INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on June 18, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, The Consortium 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 personnel records, the facility failed to provide documentation of an individual training plan developed with input from both the employee and the supervisor for two of twelve applicable employees.
Employee # 1 was hired as the project director on December 3, 2001. The most recent individual plan was completed on July 31, 2018.
Employee #6 was hired as a counselor on February 10, 2020. The individual training plan was signed by the supervisor on May 11, 2020 but there was no indication that it was developed with input from the employee.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 7/12/20, Clinical Supervisor will have reviewed Training Plans with employee #6 and will have obtained feedback on the training plan and obtained staff signature on their training plan. This training plan will be reviewed on an annual basis by the Division Director each year to verify completion and timeliness.
By 7/31/20, interim training plan for Project Director will be developed and Division Director, along with TSS Manager, will verify completeness of this form. Full annual training plan will be completed by the Board of Trustees in January of each year moving forward. Both Division Director and TSS Manager will review for completeness and timeliness.
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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 personnel records, the facility failed to ensure that three of thirteen applicable staff persons received 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 within the regulatory timeframe.
Employee #10 was hired as a counselor on October 1, 2018 and was due to have HIV/AIDS training no later than October 1, 2019. There was no documentation of the completed HIV/AIDS training as of the date of the inspection.
Employee #13 was hired as support staff on August 28, 2017 and was due to have HIV/AIDS and TB/STD training no later than August 28, 2019. There was no documentation of the completed HIV/AIDS and TB/STD trainings as of the date of the inspection.
Employee #14 was hired as support staff on June 19, 2017 and was due to have HIV/AIDS training no later than June 19, 2019. There was no documentation of the completed HIV/AIDS training 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
By 7/31/2020 Division Director and Program Supervisors will have identified upcoming approved HIV/AIDS and TB/STD and will have assisted the staff who had not completed these trainings in signing up for them.
By 7/31/2020 Division Director will develop a training tracker in conjunction with Human Resources Department to ensure that training is completed in a timely fashion for all new hires moving forward.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the review of personnel records, the facility failed to ensure that the project director completed at least 12 clock hours of training during the facility's July 1, 2018 through June 30, 2019 training year.
Employee #1 was hired as the Project Director on December 3, 2001. The personnel record documented 7 hours of training.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 7/31/20, Project Director and TSS Manager will develop a quarterly training hours audit schedule by which progress and needs in training will be observed to ensure training requirements by Project Director are met. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on an administrative review of the July 2019 through May 2020 fire drill logs, the facility failed to conduct fire drills during normal staffing conditions during the months of September 2019, October 2019 and February 2020. The fire drill logs during these months indicated that fire drills were conducted outside of normal business hours.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 6/30/20, all fire drills will occur during normal business hours. These fire drills will be conducted and documented by facilities manager and reviewed by Division Director on a monthly basis. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee in one of four applicable personnel records.
Employee #1 was hired as the Project Director on December 3, 2001. There was no annual performance evaluation in the personnel record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 7/31/20, interim performance evaluation for Project Director will be developed and Division Director, along with TSS Manager, will verify completeness of this form. Full annual performance review will be completed by the Board of Trustees in January of each year moving forward. Both Division Director and TSS Manager will review for completeness and timeliness. |