INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 12 through October 13, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Diakon Lutheran Social Ministries 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 November 8, 2010.
|
Plan of Correction
|
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.
|
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:
During the onsite licensing inspection a review of employee # 3's training record revealed that no supervisory notes were documented for the initial six months of employment. An interview was conducted with the project director on October 13, 2010 at approximately 2:30 p.m. and it was confirmed that there were no documented meetings with the clinical supervisor during her first six months of employment in that position.
|
Plan of Correction
Preparation and submission of this plan of correction is required by state and federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
The Executive Dir. will meet monthly with the current and any new Drug & Alcohol Clinical Dir.for a minimum of 6 months. Documented supervision with current Cl. Dir. of D&A monthly beginning 11/1/10. Documentation of the monthly supervision will be maintained in a locked file in the Executive Director's office.
Random audits will be completed by the Diakon Quality Assurance Representative to insure the completion of the training records. |
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 personnel records, a review of the facility summary report, and a conversation with the clinical supervisor, the facility failed to provide documentation of HIV/AIDS and TB/STD training for four out of seven personnel.
The findings include:
Twelve personnel records were reviewed on October 12, 2010. The facility summary report was reviewed on October 12, 2010. Seven personnel were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training for personnel records # 9, 10, 11, and 12.
Employee # 9 is a counselor and was hired September 10, 2009. HIV/AIDS and TB/STD training was to be completed within one year of hire, by September 10, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training.
Employee # 10 is a support staff person and was hired September 30, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by September 30, 2010. The facility failed to provide documentation of HIV/AIDS training.
Employee #11 is a support staff and was hired March 15, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by March 15, 2009. The facility failed to provide documentation of HIV/AIDS and TB/STD training.
Employee #12 is a support staff and was hired July 09, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by June 09, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training.
An interview was conducted with the clinical supervisor and it was confirmed on October 12, 2010 that these training requirements were not obtained as of the date of this licensing inspection.
|
Plan of Correction
Employee #9 has resigned.
Employee #10 will complete the required HIV/AIDS training by 2/28/2011.
Employees #11 and #12 will complete the required HIV/AIDS/TB/STD trainings by 5/31/2011. Certificates of completion will be maintained in the employees records.
Random audits of new employees training records will be done by the Clinical Director/designee. |
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 a review of training documentation it was determined that the facility failed to provide a sufficient number of staff persons, so that at least one person trained in CPR certification and first aid training is onsite during the project's hours of operation.
The findings include:
Based on the review of personnel records and training documentation it was determined that employee # 9 did not have CPR or First Aid training. An interview with the clinical supervisor on October 13, 2010 revealed employee # 9 is a school based therapist and works alone at the the schools. This employee did not have the required CPR or First Aid training.
|
Plan of Correction
Employee #9 has resigned.
Random audits of staff training will be done by Clinical Director/designee.
Any issues identified will be addressed as appropriate. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
|
Observations
Based upon a tour of the facility and an interview with the Clinical Supervisor, the facility failed to have the fee schedule posted in a prominent place.
The findings include:
On October 13, 2010 between 8:40 a.m. and 9:10 a.m. a physical plant tour was conducted. The facility failed to have the fee schedule posted in a prominent place. The clinical supervisor confirmed that the fees were not posted.
|
Plan of Correction
The fee schedule has been posted in the waiting room.
Random audits of the fee schedule posting will be monitored by Clinical Director/designee.
Any issues identified will be addressed as appropriate. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
|
Observations
Based on an interview with the clinical supervisor and a review of the client list the facility failed to maintain the authorized maximum licensed capacity for the outpatient other chemotherapy program.
The findings include:
On October 14, 2010 the client list was reviewed. There were 80 clients receiving outpatient other chemotherapy services at the program. The program is licensed to serve a client capacity of 50 clients. The facility failed to maintain the licensed capacity and exceeded the licensed capacity by 30 clients. An interview was conducted with the clinical supervisor around 10:00 a.m. and it was confirmed that they had 80 clients in this program.
|
Plan of Correction
The Clinical Director submitted a letter to DOH requesting an increase capacity for outpatient other chemotherapy services on October 14, 2010. A letter of approval was received on October 14, 2010.
Random audits will be completed by the Clinical Director or designee to insure the capacity limit is maintained. |