INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 15, 2011 and February 16, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, Another Way, 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 investigation and a plan of correction is due on March 18, 2011.
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Plan of Correction
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704.12(a)(3)(i) LICENSURE NonHosp Rehab
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).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of resident census information, counselor hours and an interview with the project director, the facility failed to ensure the staff to client ratio remained at one full time equivalent (FTE) counselor for every eight clients.
The findings include:
The client census information and clinical staff hours were reviewed on February 16 with the assistance of the facility director and project director. Inpatient non-hospital treatment and rehabilitation serving adult clients shall have one FTE counselor for every eight clients. On February 16, 2011 the Facility Director and the Project director confirmed that there were 2.6 full time equivalent (FTE) counselors and 23 clients. Based on the information, the client to counselor ratio is at 9:1 which exceeds the maximum 8:1 ratio.
The facility director and project director reported that two counselors resigned. One counselor resigned in January 2011 and the second counselor resigned in December 2010. The project and facility director confirmed that the ratio is 9:1.
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Plan of Correction
A full-time Counselor at the male program was promoted to the Facility Director position at the female program on February 2011. Another Way is in the process of hiring a full-time Counselor to fill that open position. The Facility Director will handle cases until counselor is hired. The Board of Directors are responsible for hiring. The agency plans on being in full compliance by May 31, 2011. |
705.5 (j) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(j) A residential facility shall prohibit smoking and use of candles in bedrooms.
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Observations
Based on the physical plant inspection, the residential facility failed to prohibit the use of candles in bedrooms.
Findings:
On February 16, 2011 at approximately 09:00 an inspection of the residential facility was conducted with the project and facility director. Four of twenty four resident rooms were observed to contain evidence of candles with wicks that had been ignited. The facility director indicated clients are allowed to have candles in the bedrooms, however, candles are not to be ignited. Bedrooms A3, A7, B12 and B13 were observed to contain candles where the candle wicks had been ignited.
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Plan of Correction
The candles where removed from the client rooms. The facility director reviewed no candle policy with clients in morning meditation. Signs were made and posted. Clients at admit are educated about policy of no candles when belongings are inventoried. ABC and techs will monitor daily with chore checks that no candles are in the rooms. Another Way is in full compliance March 8, 2011. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on observations made during the physical plant inspection and staff interviews, the residential facility failed to store canned food items off the floor.
Findings:
Based on a physical plant inspection of the residential facility on February 16, 2011 at approximately 09:45, canned food items were stored on the floor in the kitchen food pantry. During the inspection of the facility's physical plant the director acknowledged that storage of food on the floor is prohibited by the project's dietary policies.
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Plan of Correction
To met the standard for ensuring canned food is housed on shelving. Another Way added the third shelving unit which meets restraunt standards to the kitchen area for canned food storage. This will continue to be monitored by the kitchen managers and the night tech. We are in full compliance March 8, 2011. |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on the review of client care policies, staff interviews and client interviews, the facility failed to follow client care policies regarding physical contact between clients and staff.
Findings:
Based on client and staff interviews conducted on February 16, 2011, facility staff failed to comply with the project's policy prohibiting staff from touching clients. Staff interviews conducted during the investigation confirmed that a counselor assistant kicked a client while in a group setting. Client # 4 was interviewed on February 18, 2011 and verified that a counselor assistant kicked him on the leg or foot to wake him when he fell asleep in group.
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Plan of Correction
The counselor assistant was monitoring group with the qualified therapist conducting group. It was brought to the Facility Director's attention by the client 4's therapist that he was taped on the foot by the counselor assistant in group to wake him up. The Facility Director, Counselor Assistant, and Counselor's Therapist met and reviewed more appropriate ways to wake-up clients in group. She had ethics training from Greenbriar on 12/22/10 which addressed client issues. Client's counselor processed with client the above issues. The Counselor Assistant will continue to gain outside trainings on this matter which will be documented in her personnel file. Her assesment and how the trainings will help her job performance will be documented by her and kept on file. The Facility Director will continue to ensure that client's rights are being respected. We are in full compliance on March 8, 2011. |