INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 3-5, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SOAR Corporation Chester 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of staff records conducted during the onsite inspection, the facility failed to ensure that all of the staff received the mandatory trainings in communicable disease.Staff Person #4 was hired as a counselor on 10/05/2015, and was required to complete 4 hours of training in TB/STDs no later than 10/05/2016, but the staff person had 0 hours of training in TB/STDs at the time of the onsite inspection.These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The staff member in question will continue to check the DDAP training website weekly and shall register for the next upcoming training in this area on TB/ STD. The clinical supervisor shall review the progress to registering and completing this train and shall document this in a supervision note. as long as the training is offered in this area it shall be completed within the next 90 days. Moving forward, the Human resource director shall monitor the need for required training completion of all new staff and shall send quarterly to each staff member and their supervisor a list of trainings to complete. The list of trainings shall be sent by e-mail to serve as proof of being notified. The supervisor will follow up with the employee, and document discussion, registration and completion of such trainings. Once complete the HR director shall receive a copy of the training for the HR file |
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.
|
Observations
Based on staff interviews and a review of staff records conducted during the onsite inspection the facility failed to to provide sufficient first aid coverage for all hours of operation.There are no staff persons with documented training in first aid who work on Sundays from 6:00AM to 11:00AM.These findings were reviewed with the facility staff as part of the inspection process.
|
Plan of Correction
Within the next 30 days, The Director of Human Resources shall located and arranged for a external trainer to come to this site to complete a first aid training for all staff. The Medical staff shall including the nurses and medical doctor shall complete this training. The onsite site training shall be scheduled and completed within the next 90 days. Proof of training by means of a training certificate and first aid card shall be Kept in the employees chart. Ongoing the Human Resource Director shall schedule set up a annual cpr and first aid training in the first quarter of each year for staff to attend to remain in compliance |
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.
|
Observations
The facility failed to ensure that all of the required information for fire drills was documented in the facility's records. The fire drill log for the fire drill conducted on 05/26/2016, did not document the evacuation routes used during the fire drill.The fire drill log for the fire drill conducted on 06/13/2016, did not document the evacuation routes used during the fire drill.The fire drill log for the fire drill conducted on 07/22/2016, did not document the evacuation routes used during the fire drill.The fire drill log for the fire drill conducted on 08/19/2016, did not document the evacuation routes used during the fire drill, and it did not document length of time for the drill.The fire drill log for the fire drill conducted on 09/07/2016, did not document the time the drill was conducted, the evacuation routes used during the fire drill, and the length of time for the drill.These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The regional project director shall provide a education training on fire safety documentation to the members of the health and safety committee who facilitate the fire drills. Within the training, required information for fire drills will be discussed and the procedure to document will be discussed. this training shall be completed by 3/3/17. Furthermore, all fire drill forms shall be reviewed by the health and safety committee in their quarterly meeting to ensure that the required information for fire drills is documented on the form. This review of the fire drill form shall be a ongoing system to ensure documentation accuracy. Any issues of insufficient documentation will be addressed in this review and a record of insufficiencies shall be kept in the health and safety meeting notes. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Based on a review of patient records conducted during the onsite inspection the facility failed to ensure that the required information was transferred to receiving narcotic treatment programs when the facility transferred out narcotic treatment patients.Patient #5, a narcotic treatment patient, was transferred to another narcotic treatment program on 05/06/2016, but the facility did not transfer the patient's psychosocial summary, medical summary or urinalysis reports to the receiving program.These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The regional Project Director shall schedule and complete an internal training with the counseling and intake staff of the program regarding the transfer out process to receiving MMT programs. This training shall be completed within the next 60 days (4/3/17) with all staff. The training will cover the items included in the transfer package, the procedure for first and last dose confirmations for the transferring and receiving clinic and procedures to close out a transferred patient. Effective Immediately and ongoing, all transfer packages shall be reviewed by the clinical supervisor prior to being sent to a receiving program to ensure all required documentation is being submitted. Occurrence of insufficient transfer packages found prior to being sent shall be corrected and discussed with the counselor and documented in a supervision note. Once a transfer package is deemed complete by the supervisor, it shall be faxed by the counselor and the fax confirmation shall be kept to show proof of being sent |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
|
Observations
Based on staff interviews and a review of patient records conducted during the onsite inspection the facility failed ensure that it documented the required notifications to narcotic treatment programs who were transferring patients into the facility.Patient #7 was transferred in to the facility on 3/15/2016, but the facility failed to document that it notified the transferring narcotic treatment program of the patient's admission and initial dose.Patient #8 was transferred in to the facility on 3/15/2016, but the facility failed to document that it notified the transferring narcotic treatment program of the patient's admission and initial dose. These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The regional Project Director shall schedule and complete an internal training with the intake staff of the program regarding the transfer in process to receiving MMT programs. This training shall be completed within the next 30 days (3/3/17) with all staff. The training will cover the need to complete the dose confirmation sheets and send this back to the home clinic when a patient is being transferred to our facility. Training will focus on the process of completing the dose confirmation, including the steps of filling out the form, entering the day which the person would start dosing with our facility and the need to fax this form to the sending the patient to our facility. Training will focus on instructing staff to keep the fax confirmation showing the home clinic was notified of a patient starting dosing with our facility. The training shall define the need to send any dose confirmations for any referral, step down or transfer to this facility. Post training all transfer admissions including inpatient and MMT programs shall be reviewed on the date of intake by the supervisor to ensure dosing confirmations were sent. Occurrence of dose confirmations not being sent by the intake worker, shall be corrected by sending the confirmation that day and shall be discussed with the counselor and documented in a supervision note. The review process shall be ongoing by the supervisor |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
|
Observations
The facility failed to ensure that patients received an annual physical exam. Patient #2 was admitted for narcotic treatment on 12/10/2010. The facility had a documented physical examination performed on 7/09/2015, but the next documented physical examination was not completed until 12/08/2016.These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
To ensure that annual reviews are complete on time, Regional Project director will develop a spread sheet for the medical department to track annual evaluations within 30 days. Admin Assistant to set all due dates for evaluations in the spread sheet within 30 days. Admin assistant to check spread sheet weekly and set appointments for evaluations 2 weeks prior to the due date. Clinical Supervisor will to monitor appointments being set by cross checking the developed spread sheet to the appointments being set in the tower computer system for the MD. Cross check will be completed every 2 weeks. When identified in the cross checks, occurrence of appointments not being set shall be addressed by the clinical supervisor and discussed in a supervisor note. |