INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 24, 2010 through August 26, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Another Way, Inc. 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 September 20, 2010.
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Plan of Correction
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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 staff development records, staff development procedures and staff interviews, counseling staff failed to obtain 25 hours of training annually.
Findings:
Facility procedures define the staff development year as July 1 through June 30 annually. Two of two counselors failed to acquired twenty five hours of training for the year July 1, 2009 through June 30, 2010.
Staff development record #2 - The employee was hired on September 2008. The staff development record reviewed on August 24, 2010 included documentation of twenty hours of training for the 2009/2010 training year.
Staff development record #3 - The employee was hired on November 2001. The staff development record reviewed on August 24, 2010 included documentation of twelve hours of training for the 2009/2010 training year.
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Plan of Correction
Two clinicians did not have the proper training hours of 25 hours of training for previous fiscal year. The facility director is responsible for ensuring the clinicans are scheduled for training hours. The course of action taken will be the CEO will investigate possible on-line, mail in, etc. courses that met licensure standard to ensure all clinicans have access to the trainings. The facility will be in full compliance by July 1, 2011 Next fiscal training schedule. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on licensing inspection results, staff interviews and an inspection of the physical plant, the residential facility failed to ventilate a bathroom with either an exhaust fan or window.
Findings:
A physical plant inspection was conducted on August 25, 2010. The inspection revealed a staff bathroom that was not ventilated by either an exhaust fan or window.
An interview with the facility director, project director and maintenance staff on August 25, 2010 confirmed that the bathroom was not ventilated.
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Plan of Correction
An exhaust fan will be installed in the staff bathroom ceiling. The person responsible will be the Maintenance staff. We will be in compliance by September 30, 2010. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, staff interviews and food service records, the residential facility failed to document that hot food is maintained at 140 degrees Fahrenheit.
Findings:
On August 24, 2010, an inspection of the food preparation area of the the residential facility was completed. Hot food was prepared without documentation of the preparation and maintenance of temperatures in a food temperature log.
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Plan of Correction
A hot food log will be developed on 9/15/10 by the Facility Director following state regulations. Staff and kitchen manager will receive a memo informing them of the purpose of the log and how to complete the log on 9/20/10. The food logs will be completed daily by the kitchen manager and monitored by the Administrative Assistant. We will be in full compliance by 9/30/10 |
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 of a review of client records and facility policy and procedures, the residential facility failed to document physical examinations.
Findings:
Four active client records were reviewed on August 25, 2010. Three of four records reviewed did not include documentation of a completed physical examination.
Client # 1 was admitted February 25, 2010. The physical examination reviewed on August 25, 2010 did not include vital signs and the physician's comments on the client's general appearance.
Client # 3 was admitted June 16, 2010. The physical examination reviewed on August 25, 2010 did not include the examination date, systems review or the physician's impression and diagnosis.
Client # 4 was admitted August 7, 2010. There was no documentation of a physical examination in the client record as of August 25, 2010.
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Plan of Correction
We will be submitting an exception letter for this regulation. We currently have a psychiatrist that see's all of the clients and we also ensure that if a client has medical needs is seen by a medical doctor. The CEO and Facility Director is responsible for sending proper documentation in regards to an exception. We will be in full compliance after exception is approved. |