INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on November 8, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mount Pocono Medical 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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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
Based on a review of the facility's policy and procedures, the facility failed to identify the process for the recruitment and hiring of staff persons.
The findings included:
During an administrative review on November 7, 2011, the facility's policy and procedures were reviewed. No recruitment policy for staff persons was identified that addressed the recruitment and hiring of staff persons in the written facility policy.
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Plan of Correction
The facility did not identify a staff recruitment policy or procedure. It is the responsibility of the facility to address in writing recruitment and hiring of all employees.
The Human Resources Director is responsible for developing a policy addressing the recruitment of qualified personnel. The facility will make efforts to recruit through State Licensing Job Boards, local newspapers, staffing agencies, colleges and online job search agencies. The Facility Director will be responsible to implement this policy and insure compliance with the regulation. Under the direction of the facility director, all documentation of qualifications will be placed in the employee's personnel binder within the facility. The Project Director will provide ongoing oversight in this area.
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of employee personnel and training records, the facility failed to document that each employee provided feedback on completed trainings.
The findings included:
During the onsite inspection of November 8, 2011, ten employee personnel and training records were reviewed. Each employee record was required to have documentation of feedback on completed trainings. Ten of ten records included completed trainings without documentation of feedback.
On November 8, 2011, the Facility Director was informed of the need for feedback on completed trainings. The findings were not disputed.
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Plan of Correction
Facility Director has implemented the form to gather appropriate feedback after training process has occurred. Feedback forms will be provided as part of the training so it can be gathered at the time training is completed. Facility Director will ensure that these are gathered and filed in the personnel files of the employees. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of facility documentation, the facility failed to complete an annual evaluation of the overall training plan for the fiscal year of January 1, 2010 to December 31, 2010.
The findings included:
During the onsite inspection of November 8, 2011, the annual evaluation of the overall training plan for the fiscal year January 1, 2010, to December 31, 2010, was requested for review.
During a dialogue with the Project Director on November 9, 2011, the Project Director acknowledged that an annual evaluation had not been completed. The findings were not disputed.
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Plan of Correction
The Facility failed to provide the needed documents for the annual evaluation for the overall training plan for the year of 2010 as indicated in704.11. The Project Director has it listed to be completed for the year 2011. Facility Director will follow up with Project Director to ensure that the annual evaluation of training plan is completed by the end of the first quarter of the following year. Annual Evaluation for 2011 will be completed by March 31, 2012. |
704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of employee personnel and training records, the facility failed to document that each employee received an individual training plan based on the employee's previous education, experience, current job functions and job performance.
The findings included:
During the onsite inspection of November 8, 2011, ten employee personnel and training records were reviewed. Each employee record was required to have documentation that they received an individual training plan. Ten of ten records included training plans that were composed of the same form with identical content on all forms.
On November 8, 2011, the Facility Director was informed of the need for individual training plans. The findings were not disputed.
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Plan of Correction
Training plan is completed for the year of 2012 for the overall clinic for general and required trainings. Facility Director will make sure that training is completed and followed through for each employee. An individual section will be added to each employee so that each employee is receiving training to complement their needs and desires to grow in their respective positions. It is the Facility Directors responsibility to make sure that these are properly filled out and completed. Project Director will evaluate on a quarterly basis to make sure these are up to date. The process for the training plan is completed and is effective as of 12/31/2011. |
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 the facility personnel records, the facility failed to document HIV/AIDS and TB/STD training in two of three personnel records.
The findings included:
During the onsite inspection of November 8, 2011, ten employee personnel and training records were reviewed. Three employee records were required to have documentation that they received HIV/AIDS and TB/STD training. The facility failed to document HIV/AIDS and TB/STD training in personnel records # 2 and 3.
Record # 2 was hired on September 29, 2009. A Department approved curriculum in HIV/AIDS and TB/STD training was due to be completed no later than September 29, 2010.
Record # 3 was hired on November 8, 2010. A Department approved curriculum in TB/STD training was due to be completed no later than November 8, 2011.
The findings were not disputed.
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Plan of Correction
The new employee checklist includes boxes for required training along with the dates these are to be completed. The Facility director will follow up with employees to make sure these required trainings are completed. The remaining employee is scheduled to complete this training by 2/28/2012 the others will follow to be completed prior to their 1 year anniversary with the facility. |
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.
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Observations
Based on a review of the facility personnel records, the facility failed to ensure that a sufficient number of staff persons were trained in CPR/First Aid.
The findings included:
During the onsite inspection of November 8, 2011, ten employee personnel and training records were reviewed. One employee record documented CPR training. Three personnel records documented online CPR/First Aid training that did not have provisions for hands on experience and were not identified as trained to provide CPR/First aid.
On November 8, 2011, the Facility Director confirmed the facility has documentation of one staff person with CPR certification. The findings were not disputed.
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Plan of Correction
A scheduled CPR training with American Red Cross has been scheduled for February 2012 for all staff at the clinic. Nurses will be mandated to attend the training, even though they have the required training for their licensure via other means. Every 2 years the facility director will bring in American Red Cross for CPR training. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained upon employment to perform assigned tasks during emergencies in ten of ten personnel records.
The findings included:
During the onsite inspection of November 8, 2011, ten personnel records were reviewed. All personnel records require the documentation of training on assigned tasks during emergencies. The facility failed to document training in ten of ten personnel records.
On November 9, 2011, the Facility Director was informed of the need for emergency training for all staff. The findings were not disputed.
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Plan of Correction
The emergency plan has been updated with duties assigned to staff to ensure that evacuation processes will be completed correctly. Training has been completed to bring all staff up to date. The annual training plan has it on its schedule to be reviewed yearly for all existing staff. The employee checklist includes that this training is completed for all new employees that start with the clinic within the first 7 days of hire. Facility Director will ensure that this is completed and documented in the employees personnel binder. |
709.22(c)(2) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(2) Qualifications for membership.
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Observations
Based on a review of the facility's policy and procedures, the facility failed to identify qualifications for Board members in the facility policy or by laws.
The findings included:
During an administrative review on November 7, 2011, the facility's policy and procedures and the corporate by laws were reviewed. No qualifications for membership on the Board were specified in the documentation in the by laws or in written facility policy.
During a dialogue with the Project Director on November 8, 2011, the Project Director acknowledged that there were no qualifications identified. The findings were not disputed.
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Plan of Correction
A process is being written by the Corporate HR department along with the assistance of the Board of Directors on how one is selected for membership on the Board of Directors. The Board of Directors only meets. The Corporate HR department is responsible for this documentation and will filter the policy and process down to the clinics for their records. The Board of Directors meet every quarter and estimated date for completion will be the end of the 1st quarter. The Human Resource Director will monitor compliance on an ongoing basis. |
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on a review of the facility's policy and procedures, the facility failed to identify the process for selecting a project director.
The findings included:
During an administrative review on November 7, 2011, the facility's policy and procedures and the corporate Bylaws were reviewed. No process for selection of a project director by the Board were specified in the documentation in the By Laws or in written facility policy.
During a dialogue with the Project Director on November 8, 2011, the Project Director acknowledged that there was no process for selection. The findings were not disputed.
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Plan of Correction
The policy for selecting a Project Director has been written up by the Corporate HR Director and will be enforced by the same. The documentation for this will be kept in the personnel binder at the Corporate HR department. Process for selection is in accordance with the PA regulations along with other guidelines the Corporation feels the Project Director needs to have in order to perform in this role. This policy has been written and proper documentation is in the personnel files. The Human Resource Director will monitor compliance on an ongoing basis. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of facility documentation, the facility failed to complete an annual report for the fiscal year of January 1, 2010 to December 31, 2010.
The findings included:
During an administrative review on November 7, 2011, the annual report for the fiscal year January 1, 2010, to December 31, 2010, was requested for review.
During a dialogue with the Project Director on November 8, 2011, the Project Director acknowledged that an annual report had not been completed to provide to the public. The findings were not disputed.
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Plan of Correction
The Facility failed to provide the needed documents for the annual report for the fiscal year of 2010 as indicated in 709.22. The Project Director has it listed to be completed for the year 2011. Facility Director will follow up with Project Director to ensure that the annual report is completed by the end of the first quarter of the following year. Annual Report for 2011 will be completed by March 31, 2012. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on a review of facility documentation, the facility failed to complete a performance report to summarize progress towards meeting goals and objectives for the fiscal year January 1, 2010, to December 31, 2010.
The findings included:
During an administrative review on November 7, 2011, the performance report for the summary of goals and objectives for fiscal year January 1, 2010, to December 31, 2010, was requested for review. The report is to be completed at least annually.
During a dialogue with the Project Director on November 8, 2011, the Project Director acknowledged that a performance report had not been completed to include a summary of goals and objectives of fiscal year 2010. The findings were not disputed.
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Plan of Correction
The Facility failed to provide the needed performance report toward meeting goals and objectives for the fiscal year of 2010 as indicated in709.23. The Project Director has it listed to be completed for the year 2011. Facility Director will follow up with Project Director to ensure that the performance report of goals is completed by the end of the first quarter of the following year. The Performance Report of Goals for 2011 will be completed by March 31, 2012. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician for 24-hour emergency medical and psychiatric coverage.
The findings include:
The letters of agreement were reviewed on November 8, 2011. No letter of agreement regarding 24-hour emergency medical and psychiatric coverage was documented.
On November 9, 2011, the Project Director was informed of the absence of the letters of agreement. The findings were not disputed.
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Plan of Correction
The facility failed to provide a Linkage agreement with a hospital for 24/7 psychiatric and medical coverage for our clients. On review we found that the medical agreement with our local hospital lacked the wording to include 24/7 psychiatric and medical care. Facility Director will contact the holder of this linkage agreement and update the services to include 24/7 psychiatric and medical care. A list of required linkages and items to include is placed at the beginning of the binder to ensure that all the agreements meet standards. The Facility Director will review these on an annual basis to make sure all linkage agreements are current and meet the standards outlined. |
709.26(a)(3) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(3) Wage and salary administration.
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Observations
Based on a review of the facility policy and procedures, the facility failed to provide payroll procedures.
The findings included:
During an administrative review on November 7, 2011, the facility's policy and procedures and the corporate by laws were reviewed. No job classifications or pay scales were provided.
During a dialogue with the Project Director on November 9, 2011, the Project Director acknowledged that there were no job classifications or pay scales. The findings were not disputed.
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Plan of Correction
Payroll scale for the Eastern PA clinics has been created. The Project Director will review this payroll scale on an annual basis to make sure it is comparable to regional standards and expectations. This scale will be given to facilities at each update for their clinic binders. It is completed as of this date and will be reviewed annually and dates notated to show effective dates. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records, the facility failed to provide results of reference checks in four of ten personnel records.
The findings included:
During the onsite inspection of November 8, 2011, ten personnel records were reviewed. All personnel records require the documentation of reference results. The facility failed to document the results of reference checks in personnel records # 4, 5, 6 and 7.
On November 9, 2011, the Project Director was informed of the absence of the reference check results. The findings were not disputed.
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Plan of Correction
Reference check form has been created for clinic and is used in all new hires for the clinic. The new employee checklist includes documentation and filing of this form. This is to be completed by the Facility Director and filed prior to hiring of the new employee. |