INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 3-4, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Colonial House, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to ensure that the staff person appointed to the facility director position met the experience requirements.
The findings were:
Seven personnel records were reviewed on March 3, 2014. Employee #1 was promoted on January 1, 2014 to the facility director position. The facility director is to have 3 years of experience in a human service agency, preferably in a drug and alcohol setting which includes supervision of others, direct service and program planning. After a reviewed of employee #1's personnel record, the record did not show documentation that employee #1 had the required supervisory experience as required.
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Plan of Correction
Due to the DDAP Inspection which took place on 3/3/14-3/4/14, The Inpatient Clinical Supervisor has assumed the position of Facility Director effective: 3/6/14. The CEO has assurred that the current Facility Director meets the qualifications for the position.
The Human Resource department will ensure that job descriptions which include qualifications for the position will be completed at the time of promotion or hire. The Human Resource department will review DDAP standards for each new hire/promotion prior to the position being offered. This will be monitored by the CEO. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's fire drill record, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
The fire drill record was reviewed on March 3, 2014. Documentation of a fire drill conducted during sleeping hours is required once every six months. The fire drill record was reviewed from the last survey, April 2013 through January 2014. During that timeframe, the facility documented only two fire drills during sleeping hours June 2013 and July 2013, however there was no overnight drill conducted December 2013 nor January 2014.
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Plan of Correction
The Executive Assistant will now be responsbile for maintaining fire drill logs. The Director of Operations met with the Executive Assistant on 3/19/14 and discussed fire drill procedures. The Executive Assistant was instructed on all fire drill procedures. A written schedule was developed on 3/19/14, that included scheduling a fire drill every six months, including sleep hours. Additionally, varying routes of exits were included. This will be monitored by the Director of Operations. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document physical examinations timely in client records.
The findings include:
Ten records were reviewed on March 5, 2014. Physical examinations were required in ten client records. The facility failed to complete physical examinations within seven days as required in client records, #1, 2, 5, 6, 7 and 8.
Client #1 was admitted on December 3, 2013. The physical examination was to be completed by December 9, 2013. The physical examination was completed on December 17, 2013.
Client #2 was admitted on December 18, 2013. The physical examination was to be completed by December 24, 2013. The physical examination was completed on December 27, 2013.
Client #5 was admitted on November 21, 2013. The physical examination was to be completed by November 27, 2013. The physical examination was completed on December 17, 2013.
Client #6 was admitted on September 27, 2013 and discharged December 19, 2013. The physical examination was to be completed by October 3, 2013. The physical examination was not completed as of the date of Client #6's discharge date.
Client #7 was admitted on December 3, 2013 and discharged February 12, 2014. The physical examination was to be completed by December 9, 2013. The physical examination was completed on December 13, 2013.
Client #8 was admitted on October 24, 2013 and discharged January 22, 2014. The physical examination was to be completed by October 30, 2013. The physical examination was completed on October 31, 2013.
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Plan of Correction
The Facility Director met with the staff responsible for requesting, scheduling, verifying, and maintaing physicals on 3/21/2014. The Facility Director provided clarification on policy associated with physicals. All physicals must be received or completed within 7 days of a client's admission. In addition, physicals must be signed by a Doctor of CRNP. The Executive Assistant and Admissions Coordinator were advised and directed to pay close attention to physicals received from other entities. If an appropriate physical is not received, an appointment for a physical will be scheduled within the 7 day timeframe. The Facility Director will monitor for compliance. |