INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29-30, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Deerfield Dual Diagnosis LP 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 July 28, 2010.
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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 individual training plans in two of four personnel records reviewed.
The findings include:
Four personnel records were reviewed on June 29, 2010. Individual training plans were required in four personnel records. The facility did not provide documentation of individual training plans for the January 1 - December 31, 2010 training year in two records. Two individual training plans are documented.
The employee represented by personal record #3 was hired on January 5, 1998. Documentation of a 2010 individual training plan was not provided during the the licensing inspection which ended on June 30, 2010.
Employee #4 was hired on March 14, 2005. Documentation of a 2010 individual training plan was not provided as of June 30, 2010.
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Plan of Correction
The Clinical Supervisor has been instructed to contact the training coordinator to see that new training plans have been developed for the two staff identified during the site visit. The Program Director will follow-up with the training coordinator to see that this has been accomplished by July 16th, 2010. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two personnel records reviewed.
The findings include:
Four personnel records were reviewed on June 29, 2010. Two of the four personnel records were counselors. Two personnel records were required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training for the 2009 training year in personnel record # 4.
The employee represented by personal record #4 was hired on March 14, 2005. The facility training year is from January through December. The training year for January 2009 to December 2009 was reviewed. There was no documentation that employee # 4 obtained any training for the 2009 training year.
The Program Director confirmed that the counselor did not have the 25 clock hours of training for the 2009 training year.
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Plan of Correction
The Program Director and Clinical Supervisor will work with the staff member to insure that the appropriate training hours are accumulated in accordance with the regulations. The Clinical Supervisor will meet with the staff member to identify specific trainings and training dates to insure that 25 hours of training are accomplished by December 31, 2010. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the observation which occurred during the licensing survey, the facility failed to ensure privacy in counseling sessions and conversations.
The findings include:
Two conversations and a counseling session were conducted during the course of the licensing survey on June 29 - 30, 2010. The interactions between the counselor and the clients were not private, and were held in a cubicle without walls which extend from the floor to the ceiling. Interactions could be clearly heard by this licensing specialist, other staff members and anyone else in the vicinity.
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Plan of Correction
The Program Director will contact the Facilities Director to see if an adjacent room can be cleaned out for use as a counseling room. This is a secured room with floor to ceiling concret walls. The Program Director will have this accomplished by 07/23/2010 |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on the physical plant inspection, the facility failed to provide an operable soap dispenser, and either individual paper towels or a mechanical dryer in one of the bathrooms.
The findings include:
During the course of the licensing inspection on June 29 and 30, 2010, and a physical plant inspection on June 30, 2010, the facility failed to provide an operable soap dispenser, and either individual paper towels or a mechanical dryer in the bathroom located on off of the kitchen.
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Plan of Correction
The Clinical Supervisor placed a soap dispensor and paper towel dispensor in the newly remodled bathroom following the site visit. Since then the soap and towel dispensor have been attached to the wall. This problem has been completed. |
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 in six of six client records.
The findings include:
Six client records were reviewed on June 29 - 30, 2010. Documentation of physical examinations were required in six client records. Facility policy states if the client has not completed a physical examination within the past six months, then the facility will complete a physical examination within five days of admission. The facility failed to complete physical examinations within five days as required by the project's policy in client records #1, 2, 3, 4, 5, and 6.
In client record #1 the individual was admitted on April 6, 2010. The physical examination was to be completed within five days; by April 11, 2010. There was no documentation that a physical examination was completed as of June 30, 2010.
In client record #2 the individual was admitted on April 12, 2010. The physical examination was to be completed within five days; by April 17, 2010. There was no documentation that a physical examination was completed as of June 30, 2010.
In client record #3 the individual was admitted on June 10, 2010. The physical examination was to be completed within five days; by June 15, 2010. There was no documentation that a physical examination was completed as of June 30, 2010.
In client record #4 the individual was admitted on June 15, 2010. The physical examination was to be completed within five days; by June 20, 2010. There was no documentation that a physical examination was completed as of June 30, 2010.
In client record #5 the individual was admitted on April 21, 2010. The physical examination was to be completed within five days; by April 26, 2010. There was no documentation that a physical examination was completed as of June 30, 2010.
In client record #6 the individual was admitted on June 7, 2010. The physical examination was to be completed within five days; by June 12, 2010. There was no documentation that a physical examination was completed as of June 30, 2010.
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Plan of Correction
The Program Director has informed the Clinical Supervisor and RN that client's need to have information regarding physical examinations in the client record within five days of their admission date. The following steps have been implemented; A) The Intake Staff will request that a completed physical be sent along with other client information when the client is being transfered from an agency where a physical has been completed within the last 6 months. B) If client has not had a documented complete physical at the time of admission, a physical will be scheduled by the Intake worker on the date of admission. We have Five hours available eache week to insure that physical cane be completed within the five day time frame. |
709.52(e)(1) LICENSURE Medical/dental support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on a review of client records, the facility failed to document dental referrals in four of six client records.
The findings include:
Six client records were reviewed on June 29 - 30, 2010. The facility failed to assist the client in obtaining dental supportive services. Based on a review of the client records, documentation in four of six client records indicated a need for dental services, but the facility documented "Needs to see a dentist after discharge." in client records #1, 3, 4, and 5. The other two records did not indicate a need for a dental referral.
In client record #1 the individual was admitted on April 6, 2010. The nursing assessment dated 4-6-10 indicated the client " wants to see a dentist, instructed to make an appointment after discharge." There is no documentation of a dental referral in the client record or of an attempt by the facility to assist the client in obtaining dental services.
In client record #3 the individual was admitted on June 10, 2010. The nursing assessment dated 6-10-10 indicated impacted wisdom teeth, and the medical history indicated the client has cavities. There is no documentation of a dental referral in the client record or of an attempt by the facility to assist the client in obtaining dental services.
In client record #4 the individual was admitted on June 15, 2010. The nursing assessment dated 6-15-10 indicated missing teeth, and the need for a dentist, but facility documentation indicated the client "needs to see a dentist after discharge". There is no documentation of a dental referral in the client record or of an attempt by the facility to assist the client in obtaining dental services.
In client record #5 the individual was admitted on April 21, 2010. The nursing assessment dated 4-21-10 indicated dental problems, and the need for a dentist for a root canal, but facility documentation indicated the client "needs to see a dentist after discharge". There is no documentation of a dental referral in the client record or of an attempt by the facility to assist the client in obtaining dental services.
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Plan of Correction
The Program Director will instruct the clinical staff to be proactive when clients' identify dentalneeds. Rather than leave it up to the client to make an appointment to address their dental needs following discharge from treatment, staff will be instructed to assist the client in identifying local dental practices and scheduling appointments. If the client decides that he/she does not want to schedule services, the staff member will document accordingly. |