INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection, conducted on December 17 - 18, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation 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(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 employee training files, the facility failed to ensure that staff persons received at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum within the required timeframes.
The findings include:
One employee training file was reviewed on December 17, 2014, for documentation that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training.
The facility failed to ensure that employee # 9 received the required 4 hours of TB/STD training within the first year of employment.
Employee # 9 was hired as a counselor on 12/3/13 and was required to receive 4 hours of TB/STD training by 12/3/14. There was no documentation of this training at the time of review on 12/19/14.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The subject employee has self scheduled themselves to take the training on January 27, 2015. The subject employees supervisor will vertify on that date that the subject employee is indeed at the training. Within one week from completion of the training the subject employees supervisor will request a certificate of completion which the supervisor will then give to the office manager to place in the training folder no later than February 6, 2015.
The training originally scheduled for 1/27/15 was cancelled due to weather conditions. A new training has not yet been rescheduled but is expected to be in place by March 31, 2015.
The office manager has created a spreadsheet to track staff's mandatory training requirements. Each staff person in need of training and tehir supervisor is informed monthly of any requirements that are not met. The supervisor reviews this information as part of regular supervision and ensures that the required trainings are completed. The executive director reinforces that importance of compliane in this area with all staff at monthly staff meetings.
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the documentation provided for the facility's CPR certification and first aid training, and a review of staff work schedules, the facility failed to verify first aid training to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
The findings include:
The facility's hours of operation are:
Monday through Thursday 6:00 AM to 9:00 PM
Friday 6:00 AM to 5:00 PM
Saturday 8 AM to 10 AM
On December 17, 2014, the facility's CPR certification, first aid training and work schedules were reviewed.
The facility provided CPR certification cards for staff; however, the cards did not include documentation of first aid training. While the facility has nursing staff on duty, they only work from 6:00 AM - 3:00 PM. The facility was unable to provide any additional documentation verifying that non-nursing staff who would work beyond 3:00 PM were trained in first aid. The facility failed to verify first aid coverage during the evening hours on Monday through Thursday 3PM until 9PM and Friday 3 PM until 5PM.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
First aid training will be scheduled with the company that has provided CPR training and also offers first aid training by the office manager. The training will be conducted during the month of February. The office manager will assign at least two staff persons that work the evening hours on Monday through Thursday 3PM to 9PM and Friday 3 PM to 5PM. In addition at least two staff from the day time shift will also be assigned to the training. The office manager will personally visit the trainig to verify that the required individuals are in attendance and will place a certiicate of completion in their training folder by February 28th. |
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 at least 25 clock hours of annual training in three of four employee records reviewed.
The findings include:
Four employee records requiring documentation of training hours for the 2013-2014 training year were reviewed on December 17, 2014. The facility failed to ensure that each counselor completed at least 25 clock hours of annual training, employee # 5, 6 and 7.
The facility's training year is from July 1 through June 30.
Employee # 5, a counselor, was hired 1/31/01. Employee # 5 was required to complete 25 hours of annual training for the 2013-2014 training year. Employee # 5's training file only included documentation of 12 training hours.
Employee # 6, a counselor, was hired 11/1/11. Employee # 6 was required to complete 25 hours of annual training for the 2013-2014 training year. Employee # 6's training file only included documentation of 17 training hours.
Employee # 7, a counselor, was hired 7/16/12. Employee # 7 was required to complete 25 hours of annual training for the 2013-2014 training year. Employee # 7's training file only included documentation of 2 training hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has reorganized responsibilites for the tracking of training hours for all applicable staff. The office manager will be the central point of contact for record keeping. All program managers will be informed of staff progress toward meeting the requirements. Furthermore the Executive Director will review the information at full staff meetings with all staff to ensure compliance.
At each monthly staff meeting the office manager will review a list of training hours still required by staff to meet the requirement. The program coodinators will then ensure that staff are scheduled for required trainings and report to the executive director at monthly managment meetings. By April 1st of each year the executive director will review progress. Any staff still in need of training hours will be scheduled by their supervisor who will report the information to the executive director. The executive director and the office manager will then reconcile the information to ensure compliance. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate bathrooms by use of an exhaust fan or window in six of four bathrooms.
The findings include:
A physical plant inspection was conducted on December 18, 2014.
The exhaust fans in four out of six bathrooms were not operable at the time of inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The office manager has scheduled the required work to be completed during the week of January 26th. The executive director will personally observe the work to ensure completion. The office manager will conduct quarterly inspections of the facility to ensure that all exhaust fans are in working order. The results will be communicated in writing to the executive director. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's fire drill log, the facility failed to conduct fire drills on different staffing shifts.
The findings include:
The facility's hours of operation are:
Monday through Thursday 6:00 AM to 9:00 PM
Friday 6:00 AM to 5:00 PM
Saturday 8:00 AM to 10:00 AM
On December 17, 2014, the facility's fire drill log was reviewed covering the period of December 20, 2013 through October 30, 2014.
The facility failed to conduct a fire drill during the evening shift for the reviewed time period.
The latest a fire drill was conducted during the period of December 20, 2013 through October 30, 2014 was at 4:30 PM on 2/6/14 with one person in the facility.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The office manager has assigned the responsiblity of conducting an fire drill during evenign hours to the evenign receptionist. The evening receptist will conduct a fire drill during the evening shift on a monthly basis. The event will be documented in a log book which will be reviewed by the office manager and then reported to the executive director during monthly supervison. Fire drills during the day time shifts will continue to occur on a monthly basis. |
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 a review of client records, the facility failed to comply with the limitations imposed by 4 Pa. Code 255.5. an informed and voluntary consent for the disclosure of information in six of nine records reviewed.
The findings include:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed
Nine client records requiring documentation of informed and voluntary consents were reviewed on December 17 - 18, 2014.
Six county funded client records contained two forms that documented the release of information to the funding source which exceeded the limitations imposed at 4 Pa. Code; client record # 1, 4, 6, 7, 10, and 12.
The first form, the "clinical summary" documented the release of the client's critical issues; drug and alcohol treatment history; drug and alcohol history including substance, route, frequency, amount, last use, longest time sober and why relapsed; current and past mental health history; abuse/trauma; gambling issues; medical history including medication and when last meds taken; pain management; stage of change; and legal issues.
The second form, the "request for client registration and approval of care" documented the release of the client's primary substance, substance use history, route, and frequency of use.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance on 12/17/13 and 12/13/12.
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Plan of Correction
The executive director has instucted staff to comply wiht the limitations imposed by 4 PA Code 255.5 on all forms and other means of communications to all entities including the SCA. Therefore, regardless of the information required by the SCA, such information will not be provided if it violates 255.5. The executive director will monitor the situation by addressing it with supervisors at by-monthly management meetings. In conducting a quality assurance check of the client records superviors will be instructed to ensure that compliance is achieved in this area. |