INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on January 19, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Treatment trends, Inc. (keenan 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of employee training records, that the facility failed to assure that each employee received a written individual training plan in one of six personnel records.
The findings include;
A review of six employee training records on January 20, 2012, specifically #1, 2, 3, 4, 5, and 6, revealed that the individual training plan was not completed in personnel record # 1. Personnel #1 was hired in 7-1-1983. The last documented training plan was November 2010.
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Plan of Correction
The following will occur to ameliorate the exclusion of employee #1 from having a completed training placed in #1's personel file. The Chairman of the Board of Directors will complete an evaluation of Employee #1 by March 6, 2012. This will be done annually moving forward. The Chairman of the Board has been informed of the licensing requirements of BDAP and will adhere to them. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on observation of outside trash containers, the facility failed to store trash in covered containers.
The findings include:
During a physical plant inspection on January 20th, 2012, an inspection of the trash area revealed the facility failed to maintain the trash in covered containers on two of two dumpsters. The trash dumpsters were located outside the facility on the side of the Keenan House building.
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Plan of Correction
All health and safety regulations are a TTI priority. Code violation, 705.2(4) will be addressed by 2/8/2012 in the following manner:
The Quality Assurance Manager will meet with the emplyees of TTI who serve in the kitchen and clients with duties pertaining to trash removal by 2/8/2012, to educate them on the helath code and the importance of keeping trash containers covered. Dumpsters located outside of the facility will be checked after trash removal from the building by the Quality Assurance Manager and TTI kitchen Staff throughout the day. Further, the waste removal company has been contacted and they have agreed to close the dumpster lids when replacing the dumpsters at the collection site. This item will be discussed at the next two TTI quarterly Health and Safety commitee meetings to ensure administrators onsite at Keenan House, oversight administrators from TTI and client's responsible for trash removal from the building are following the proper protocol. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel files and administrative policies and procedures, the facility failed to document annual performance reviews in one of six personnel records.
The findings include:
Six personnel files were reviewed on January 20, 2012. The annual performance evaluation was not evaluated since November 2010 in file #1. Personnel #1 was hired on 7-1-1983 as Project Director.
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Plan of Correction
Since November of 2010, Employee #1 had not had and annual performance evaluation which is in violation of standard 709.26(d)(s)(i). By March 6, 2012, the Chairman of the Board of Directors will complete an evaluataion of Employee #1. This will be done annually from here forward. The Chairman of the Board has been informed of the licensing requirements of BDAP and will adhere to them. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a client record review, the facility failed to have a current psychosocial evaluation included in the client record in one of one client record.
The findings include:
Eleven client records were reviewed on January 20, 2012. One record was reviewed for a readmission to the facility. Client record #1 was initally admitted into treatment in January 2011 and discharged in April 2011. The client was a re-admit on August 18, 2011. The review of client # 1's record revealed that the previous psychosocial evaluation was included in the client record with no documentation of a new psychosocial evaluation, completed at the time of the client's second admission on August 18, 2012.
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Plan of Correction
One client record was in violation of 709.51(b)(6)due to staff failure to complete a new psycosocial evaluation for a re-admission when the previous psychosocial was completed 6 months previously.
During our next regular staff meeting scheduled for 2/6/2012, The Clinical Supervisor will educate the clinical staff on code 709.51(b)(6). When a client is re-admitted to our program, the Clinical Supervisor and the primary counselor assigned to the case will review the closed chart and determine if a new psycosocial evaluation is required. Psychosocial evaluations must have been completed less than 6 months from the date of readmission |