documentation of the status of the smoke alarm during a drill
Facility staff will be re-trained on DDAP regulation 705.28 (d) (4) by the Maintenance & Facility Director with guidance from the SD Program Administrator on conducting Fire Drills and procedures for maintaining a written fire drill record.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility ' s March 2020 through September 2020 fire drill logs, the facility failed to set off a fire alarm or smoke detector during the March 2020 fire drill.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The maintenance and facility director has been made aware by the SUD Program Administrator of DDAP finding and have adjusted their policy to include activating fire alarm or setting off smoke detector to trigger the alarm
Facility staff will be re-trained on DDAP regulation 705.28 (d) (7) and procedures for conducting Fire Drills once monthly by the Maintenance & Facility Director with guidance from the SUD Program Administrator.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in one of seven client records reviewed.
Client #3 was admitted on March 25, 2021 and was active at the time of inspection. The comprehensive treatment plan was completed on June 4, 2021; however, the facility's policy and procedure manual stated that the facility is to complete the client's comprehensive treatment plan within 30 days of the client's admission to the facility.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor will continue to train staff on writing effective treatment plan and frequency of plan.
Treatment plan procedures will be reviewed with newly hired staff during their orientation documentation training and monthly during individual supervision
Routine and regular file reviews will be conducted to ensure that all treatment plans are completed in accordance with facility policy and with DDAP regulation 709.24 (a) (3).
We recently transition all our service delivery process into Electronic Health Record (MyEvolv) and appropriate triggers and reminders have been set to trigger plan review during the appropriate time.
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client #3 was admitted on March 25, 2021 and was active at the time of inspection. There was evidence of disclosures to the funding source on March 25, 2021, April 1, 2021, April 8, 2021, April 16, 2021, April 23, 2021, June 4, 2021, and June 10, 2021; however, the consent to release information form to the funding source was not signed and date by the client until June 14, 2021.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our Electronic Health Record (MyEvolv) has security protocols instituted that will not allow client information disclosure without the signed appropriate consent in the system.
All staff are trained on E.H.R by the Data Dept. Project Manager and are able to perform their task and process appropriate consent in the system
Routine and regular client chart reviews will be conducted by the Program Administrator to ensure that all informed and voluntary consent forms are completed in accordance with facility policy and DDAP regulation 709.28 (c).
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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of the facility's unusual incident report log, the facility failed to file a written unusual incident report with the Department within three business days following an incident involving the off-site death of a client.
On April 1, 2020, the facility was notified of the off-site death of a client; however, there was no documentation that the incident was reported to the Department as of the date of the inspection.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Incident Report Policy has been modified to include regulation 709.34 (c), (2): Reporting of unusual incidents.
Incident management and report procedure has been reviewed with all staff individually by their supervisor and will continue to be addressed during supervision
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