INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 19, 2014 - May 21, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Libertae Family House Libertae, 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(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 three of four employee records reviewed.
The findings include:
Four personnel records requiring documentation of individual training plans were reviewed on May 19, 2014. The facility failed to provide documentation of individual training plans in personnel records # 7, 8 and 9.
The information was reviewed with and confirmed by the facility director.
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Plan of Correction
The responsible party is the Operations Manager.
The Operations Manager will create and review individual training plans for staff # 7, 8, and 9 by July 7, 2014
Moving forward the Operations Manager will complete individual training plans during annual evaluations. |
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 records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training within the required time frame in two of four personnel records reviewed.
The findings include:
Four personnel records requiring documentation of HIV/AIDS and TB/STD training were reviewed on May 19, 2014. The facility failed to ensure that employees # 8 and 9 received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training within two years of employment.
Employee # 8 was hired as a treatment technician on March 11, 2010 and was required to receive 6 hours of HIV/AIDS and at least 4 hours of TB/STD training by March 11, 2012. The record did not include documentation of either training as of May 19, 2014.
Employee # 9 was hired as a treatment technician on October 5, 2011 and was required to receive 6 hours of HIV/AIDS and at least 4 hours of TB/STD training by October 5, 2013. The record did not include documentation of either training as of May 19, 2014.
The information was reviewed with and confirmed by the facility director.
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Plan of Correction
The responsible party is the Operation Manager.
The Operations Manager located HIV/AIDS and training certificates for Employee #9 and will forward them to DDAP License Specialist on 6/25/2014.
The Operations Manager scheduled a TB training with the Bucks County Department of Health for 10/6/2014 for employees #8 and #9 and all who needed to attend.
The Operations Manager informed Employee #8 of the need to attend the next scheduled HIV/AIDS training prior to 10/6/2014
Om May 26. 2014 the Operations Manager created tracking sheet to better track staffing needs. |
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 annual training for the 2012/2013 training year in one of four personnel records reviewed.
The findings include:
The facility's training year runs from July 1 to June 30.
Four personnel records were reviewed on May 21, 2014. The facility failed to ensure that employee # 6 obtained 25 clock hours of annual training for the 2012/2013 training year.
Employee # 6 was hired as a counselor on Sept. 7, 2011. The facility failed to ensure that employee # 6 obtained 25 clock hours of annual training as the record only contained documentation of 8.5 clock hours of training for the 2012/2013 training year.
The information was reviewed with and confirmed by the facility director.
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Plan of Correction
The responsible party is the Clinical Director.
Correction: Employee #6 has provided documentation of meeting the 16 training hours for 2012-2013 training year. The training certificates will be forwarded to the Licensing Specialist on 6/25/2014.
To ensure this will not happen again, The Clinical Director will ensure that the annual 25 training hours for employee #6 and all clinicians are completed by tracking the hours with clinicians bi-monthly during individual clinical supervision. Also, training options will continued to be reviewed in the clinical team meetings and Clinical Department meetings to make them available. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that the grounds of the facility were in good repair at all times.
The findings include:
A physical plant inspection was conducted on May 19, 2014 at approximately 11:00 AM. The following deficiencies were found:
1.Four ceiling tiles with brown stains were observed in the first floor employee bathroom.
2.One ceiling tile with a large brown stain was observed in the first floor client bathroom.
3.There were three 1'' by 1'' holes in the middle of the wall in the shared room between Rooms 11 and 12.
4.The window screen frames on the windows in Room 19 and the shared room attached to Room 19 were bent and in disrepair.
5.There was a 3'' by 3'' hole in the window screen in the shared room attached to Room 21.
6.The paper towel holder in the shared bathroom between Room 13 and Room 14 was detached from the wall and resting on top of the toilet tank.
The resident manager confirmed the findings.
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Plan of Correction
The responsible party is the Executive Director, Family House Resident Manager and The Maintenance Associate.
1. The four ceiling tiles will be replaced by July 15, 2014
2. The one ceiling tile in the first floor client bathroom will be replaced by July 15, 2014.
3. The 1" by 1" holes in the wall of rooms 11 and 12 were repaired while inspectors were on grounds on 5/20/14.
4. The window screen frames on the windows in room 19 were repaired while inspectors were on grounds on 5/20/2014.
5. The 3"by 3" hole in the window screen in shared room attached to Room 21 was repaired while inspectors were on grounds on 5/20/2014
6. The paper towel holder in the shared bathroom between room 13 and room 14 were repaired while inspectors were on grounds on 5/20/14.
The Executive Director will continue to ensure that rounds of the grounds will be done by the Resident Manager (supervised by Operations Manager) in order to list the repairs on the maintenance list and that they are repaired as they arise by priority. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all trash was stored in covered containers.
The findings include:
A physical plant inspection was conducted on May 19, 2014 at approximately 11:00 AM. The facility failed to cover the trash cans in the outdoor child play area and in the indoor child play area.
The resident manager confirmed the findings.
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Plan of Correction
The Responsible Party is the Parenting Specialist/Family Services Coordinator.
The Child Aide in the Family Center put the covers on the trash can in the outdoor child play area and in the indoor child play area in the presence of the state inspector on 5/19/2014.
The Parenting Specialist/Family Services Coordinator will ensure on a daily basis that the trash can covers are properly placed on the trash cans.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that there were no heaters located within the facility that were not permanently mounted or installed.
The findings include:
A physical plant inspection was conducted on May 19, 2014 at approximately 11:00 AM.
Two portable space heaters that were not permanently mounted or installed were observed in the maintenance office.
The resident manager confirmed the findings.
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Plan of Correction
The responsible party is the Executive Director.
Two portable space heaters were removed from the property on 5/19/2014.
While the state inspectors were on grounds.
So this does not recur the Executive Director will review the safety protocol of not having space heaters on grounds during the July 7, 2014 all staff meeting.
To ensure this deficiency does not reoccur, Maintenance will check for space heaters during their monthly rounds to ensure they are not on grounds. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all exits from the facility were unobstructed.
The findings include:
A physical plant inspection was conducted on May 19, 2014 at approximately 11:00 AM.
A large plastic bin that was overfilled with random objects was obstructing the pathway to the exit door in the staff lounge.
The resident manager confirmed the findings.
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Plan of Correction
The responsible party is the Resident Manager and Maintenance Associate.
The large plastic bin was removed on the same day of the inspection on 05/19/2014.
The Resident Manager and Treatment techs. will check during daily rounds the exit pathways to ensure there are no obstructions.
As in previous POC rejection reasons the DDAP system showed an error box and would not allow 5/19/14 to be entered in the COD space it had to be 5/20/14.
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent to release client information form, to include the specific information disclosed, dated signature of client or guardian and/or dated signature of witness, in two of seven client records reviewed.
The findings included:
Seven client records were reviewed for documentation of consent to release client information forms during the on-site inspection. The facility failed to obtain a consent to release client information form, to include the specific information disclosed, dated signature of client or guardian and/or dated signature of witness, in client records # 12 and 18.
Client record # 12 contained a consent to release client information form for emergency contacts that was dated 5/16/2014. The facility failed to obtain a dated signature of a witness on the consent form.
Client record # 18 contained a consent to release client information form addressed to a family member that was dated 1/23/2014. The facility failed to include the specific information disclosed as the consent form included the following language for information to be disclosed: "......and other legal matters in common." The facility also failed to obtain a dated signature of the client on the consent form. The record also included a consent to release client information form for emergency purposes that was dated 12/23/2013. The facility failed to obtain a dated signature of a witness on the consent form.
The information was reviewed and confirmed with multiple staff members.
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Plan of Correction
The responsible party is the Clinical Director.
Secondly, the Social Services Director and the Therapists supervising clinical interns are also responsible.
For client record #12 the client no longer was no longer in treatment for a new release to be signed by a witness.
For client #18 new consents were filled out with this client #18 who was a current client on 5/22/14.
The specific information was corrected as to the disclosed information on the first consent. A dated signature was also obtained.
The original witness signature was obtained for the second release form for emergency purposes.
The Clinical Director, the Social Services Director and Therapists reviewed the current release of information and will offer a training to included a refresher for new clinical and life skills interns by October 6, 2014.
Moving forward The Clinical Director will include this training for all new interns accepted to train at Libertae.
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