INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28 and August 29, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Counseling and Adoption 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 and a plan of correction is due on October 2, 2007.
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Plan of Correction
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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 agency policy manual, it was determined that the facility failed to meet the requirements of this regulation. The regulation requires that timeframes for the completion of the assessment, plan, feedback mechanism and annual evaluation of the training plan be specified in the procedures. No timeframes were documented in the policy/procedure manual.
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Plan of Correction
The policy addressing "Staff Development" has been revised to outline responsible individuals and timeframes for the completion of the assessment, plan, feedback and annual evaluation of the plan. This revised policy will be presented to the Board on October 17th for approval. The Director will review and document compliance with the policy. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the agency manual and employee training records, it was determined that the facility failed to consistently documented training feedback forms because training evaluation forms were not documented consistently in two of four employee files (#1 and #4).
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Plan of Correction
The revised policy on Staff Development with the timeframes for the completion of training evaluation forms will be reviewed with staff within 30 days. The training plan will include a check off space for when the training evaluation forms are returned. The Director will monitor on-going compliance with this procedure. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
Based on an on site inspection of the physical plant it was determined that the facility failed to meet the requirements of this regulation because there was an egress from the front porch which had more than two steps but did not have a hand rail installed.
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Plan of Correction
The egress from the front porch (which was a carriage step) is not used, nor is it feasible to construct a railing. Therefore a linked chain with a sign will be constructed across the egress. A contractor has been secured to complete the work within 30 days. The Director will oversee its completion. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of employee personnel and training records it was determined that the facility failed to meet the requirements of this regulation because employee # 2, who was hired during the past year, did not receive training in the use of a fire extinguisher within the seven day period required.
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Plan of Correction
The new employee had presented documentation of fire safety training obtained at his other employment 3 months before his current employment,therefore it was accepted in lue of repeating the training. On 8/30/07 the employee did again receive training on the use of a fire extinguisher. Documentation placed in employee's personnel file. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 employee personnel and training records it was determined that the facility failed to meet the requirements of this regulation because employee # 2, who was hired during the past year did not receive training in the performance of assigned tasks during emergencies within the seven day period required.
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Plan of Correction
On 8/30/2007, using the Emergency/Disaster Plan, the Director reviewed the procedures outlined and the individuals responsibilities during an emergency. Documentation was placed in personnel file. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on the review of personnel records and agency policy, it was determined that the facility failed to comply with this regulation and agency guidelines stated in the policy manual which require two reference checks to be documented for each employee. During the inspection four employee records were reviewed. Only one of these records was for an employee hired during the last year (# 2). No reference checks were found in this employee's file. Agency policy requires that two reference checks be completed on each employee.
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Plan of Correction
Two telephone reference checks were completed but were not placed in employee's personnel file. This has been corrected and as of 9/5/07 a check list has been developed for new hires to ensure all documentation is obtained and filed. The Director will monitor. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on reviews of client records it was determined that the facility failed to meet the requirements of this standard because 3 of 6 client records contained incomplete medical histories. Records # 1, 4, and 6 had missing or incomplete medical histories documented. Record # 4 had an incomplete listing of symptoms and illnesses.
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Plan of Correction
The Director has reviewed this standard with staff and will monitor documentation of symptoms and illnesses by reviewing charts on all new clients before case is presented in supervision. Compliance will be monitored through the UR committee. Compliance to be achieved by October 1, 2007. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records it was determined that the facility failed to document complete drug and alcohol histories in 5 of 6 client records reviewed. Specifically, in client records #1, 2, 4, 5 and 6 the lengths and patterns associated with the client's progression of drug and/or alcohol use were incomplete in that they did not document amounts used during various stages in each client's history.
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Plan of Correction
The Director has reviewed this standard with staff and will monitor documentation of complete drug and alcohol histories to include clients' progression of usage at various stages by reviewing charts on all new clients before the case is presented in supervision. Compliance will be monitored through the UR Committee. Compliance will be achieved by
October 1, 2007. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records and agency policy it was determined that the facility failed to document complete personal histories in that required components of client histories were missing or incomplete in the following client records: #1, 2, 4, 5 and 6 or five of the five applicable client records reviewed for this survey. Specific issues noted were family histories which did not provide detail on the family of origin or current family constellation in each of the five records listed. Employment histories were incomplete in client records #1, 2, 4 and 5. Sexual histories were incomplete in client records #1, 2 and 4. Agency policy and procedure and the requirements for this regulation specified the details to be collected in personal histories. In each of the records reviewed, required details were missed.
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Plan of Correction
The Director has reviewed this standard with staff and will monitor documentation of detailed family histories. Although genograms are obtained that contain family dynamics,this information will now be incorporated into the narrataive format. Attention will also be given to obtaining and documenting more detailed information on employment and sexual histories. The Diector will review charts on all new clients before the case is presented in supervision for completeness of information. Compliance will be monitored through the UR committee. Compliance will be achieved by
October 15, 2007. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records it was determined that the facility failed to meet the requirements of this regulation because required components of the psychosocial evaluation were missed in the following client records: #1, 2, 4, 5 and 6 (representing 5 of 5 applicable client records). Specific components missing in client records included the composite picture of the client, the coping/defense mechanisms used by the client and available or potential support systems.
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Plan of Correction
In July 2007, the psychosocial evaluation was modified to better capture the component parts required to include strengths, support systems, coping mechanisms, and negative factors. The charts cited in this deficiency were cases opened prior to this revision. In addition this requirement was reviewed with staff by the Director, who will monitor compliance along with the UR committee's chart review. This will be completed by October 15, 2007. |
709.93(a)(2) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(2) Medication records.
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Observations
Based on a review of client records it was determined that the facility failed to meet the requirements of this regulation because required information was missing from the medication records collected in one of two applicable client records (#5). Required information required includes the drug taken, dose and frequency. The only information provided was the name of the drug taken.
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Plan of Correction
The Director has reviewed this standard with staff and will monitor documentation of medications to include dose and frequency by reviewing charts on all new clients before the case is presented in supervision. Compliance will be achieved by October 1, 2007 and monitored through the UR committee. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on the review of client records, it was determined that the facility failed to meet the requirements of this regulation because the required components were not fully addressed in the following client records: #4, #5 and #6 (3 of 3 applicable). Specific components missing included services offered which stated only that outpatient services were provided but did not indicate the type of service the client received while in treatment ( individual, group, family, education,etc.) Client records also failed to address the clients' status at discharge.
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Plan of Correction
The Director has reviewed this standard with the staff and will monitor the documentation of the Discharge Summary. The Discharge Summary format has been outlined for easy reference to the reason for treatment, type of service, client's response to treatment and the client's status at discharge. Compliance will be monitored through the UR committee. Compliance will be achieved within 45 days. |