INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 4, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Reading Hospital 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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704.6(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.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months of employment in that position in one of one applicable personnel record reviewed.
Employee #3 was hired as a clinical supervisor on January 9, 2023. There was no documentation, in the personnel record, of monthly clinical supervision meetings at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will hold supervision meetings with clinical supervisor monthly for the remainder of the first 6 months in this role ending 7/9/23. Supervision meeting held 5/3/23. Future meetings scheduled for 6/7/23 and 7/6/23. At the meeting on 7/6/23, frequency of ongoing meetings will be determined. Project Director will review supervision notes to ensure that supervision was completed.
Facility director will meet with all new staff for supervision monthly for the first 6 months. |
704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to include, in their comprehensive staff development program for agency personnel, policies and procedures for the program indicating who is responsible and the time frames for completion for the following components: an assessment of staff training needs, an overall plan for addressing those needs, a mechanism to collect feedback on completed trainings, and an annual evaluation of the overall training plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training procedure created 5/26/23 indicating who is responsible and the time frames for completion for the following components: an assessment of staff training needs, an overall plan for addressing those needs, a mechanism to collect feedback on completed trainings, and an annual evaluation of the overall training plan.
Facility director will ensure that the training procedure is followed beginning immediately. |
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 personnel records, the facility failed to develop an individual training plan that is based upon an employee's previous education, experience, current job functions and job performance in one of three personnel records reviewed.
Employee #1 was hired as the project director on April 10, 2022. The individual training plan completed on April 28, 2023 only listed the communicable disease trainings, which are required by the Department, and did not include any possible trainings that are based upon the employee's previous education, experience, current job functions, and job performance.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency was addressed by adding role specific training to the individual training plan which includes: Substance Use Disorder Confidentiality. The deficiency was corrected and education was completed 5.31.23 and an updated plan was signed by supervisor.
All future plans will include different role specific trainings. The project director is responsible for future adherence. |
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 personnel records, the facility failed to ensure that a sufficient number of staff persons were trained in CPR and first aid during the facility's hours of operation.
The facility's hours of operation are Monday through Friday from 8:00AM to 5:00PM. The facility provided documentation that only one employee, who works a total of 20 hours at the facility, had a current CPR certification and was first aid trained.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor, Facility Director, and support staff completed CPR/First Aid training on 5/12/23 and were certified in CPR. The Clinical Supervisor works 32 hours per week and the other staff are full time, so there will now be someone who is CPR certified and first aid trained present during all hours of operation. Facility Director will ensure that all staff maintain CPR certification and that future staff will be trained and certified in CPR/First Aid as soon as possible after hire date through the training procedure process. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's May 2022 through April 2023 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month during the months of June 2022 through April 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A log of monthly fire drills was created with Facilities Management starting in June 2023 through 2024. Drills will occur during clinic hours of operation and were added to facilities calendars to ensure ongoing adherence. The facilities director will be responsible for ensuring the corrective action is implemented. The deficiency will be corrected starting June 2023. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's May 2022 through April 2023 fire drill logs, the facility failed to identify, on the only drill log completed in May 2022, the amount of time it took for the evacuation and which exit route was used during the fire drill conducted.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill log was updated to align with DDap standards including the amount of time for evacuation and which route was taken to vacate during the drill. Drills were added to facilities calendars to ensure ongoing adherence. The facilities director will be responsible for ensuring the corrective action is implemented. The deficiency will be corrected starting June 2023. |
711.91(b)(2)(ii) LICENSURE Hours of Operation - Orientation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed provide a familiarization with the project's hours of operation during the client orientation to the project in seven of seven client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director updated Welcome packet to include program hours, address and fee schedule on 5/26/23. The Clinical Supervisor will ensure that the updated Welcome packet will be given to all patients at intake as well as all current patients. |
711.91(b)((2)(iii) LICENSURE Fee Schedule
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed provide the fee schedule during the client orientation to the project in seven of seven client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director updated Welcome packet on 5/26/23 to include fee schedule which identifies that because it is a grant funded program, there are no fees charged for services. The Clinical Supervisor will ensure that the updated Welcome packet will be given to all patients at intake as well as all current patients beginning immediately. |
711.91(b)(7) LICENSURE Preliminary Treatment Plan
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to include documentation of a preliminary treatment plan during the intake process in seven of seven client record reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A Preliminary Treatment Plan was created on 5/25/23 which will be completed by the Clinical Supervisor with all new patients at intake beginning 5/30/23. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with the client in seven of seven client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning immediately, the therapist will print treatment plan, have patient sign, and then scan to Health Information Management to be put in the patient's chart. Therapist will document in progress note that a treatment plan was completed with the patient. Facility Director will review charts to ensure ongoing completion of treatment plans. |
711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the client's comprehensive treatment plan in seven of seven client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 5/23/23, therapist has begun including the frequency and type of visits in the treatment plan. The Facility Director will review charts to ensure that frequency and type of visits continues to be included in the treatment plan. |
711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the client's individual treatment plan in seven of seven client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 5/23/23, therapist has begun including support services such as care coordinator, CRS and mutual aid groups in the treatment plan. The Facility Director will review charts to ensure that support services continues to be included in the treatment plan. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of four applicable client records reviewed
Client #1 was admitted on February 6, 2023 and was active at the time of inspection. The individual treatment plan was completed on February 14, 2023, and the first update was due no later than April 14, 2023; however, the update was not completed at the time of inspection.
Client #2 was admitted on February 7, 2023 and was active at the time of inspection. The individual treatment plan was completed on February 21, 2023, and the first update was due no later than April 21, 2023; however, the update was not completed at the time of inspection.
Client #3 was admitted on February 9, 2023 and was active at the time of inspection. The individual treatment plan was completed on February 23, 2023, and the first update was due no later than April 23, 2023; however, the update was not completed at the time of inspection.
Client #4 was admitted on February 9, 2023 and was active at the time of inspection. The individual treatment plan was completed on February 23, 2023, and the first update was due no later than April 23, 2023; however, the update was not completed at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, treatment plans will be updated every 60 days. The Facility Director will review charts to ensure that treatment plans are updated every 60 days. |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document that copies of client consents were offered to the client in one of one applicable client records reviewed.
Client #6 was admitted on February 15, 2023 and was active at the time of the inspection. There were release of information forms to a government agency and another treatment provider that were signed and dated by the client on February 15, 2023; however, there was no documentation that a copy of either consent form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, therapist will document on release of information forms that the patient was offered a copy and if they accepted or denied. The Facility Director will review charts to ensure documentation that the patient was offered a copy of each release and if they accepted or denied a copy. |