INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 20-21, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Innovative Recovery Services, 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.
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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 the review of personnel records, the facility failed to document that each counselor shall complete at least 25 clock hours of training annually in one of one personnel record.
The findings include:
Four personnel records were reviewed on August 20-21, 2012. Three personnel records were reviewed as clinical staff. One personnel record reviewed was medical personnel. The training year of January 1- December 31, 2011 was reviewed. The Project/Facility Director's primary job duty is that of a counselor and thus requires 25 clock hours of training annually. The facility did not document 25 clock hours of training for the 2011 training year.
Employee # 1 was hired on September 21, 2009. Employee # 1 completed 20 clock hours of training for the 2011 training year.
The Project/Facility Director was interviewed on August 21, 2012 and confirmed the findings.
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Plan of Correction
Facility Director will monitor staff to ensure completion of the required training hours annually. Additionally, Facility will hold an in-house training for staff covering Licensing Alert pertaining to Satisfaction of Staff Training Requirements which lists acceptable web based training providers to ensure that all staff members are aware of who is approved to provide this type of training. Facility Director will complete the training before 9/30/12 and will maintain documentation on site. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on the review of the fire drill logs, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on August 21, 2012. The fire drill logs were reviewed for the time period of October 2011 to August 2012. The facility failed to document that a smoke detector or fire alarm had been set off during the fire drills conducted in April, May, June and July, 2012.
The Project/Facility Director was interviewed on August 21, 2012 and confirmed the findings.
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Plan of Correction
Facility Director will submit to the Department of Health for an exception request outlining an alternate procedure for conducting Fire Drills without monthly use of the Fire Alarm so as not to disrupt the other businesses in our building. The request will be submitted by October 31, 2012 and Facility Director will ensure that until we have the exception in place, the Fire Alarm is set off monthly to conduct the drill. Documentation will be maintained on site. |
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 January 1, 2011 to December 31, 2011.
The findings included:
During the onsite inspection of August 20-21, 2012, the annual report for the fiscal year January 1, 2011 to December 31, 2011 was requested for review. There was no documentation provided that the annual report had been completed for the fiscal year ending December 31, 2011.
The Project/Facility Director was interviewed on August 21, 2012 and confirmed the findings.
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Plan of Correction
The Board of Directors will compile an Annual Report by June 30 of each year reviewing activities and accomplishments, financial statements, and names of the Board members. Project Director will monitor and assist the Board of Directors as needed as well as ensure that the completed Report is available to the public beginning on 6/30/2013 and continuing by 6/30 of each subsequent year. The current Annual Report shall be compiled and made available by 10/31/2012. Documentation will be maintained on site for review. |
709.23(b) 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:
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Observations
Based on a review of administrative policies and Board meeting minutes the project failed to demonstrate that the project director had assisted the governing body in formulating policy and had presented the information to the governing body at least annually.
The findings included:
The administrative policies and Board meeting minutes from 2011 and 2012 were reviewed on August 20 and 21, 2012. No documentation was presented to support the fact that the Project Director and the governing body collaborated on the formulation of goals and objectives for the fiscal year which began on January 1, 2012.
The Project/Facility Director was interviewed on August 21, 2012 and confirmed the findings.
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Plan of Correction
Project Director shall prepare and present to the Board of Directors an overall annual performance report by March 31 of each year as well as quarterly updates thereafter on the clinic performance which will be used by the Board to guide the clinic operations. The Board of Directors will indicate their receipt and review of these reports with a dated signature and all documentation will be maintained on site. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document annual staff work performance evaluations in one of two personnel records.
The findings include:
Four personnel records were reviewed on August 20-21, 2012. Annual staff work performance evaluations were required in two personnel records. The facility did not document annual staff work performance evaluations in personnel record # 2.
Employee # 2 was hired on July 26, 2011. Per policy, evaluations are completed annually on the employee's anniversary date. The annual work performance evaluation for 2012 was due by July 26, 2012. The facility failed to document an annual work performance evaluation.
The Project/Facility Director was interviewed on August 21, 2012 and confirmed the findings.
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Plan of Correction
Facility Director shall prepare and update a complete list of employees which includes their hire date and will provide an annual performance evaluation each year within 15 days of the anniversary of their original hire date. Facility Director shall complete an Annual Evaluation for Employee #2 by 9/30/12 and maintain documentation in that Employee Chart. Additionally, Facility Director will maintain copies of all signed evaluations on site as part of each employee's employment record. |