INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19-20, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Rehabilitation Services, Inc., Supervised Independent Living Program 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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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to provide annual documentation that the counselor assistant was working toward meeting one of the requirements for the position of counselor within the prescribed five year period.
The findings include:
During the review of personnel records on September 19 - 20, 2011, the Licensing Specialist reviewed the counselor assistant personnel record. Regulation requires a counselor assistant to present annual documentation of work toward counselor status. Although annual paperwork was documented in the record of employee #3, the documents did not reflect an appropriate course of action to meet the Chapter 704 requirements.
Regulation within 704.10 (c) identifies the time frame of 5 years employment to achieve the requirements of counselor. The Licensing Specialist reviewed the documentation on 9/19/2011. The personnel record identified an employment start date of 9/11/06. Requirements for promotion have not been met.
The findings were reviewed with the Project Director, Facility Director and Assistant Facility Director. The Project Director confirmed that this problem existed.
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Plan of Correction
On October 4, 2011, Cheryl D. Williams, Director of the Bureau of Drug and Alcohol Program Licensure, granted an exception for employee #3 extending his qualifications as a counselor assistant until February 6, 2012. The Faclilty Director will ensure that all future Counselor Assistants follow the regulations to meet the qualification of Counselor in a timely manner. |
704.12(a)(3)(ii) LICENSURE NonHosp Rehab/Adol
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(ii) Projects serving adolescent clients shall have one FTE counselor for every six clients.
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Observations
Based on a review of current census with current eligible clinical personnel, the facility was not in compliance with resident/staff ratios during primary care hours. Projects serving adolescent clients shall have one FTE counselor for every six clients.
The findings include:
During an onsite review of staffing forms on September 19 - 20, 2011, the Licensing Specialist reviewed the current resident to staff ratios. Due to the counselor assistant being pulled out of the eligible staff ratios, the ratio for resident to staff was 7 to 1.
The findings were reviewed and confirmed with the Project Director, Facility Director and Assistant Facility Director.
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Plan of Correction
The exception granted by Ms. Williams noted in our response in paragraph 704.10 remediates the resident/staff ratios that were cited. |
705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on an inspection of the physical plant, the facility failed to maintain counseling areas with furnishings which were in good repair.
The findings include:
During an onsite physical plant inspection on September 20, 2011, the Licensing Specialist observed the first and second floor lounge areas. These areas serve a dual purpose as lounge and clinical areas. Three out of three sofas in the first floor lounge had torn seams on the seat cushions and one sofa was badly stained. One out of two sofas in the second floor lounge had torn seams.
The findings were reviewed and confirmed with the Project Director and Facility Director.
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Plan of Correction
On October 7 and 19, 2011, the furniture cited in the report was replaced. In the future, the facility director will ensure the furnishings are repaired and/or replaced more expeditiously. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on an inspection of the physical plant, the facility failed to maintain sleeping areas with furnishings which are in good repair.
The findings include:
During an onsite physical plant inspection on September 20, 2011, the Licensing Specialist observed the sleeping areas. Random inspection was conducted to determine the condition of four mattresses. Three out of four mattresses inspected had large tears and stains on them.
The findings were reviewed and confirmed with the Project Director, Facility Director and Assistant Facility Director.
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Plan of Correction
On September 28, 2011, the mattresses cited in the report and all other mattresses of similar condition were replaced. In the future, the facility director will ensure that mattresses are repaired and/or replaced more expeditiously. A monthly inspection and log of each facility mattress will be recorded and maintained by the Facility Director. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on an inspection of the physical plant, the facility failed to ensure each bathroom was maintained in a functional, clean and sanitary manner at all times.
The findings include:
During an onsite physical plant inspection on September 20, 2011, the Licensing Specialist observed the bathroom areas. The second floor bathroom contained two shower stalls. Each of the two stalls had dirt/mildew in the corners and at edges of the tile. A cover was missing on the light fixture in the third floor bathroom.
The findings were reviewed and confirmed with the Project Director, Facility Director and Assistant Facility Director.
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Plan of Correction
The shower stalls were cleaned and a sealant was applied to the seams to inhibit the accumulation of mildew. The light cover was replaced. The facility director will monitor these areas to ensure they are clean, serviceable and in compliance. |
705.7 (b) (2) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
Based on an inspection of the physical plant during the annual onsite licensing inspection of September 19 - 20, 2011, the facility failed to ensure that cleaning and disinfecting food preparation areas and appliances followed each prepared meal.
The findings include:
During an onsite physical plant inspection on September 20, 2011, the Licensing Specialist observed the food preparation areas. The kitchen was located on the second floor. Residents are involved in meal planning, cooking, and the cleaning of the area. The range had a drawer below the oven that was broken. The vent above the cooking area was greasy. The facility had two refrigerator/freezers and a freestanding freezer. The main refrigerator in the kitchen had condensation dripping onto the stored food. This refrigerator also had food splashes on the upper wall.
The findings were reviewed and confirmed with the Project Director, Facility Director and Assistant Facility Director.
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Plan of Correction
The range storage drawer has been repaired. The facility handyman thoroughly cleaned the vent cover, which eliminated the grease stains and dirt. A new sealant strip for the refrigerator will be purchased and installed by November 1, 2011, which will prevent condensation from forming. The refrigerator has been cleaned and the facility director will ensure it is maintained in a clean condition. A task has been added to the daily shift report to ensure that a staff member checks the kitchen applicances to ensure that they are cleaned and in working order. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the Project's policies and procedures, the facility failed to document a complete policy addressing confidentiality of client identity and records consistent with 4 Pa. Code subsection 255.5.
The findings include:
During an onsite review of the Project's policy and procedures on September 19 - 20, 2011, the Licensing Specialist reviewed the policies and procedures on confidentiality. The policies failed to include the entirety of 4 Pa. Code subsection 255.5. A policy addressing the limitations of disclosure at 4 Pa. Code subsection 255.5 (b) (1-5) was included. The remainder of the confidentiality regulations at 4 Pa. Code subsection 255.5 (a) (1 - 10 ) were not addressed. The policy for medical emergency release of information did not use the stricter language of "where the client's life is in immediate jeopardy."
The policy did not include who, by title, will have primary responsibility for maintenance of the client records.
The findings were reviewed and confirmed with the Project Director, Facility Director and Assistant Facility Director.
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Plan of Correction
DARS, Inc. added to existing Confidentiality Policy 4 Pa. Code subsection 255.5(a)(1-10). Also included was language pertaining to the release of information for medical emergencies, which was clarified as an immediate life threatening emergency.
The updated policy also addressed who specifically would maintain client records, which has been designated to the facility director. |
709.28(a)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(2) Staff access to client records.
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Observations
Based on a review of the Project's policies and procedures during the annual onsite licensing inspection of September 19 - 20, 2011, the facility failed to document a complete policy addressing staff access to client records.
The findings include:
During an onsite review of the Project's policy and procedures on September 19 - 20, 2011, the Licensing Specialist reviewed the policies and procedures on confidentiality. The policies did not outline the methods of staff access to client records.
The findings were reviewed and confirmed with the Project Director, Facility Director and Assistant Facility Director.
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Plan of Correction
All active client records will be kept in a file cabinet located in the facility director's office. All clinical staff, to include the facility director, assistant facility director, counselor, and/or counselor assistants will have a key to the office. The office door will be kept locked at all times other than when staff are actually retrieving or returning records. Staff needing access to the client records, will gain access by unlocking the door to the facility director's office when the facility director is out. Upon retrieving or returning the client record, the staff will immediately lock the office door, if the facility director is out of the office. This procedure will be added to the policy and procedure. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to provide documentation of a complete physical examination.
The findings include:
During an onsite record review on September 19 - 20, 2011, the Licensing Specialist reviewed five records. Five out of five records presented no documentation of the physician's assessment of client's general appearance during the physical examination. The physical exam form provided an area for general appearance which was not completed.
The findings were reviewed and confirmed with the Project Director, Facility Director and Assistant Facility Director.
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Plan of Correction
We communicated with the phyician(s), regarding the requirement for more detailed documentation of the physician's assessment of the client's general appearance during all physical examination. The physician was provided a copy of the standard and agreed to provide this documentation for all future physical examinations.
The physician also agreed to review all physical examinations of clients that were completed at another facility within the preceding 12 months of the client's entry to our program to determine if a new physical examination is necessary. If the physical examination is adequate, the physician will validate the physical examination form with an approved signature. If inadequate, a new physical examination will be performed. Facility Director will review each physical examination upon completion to ensure the standard is upheld. If standard is not upheld, Facility Director will consult with the physician for corrective measures.
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