INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30, 2010 through July 1, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Lower Merion Counseling Services 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 July 26, 2010.
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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 personnel records, staffing requirements facility summary report and a staff interview, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Five personnel records were reviewed on June 30, 2010 and the staffing requirements facility summary report was reviewed on June 30, 2010 and July 1, 2010. There was no documentation of HIV/AIDS and TB/STD training in five employee records. Of the five employees, one was to have HIV/AIDS and TB/STD training within the first year of employment and the rest were required to have HIV/AIDS and TB/STD training within the two years of employment.
Employee #5 was hired April 21, 2009 and was required to have HIV/AIDS & TB/STD training by April 21, 2010. There was no documentation of HIV/AIDS & TB/STD training in the employee's record as of June 30, 2010.
Employee #8 was hired July 5, 2007 and was required to have HIV/AIDS & TB/STD training by July 5, 2009. There was no documentation of HIV/AIDS & TB/STD training documented in the staffing requirements facility summary report, dated June 28, 2010.
Employee #9 was hired December 18, 2006 and was required to have HIV/AIDS & TB/STD training by December 18, 2008. There was no documentation of HIV/AIDS & TB/STD training documented in the staffing requirements facility summary report, dated June 28, 2010.
Employee #10 was hired November 19, 2007 and was required to have HIV/AIDS & TB/STD training by November 19, 2009. There was no documentation of HIV/AIDS & TB/STD training documented in the staffing requirements facility summary report, dated June 28, 2010.
Employee #11 was hired July 9, 2007 and was required to have HIV/AIDS & TB/STD training by July 9, 2009. There was no documentation of HIV/AIDS & TB/STD training documented in the staffing requirements facility summary report, dated June 28, 2010.
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Plan of Correction
All staff members whose required HIV/AIDS and TB/STD/Hep training is found to be overdue will enroll in and attend the soonest trainings offered by BDAP, no later than 9/30/10..
To prevent future recurrence of this issue,
?X The Administrative Director shall monitor all personnel files on a monthly basis to ensure that all required training is met within the required timeframe.
?X The Administrative Director will explain all training and continuing education requirements to newly hired personnel during agency orientation within the first seven days of hire.
?X Supervisors will review completion of required trainings and plan future trainings with individual staff members at least once yearly during annual performance reviews.
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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 personnel records, the facility failed to document the instruction of staff in the use of the fire extinguisher within seven days of staff employment, in four of seven personnel records.
The findings include:
Seven personnel records were reviewed on June 30, 2010. Seven personnel record was required to document fire extinguisher training, #1, 2, 3, 4, 5, 6 and 7. The facility failed to document the completion of fire extinguisher training within seven days of staff employment in personnel records #2, 5, 6 and 7.
Employee # 2 was hired on July 6, 2009. The training was due within seven days, by July 12, 2009. The training was documented on June 6, 2010, which is later than the seven days required.
Employee # 5 was hired on April 21, 2009. The training was due within seven days, by April 26, 2009. The training was documented on May 1, 2009, which is later than the seven days required.
Employee # 6 was hired on December 28, 2009. The training was due within seven days, by January 3, 2010. The training was documented on June 18, 2010, which is later than the seven days required.
Employee # 7 was hired on January 11, 2010. The training was due within seven days, by January 17, 2010. The training was documented on June 17, 2010, which is later than the seven days required.
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Plan of Correction
The Administrative Director will provide fire safety training, including use of fire extinguishers, to all new employees within the first seven days of hire. The Administrative Director will also ensure that this training is appropriately documented in each staff member's file within 24 hours of training.
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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 personnel records, the facility failed to document that staff are trained to perform assigned tasks during emergencies within seven days of staff employment, in four of seven personnel records.
The findings include:
Seven personnel records were reviewed on June 30, 2010. Seven personnel record was required to document that staff are trained to perform assigned tasks during emergencies, #1, 2, 3, 4, 5, 6 and 7. The facility failed to document the completion of training within seven days of staff employment in personnel records #2, 5, 6 and 7.
Employee # 2 was hired on July 6, 2009. The training was due within seven days, by July 12, 2009. The training was documented on June 6, 2010, which is later than the seven days required.
Employee # 5 was hired on April 21, 2009. The training was due within seven days, by April 26, 2009. The training was documented on May 1, 2009, which is later than the seven days required.
Employee # 6 was hired on December 28, 2009. The training was due within seven days, by January 3, 2010. The training was documented on June 18, 2010, which is later than the seven days required.
Employee # 7 was hired on January 11, 2010. The training was due within seven days, by January 17, 2010. The training was documented on June 17, 2010, which is later than the seven days required.
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Plan of Correction
The Administrative Director will provide fire safety training, including performance of assigned tasks during emergencies, to all new employees within the first seven days of hire. The Administrative Director will also ensure that this training is appropriately documented in each staff member's file within 24 hours of training. |
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 a review of fire drill record, the facility failed to document the fire alarm/smoke detector system was operational.
The findings include:
The fire drill logs were reviewed on June 30, 2010. Per regulation, facilities shall set off a fire alarm or smoke detector during each fire drill. The facility was verbally announcing the fire drills for the months of July 2009, August 2009, September 2009, October 2009, November 2009, December 2009, January 2010, February 2010, March 2010, April 2010, May 2010 and June 2010. The facility does not have an exception to this regulation.
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Plan of Correction
The Program Director will educate the Administrative Director of the necessity to set off a fire alarm or smoke detector during each fire drill. The Administrative Director will set off a fire alarm or smoke detector during each fire drill and document this activity. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of the audit for July 1, 2008 through June 30, 2009, the project failed to complete audit by the end of the project's fiscal year.
The findings include:
The policy and procedure manual was reviewed on June 7, 2010. The annual audit was not made available until June 6, 2010. The documentation was required to be made available prior no later than December 30, 2009.
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Plan of Correction
The Annual Audit will be made available by the Corporate Budget Analyst prior to the end of the fiscal year ending on June 30th of that year. If for some reason unforeseen circumstances the audit will not be made available by that date, a request for an extension will be submitted. |
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 files and administrative policies and procedures, the facility failed to meet the requirements of this regulation as evidenced by the absence of annual performance reviews in two of four records.
The findings include:
Seven personnel records were reviewed on June 30, 2010. Annual performance reviews were required in four records, #1, 2, 3 and 4. Records #5, 6 and 7 are contract employees and are not required to have annual performance reviews documented. Per the facility's policy and procedure annual, performance reviews are done yearly on an employee's anniversary date.
According to documentation revealed in employee record # 3, the last documentation of an annual performance review was documented September 5, 2008.
According to documentation revealed in employee record # 4, last documentation of their annual performance review was documented June 3, 2009.
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Plan of Correction
The Program Director will ensure that all personnel receive individual performance evaluations at least once annually on or before their anniversary date.
The Administrative Director will be responsible for tracking this event and notifying the Program Director of upcoming reviews at least 2 weeks prior to the staff member's anniversary date.
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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 a review of client records, the facility failed to document complete psychosocial evaluations in four of four client records reviewed.
The finding includes:
Four records were reviewed on July 1, 2010. Psychosocial evaluations were required in four records reviewed, #1, 2, 3 and 4. Also, per the facility's policy and procedure manual, the psychosocial evaluations are done at intake.
Client records #1, 2, 3 and 4 failed to document the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client # 1 was admitted on 4/27/10; the psychosocial evaluation was completed on 5/10/10.
Client # 2 was admitted on 6/3/10; the psychosocial evaluation was completed on 6/11/10.
Client # 3 was admitted on 3/26/10; the psychosocial evaluation was completed on 4/1/10.
Client # 4 was admitted on 12/22/10; the psychosocial evaluation was completed on 12/29/10.
None of the psychosocial evaluations were completed at intake.
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Plan of Correction
The Program Director will educate all staff of the necessity to complete the intake assessment in its entirety, with no questions unanswered, at the time of the assessment interview. The Program Director will also educate all staff that the psychosocial evaluation must be completed no later than 30days from intake, and the Program Director will update agency policy and procedures accordingly.
The CQI Specialist will review all charts within 30days of the intake assessment to ensure all assessment and documentation is completed in their entirety and within the 30day timeframe.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to conduct a case consultation in one of one client records.
The findings include:
Four client records were reviewed on July 1. Cases consultations were required in one client records. Per the facility's policy and procedure manual, case consultations are to be documented every 90 days from the client's admission date. Client #1 was admitted on 12/22/09 and discharged on 5/28/10; there was no documentation of case consultations in client record #1.
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Plan of Correction
Agency policy and procedures for 709.93(a)(8) state that "case consultations shall be completed at least every 90days from the point of admissions."
To ensure that case consultations are completed within the specified timeframe, the Program Director will educate all staff of this policy, and the CQI Specialist will track all charts to maintain this schedule and advise assigned clinicians.
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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, the facility failed to document discharge summaries in accordance with facility policy in one of two discharge records reviewed.
The finding includes:
Four client records were reviewed on July 1, 2010. Discharge summaries were required in two discharge records reviewed, #2 and 4. Per the facility's policy and procedure manual discharge summaries are to be completed within 7 days after the client's discharge date. Client record #3 was discharged on 5/3/10 and their discharge summary should have been completed by 5/10/10; it was not documented until 5/19/10.
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Plan of Correction
Agency policy and procedures for 709.93(a)(10) states that discharge summaries shall be completed "within one week post discharge."
To ensure that this documentation is completed within the specified timeframe, the Program Director will educate all staff of this policy and the CQI Specialist will review all closed charts for compliance within 6 days of closure.
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