INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 21, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System DD/FIR 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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704.11(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 personnel records and the facility's Staffing Requirements Facility Summary Report form, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff in five of six personnel records reviewed.
The findings include:
From August 6, 2013 to August 7, 2013 and on August 21, 2013, six personnel records and the Staff Requirements Facility Summary Report form were reviewed to verify that employees had HIV/AIDS and STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff. The facility failed ensure that staff persons received a minimum of 6 hours of HIV/AIDS training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff in five of six records reviewed, 6, 7, 8, 9, and 10.
Employee # 6 is a community recovery specialist and was hired on May 9, 2011. Employee # 6 would have been due to complete HIV/AIDS training by May 9, 2013. However, personnel record # 6 did not include documentation of HIV/AIDS training as of August 21, 2013.
Employee # 7 is a community recovery specialist and was hired on May 9, 2011. Employee # 7 would have been due to complete HIV/AIDS training by May 9, 2013. However, personnel record # 7 did not include documentation of HIV/AIDS training as of August 21, 2013.
Employee # 8 is a community recovery specialist and was hired on July 13, 2009. Employee # 8 would have been due to complete HIV/AIDS training by July 13, 2013. However, personnel record # 8 did not include documentation of HIV/AIDS training as of August 21, 2013.
Employee # 9 is a community recovery specialist and was hired for his current position on June 19, 2011. Employee # 9 would have been due to complete HIV/AIDS training by June 19, 2013. However, personnel record # 9 did not include documentation of HIV/AIDS training as of August 21, 2013.
Employee # 10 is a case manager and was hired for her current position on July 11, 2011. Employee # 10 would have been due to complete HIV/AIDS training by July 11, 2013. However, personnel record # 10 did not include documentation of HIV/AIDS training as of August 21, 2013.
The findings were confirmed during an interview with the admissions coordinator on August 21, 2013 at approximately 3:00 P.M.
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Plan of Correction
The six staff identified have been assigned to complete HIV/AIDS training during the September and October 2013 New employee orientation sessions.
The clinical supervisors and the Department Administrator will monitor completion of mandatory trainings of all new hires on a quarterly basis.
The Residential Program Director will insure that employee's # 6,7,8,9 & 10 complete the required HIV/AIDS training as well as for all other staff.
Full compliance will be acheived by November 1, 2013. |
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 ensure that each counselor completed 25 clock hours of required training in one of one personnel record reviewed.
The findings include:
From August 6, 2013 to August 7, 2013, one personnel record requiring documentation of 25 clock hours of training was reviewed. The facility failed to provide documentation of 25 clock hours of training in one of one personnel record reviewed, specifically, personnel record # 5.
Employee # 5 is a counselor and was hired on October 10, 2010. Employee # 5 was required to complete 25 clock hours of annual training hours by December 31, 2012. However, personnel record # 5 did not include documentation of annual training hours for the January 1, 2012 to December 31, 2012 training year as of August 7, 2013.
The findings were confirmed during an interview with the Vice President on August 7, 2013 at approximately 9:30 A.M.
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Plan of Correction
The clinical supervisor will review progress toward achieving training hours of all counselors once a month during supervision beginning immediately and on an ongoing basis.
Training attendance will be mandated by and monitored by the clinical supervisor.
Quarterly review of the training records will be conducted by the administrative assistant for the department who will report training hours to the clinical supervisor beginning in September and ongoing.
Clinical staff will be provided a list of approved on line training sites by September 30, 2013 and provided monthly updates of available training beginning September 2013 by the administrative assistant.
Full compliance for training hours will be achieved for calendar year 2013.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in one of one personnel record reviewed.
The findings include:
From August 6, 2013 to August 7, 2013, one personnel record requiring documentation of fire extinguisher training was reviewed. The facility did not instruct staff in the use of the fire extinguisher upon staff employment in one of one personnel record reviewed, specifically, personnel record # 4.
Employee # 4 is a counselor and was hired on June 30, 2013. Employee # 4 was due to complete fire extinguisher training upon employment by June 30, 2013. However, employee # 4 did not complete fire extinguisher training until July 12, 2013.
The findings were confirmed during an interview with the Vice President on August 7, 2013 at approximately 9:30 A.M.
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Plan of Correction
Policy regarding the reciept of fire saftey training within 7 days on hire was reviewed with the Department Head and clinical supervisors on 8/23/2013 by the Vice President of Behavioral Health Services.
Effective immediately all staff (including temporary employees) who begin work prior to the once a month New Employee Orientation will complete the Fire Extinquisher training manual with the clinical supervisor. This will be monitored by the Residential Program Director of a monthly basis. The Residential Program director will be responsible for insuring that fire extinguisher traing is completed on time. Full compliance will be achieved by September 30, 2013 |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 were trained upon employment to perform assigned tasks during emergencies in one of one personnel record reviewed.
The findings include:
From August 6, 2013 to August 7, 2013, one personnel record requiring documentation that all personnel on all shifts had been trained to perform assigned tasks during emergencies were reviewed. The facility failed to ensure that employees completed emergency training upon employment in one of one personnel record reviewed, specifically, employee # 4.
Employee # 4 is a counselor and was hired on June 30, 2013. Employee # 4 was due to complete emergency training upon employment by June 30, 2013. However, employee # 4 did not complete emergency training until July 12, 2013.
The findings were confirmed during an interview with the Vice President on August 7, 2013 at approximately 9:30 A.M.
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Plan of Correction
Policy regarding the reciept of emergency training within 7 days on hire was reviewed with the Department Head and clinical supervisors on 8/23/2013 by the Vice President of Behavioral Health Services. Effective immediately all staff (including temporary employees) who begin work prior to the once a month New Employee Orientation will complete Emergency training with the clinical supervisor and recieve a tour of the building identifying emergency exits, fire extingisher locations and his or her role. This will be monitored by the Residential Program Director of a monthly basis. The Residential Program director will be responsible for insuring that emergency traing is completed on time. Full compliance will be achieved by September 30, 2013 |
711.52(c)(3) LICENSURE Support Service
711.52. 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 in the individual treatment and rehabilitation plan in five of six client records reviewed.
The findings include:
On August 21, 2013, six client records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in five of six records reviewed, specifically, client records # 1, 3, 4, 5, and 6.
Client # 1 was admitted February 9, 2013. The individual treatment and rehabilitation plan was completed on February 19, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 21, 2013.
Client # 3 was admitted March 1, 2013. The individual treatment and rehabilitation plan was completed on April 8, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 21, 2013.
Client # 4 was admitted April 6, 2013. The individual treatment and rehabilitation plan was completed on April 12, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 21, 2013.
Client # 5 was admitted March 21, 2013. The individual treatment and rehabilitation plan was completed on March 25, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 21, 2013.
Client # 6 was admitted February 13, 2013. The individual treatment and rehabilitation plan was completed on February 20, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 21, 2013.
The findings were confirmed during an interview with one of the clinical supervisors on August 21, 2013 at approximately 3:00 P.M.
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Plan of Correction
Policy regarding support services was reviewed with the clinical supervisors on August 23rd by the Director of Residential Services.
The clinical supervisors provided in service training to the counselors regarding support services during the week of August 26, 2013.
Identified charts were reviewed and where appropriate support services were added to the treatment plans or or before August 31 by the counseling staff.
Clinical supervisors will be responsible for monitoring the inclusion of support services on treatment plans during weekly and monthly supervison sessions.
Full compliance will be acheived by September 30, 2013. |