INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 14-16, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Services of Beaver Valley, 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 January 11, 2009.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of employee personnel and training records, and an interview with the project director, the facility failed to document monthly supervisory sessions for each new supervisor for the first six months of employment.
The findings include:
Seven personnel records were reviewed on December 15, 2009. One personnel record reviewed was that of the current clinical supervisor who was hired for that position on August 3, 2009. Documentation of monthly supervision is required for all newly hired clinical supervisors for the first six months of employment in that position. The facility did not document monthly supervision notes in personnel record #2.
An interview with the project director took place on December 16, 2009 at 11:05 AM and it was confirmed that monthly supervision between the project director and clinical supervisor was not documented.
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Plan of Correction
In order to correct this deficiency, documentation of monthly meetings started immediately (12-17-09). In addition to individual meetings, the Executive Director documented guidance given to the Clinical Supervisor in Supervisor's Meetings. The Executive Director will complete six monthly meetings with the Clinical Supervisor before assessing the frequency of future supervisory meetings. |
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 personnel records, CPR/first aid certification cards and an interview with the project director, the facility did not document that a sufficient number of staff persons were trained in CPR and first aid.
The findings include:
Ten personnel records and employee CPR/first aid certification cards were reviewed on December 15, 2009. Three of the personnel records reviewed were that of facility drivers who transport clients to and from the facility. Two of three driver personnel records did not document current CPR/First Aid certification. Personnel records # 9 and 10 did not include documentation of current CPR/First Aid certification.
Employee # 9 was hired on September 24, 2009.
Employee # 10 was hired on May 7, 2007.
An interview with the project director took place on December 15, 2009 and it was confirmed that no current CPR/First Aid could be provided for the drivers.
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Plan of Correction
Drug & Alcohol Services currently gives all employees a Monthly Training Report of hours required and how many each person needs to meet yearly goals. In order to correct this deficiency, all mandated training will be listed on this report with the dates training needs to be completed. The Director of Planning & Development is responsible for personnel records and will be responsible for monitoring training needs and helping to schedule required trainings, in a timely manner. The two drivers who were not in compliance have been scheduled for training on January 19, 2010. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of the fiscal audit for July 1, 2007 through June 30, 2008, the project failed to complete the fiscal audit as stated in the policy and procedure manual, by the end of the project's fiscal year.
The findings include:
A review of the annual audit was conducted on December 14, 2009. The project's audit for July 1, 2007 through June 30, 2008 was due to be completed no later than December 30, 2008. The project's audit was not completed until May 1, 2009.
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Plan of Correction
In order to correct this deficiency the Executive Director will contact the accounting firm and inform them that our annual audit will need to be scheduled in July instead of November. This audit was completed June 30, 2008. Contact will be made by December 31, 2009. The Executive Director is responsible for contacting the auditors and scheduling the annual audit. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records and an interview with the project director and clinical supervisor, the facility failed to document treatment plan review and updates within sixty days, in five of five client records.
The findings include:
Twelve client records were reviewed on December 15-16, 2009. Five client records required treatment plan review and updates due to their length of treatment. Per the facility policy, treatment plan review and updates are required to be completed every sixty days. The facility failed to document treatment plan review and updates within sixty days, in client records # 3, 8, 10, 11 and 12.
In client record # 3, the client was admitted on September 21, 2009. The comprehensive treatment plan was completed on September 21, 2009. The first treatment plan update was due no later than November 21, 2009 and was not completed until December 1, 2009.
In client record # 8, the client was admitted on September 17, 2009. The comprehensive treatment plan was completed on September 17, 2009. The first treatment plan update was due no later than November 17, 2009 and was completed on December 3, 2009.
In client record # 10, the client was admitted on September 23, 2009. The comprehensive treatment plan was completed on September 30, 2009. The first treatment plan update was due no later than November 30, 2009 and was completed on December 8, 2009.
In client record # 11, the client was admitted on October 8, 2009. The comprehensive treatment plan was completed on October 14, 2009. The first treatment plan update was due no later than December 14, 2009. There was no documentation of a treatment plan update.
In client record # 12, the client was admitted on September 18, 2009. The comprehensive treatment plan was completed on October 5, 2009. The first treatment plan update was due no later than December 5, 2009 and was completed on December 16, 2009.
The clinical supervisor and project director confirmed the treatment plan updates were not completed within the 60 day timeframe.
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Plan of Correction
In order to correct this deficiency the Clinical Supervisor will develop a memo to all therapists advising them of this deficiency. This memo will be completed and distributed by 12-23-09. This memo will have a directive for all therapists to review all of their charts to ensure they are in compliance by 1-6-10. The Clinical Supervisor will meet with each therapist by 1-8-10 to re-enforce training on meeting the 60 day timeframe. The Clinical Supervisor will monitor 60 day treatment plan updates by using a Chart Review Form. Reviews will be ongoing. The Clinical Supervisor will complete written counseling statements to therapists who continue to have difficulty with this standard. |