INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 2, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Warren General 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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704.11(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 six of six personnel records reviewed.
The findings include:
Six personnel records were reviewed on July 2, 2012. Individual training plans were required in six personnel records. Per agency policy, individual training plans were due to be completed in June of each year. The facility did not document individual training plans in personnel records # 1, 2, 3, 4, 5 and 6.
An interview with the facility director and counselor on July 2, 2012 confirmed he findings.
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Plan of Correction
Responsible Staff: Facility Director, Supervisor and Counselor. PoC: Facility Director and Counselor will review the staff development program and will annually develop individual training plans with the input of each employee. The target date for completion of a current comprehensive staff development plan is August 31, 2012. Thereafter, the Facility Director will be responsible for ensuring that the individual training plans are implemented and completed with each employee.
Warren General Hospital Detoxification Services Policy Number 504 states, in pertinent part: "POLICY: It is the policy of Warren General Hospital to conduct an annual assessment of the training in which the staff participated during the past year and to identify training needs for the next year." Implementation of Policy 504 is as follows: "1. In June,the supervisor will complete an assessment and feedback survey form with each staff member....2. The supervisor shall complete an Annual Training Evaluation for each employee. This shall be completed at the end of the fiscal year [which is June 30.] 3. The...Facility Director shall review the individual annual training evaluations...."
To ensure that this deficiency does not recur, the Facility Director will complete the review of employee training evaluations by June 30 each year. The completed evaluations will indicate the trainings that were completed for that fiscal year and will contain the training plan for the following fiscal year. The Facility Director will track fulfillment of employee training plans in a Staff Education Log Book.
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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 personnel training records, the facility failed to provide documentation of HIV/AIDS and TB/STD and other communicable diseases training in one of two personnel records, as required by regulation.
The findings include:
Six personnel records were reviewed on July 2, 2012. Two personnel records were required to have documentation of HIV/AIDS and of TB/STD training. The facility did not provide documentation of HIV/AIDS and/or TB/STD training in personnel record # 6.
Employee # 6 was hired on June 23, 2005. HIV/AIDS and TB/STD training was due to be completed no later than June 23, 2007. The facility failed to provide documentation of HIV/AIDS and TB/STD training.
An interview with the facility director and counselor on July 2, 2012 confirmed the findings.
This is a repeat citation.
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Plan of Correction
Responsible Staff: Facility Director and Drug and Alcohol Counselor. PoC: The Facility Director will identify Department-approved curriculum for required trainings by August 31, 2012 and will schedule employees for the required trainings. Facility Director will incorporate the required trainings into the annual training schedule for all new employees. Facility Director will initiate and maintain a Log Book to document that required staff education occurs within two years of the start of employment. Facility Director and Drug and Alcohol Counselor will meet on a monthly basis to ensure that the trainings occur for each employee within the two year period.
Facility Director will schedule Employee #6 to attend HIV 101 training in Marienville, PA on September 13, 2012, and TB/STD/OHRI training in Should say Marienville, PA on September 20, 2012. Both trainings are sponsored by Abraxis I and have been approved by the Pennsylvania Certification Board (PCB). Facility Director will ensure that Employee #6 has attended by verifying same with Employee #6, receiving documentation of attendance from Employee #6 and entering attendance in an education Log Book. If Employee #6 is unable to attend these trainings, Facility Director has informed Employee #6 that employment will be terminated for failure to comply with policy that requires these trainings. Compliance shall be obtained no later than November 2, 2012.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the review of personnel records, the facility failed to document that the project director completed at least 12 clock hours of training annually in one of one personnel record.
The findings include:
Six personnel records were reviewed on July 2, 2012. One personnel record was reviewed as the project director. The training year from July 1, 2011 to June 30, 2012 was reviewed. The facility did not document 12 hours of annual training for employee # 1. Employee # 1 had 0 training hours documented for the reviewed training year.
The facility director and counselor were interviewed on July 2, 2012 and confirmed the findings.
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Plan of Correction
The Facility Director will ensure that Project Director completes the 12 hours of required annual training in topics set for in 28 Pa. Code 704.11(d). Facility Director will confer with Project Director at mid-fiscal year to ensure that Project Director completes the required training in a timely fashion. Upon further investigation of the Project Director's training during fiscal year 2011-2012, it was discovered that Project Director had completed 24 hours of training. Therefore, there was a failure of documentation but not of training. |
157.25 (a) LICENSURE Notification and termination.
157.25 Notification and termination.
(a) The director shall notify the patient, in writing, of a decision to involuntarily terminate the patient's treatment in the service. The notice shall include the reason for termination.
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Observations
Based on a review of patient records, the facility failed to notify the patient, in writing, of a decision to involuntarily terminate the patient's treatment at the project, in two of two patient records.
The findings include:
Six patient records were reviewed on July 2, 2012. Two patient records reviewed had been involuntarily terminated from the project. The patient's were required to be notified, in writing, of a decision to involuntarily terminate the patient's treatment at the project. The facility failed to notify the patient, in writing, in patient records # 5 and 6.
Patient # 5 was admitted into treatment on March 28, 2012 and was involuntarily terminated from the project on March 30, 2012. There was no documentation of written notification to the patient at the time of the licensing inspection, on July 2, 2012.
Patient # 6 was admitted into treatment on May 4, 2012 and was involuntarily terminated from the project on May 7, 2012. There was no documentation of written notification to the patient at the time of the licensing inspection, on July 2, 2012.
An interview with the counselor on July 2, 2012 confirmed the findings.
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Plan of Correction
Responsible Staff: Facility Director and Counselor
POC: A written Notice of Termination that includes the reason for involuntary termination will be developed by August 31, 2012. The form will be developed by the Facility Director and Counselor and approved by the Medical Director. If a situation occurs prior to the approval of the form, a written notice, including the reason for the involuntary termination as well as the documentation of client's decision to request reconsideration or declination of reconsideration, will be typed and a copy given to the client.
All staff will receive education regarding the written Notice of Termination by August 31, 2012.
100% of involuntarily terminated client charts will be reviewed for compliance for six months.
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