INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 4-5, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Freedom Healthcare 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 April 4, 2009.
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Plan of Correction
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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 personnel records and discussion with the clinical supervisor, the facility failed to ensure that staff members completed a feedback form on all training attended in three of three personnel records.
The findings were:
Six personnel records were reviewed on March 4-5, 2009. Three were required to have feedback forms completed. The facility did not document that feedback forms on all training attended had been completed in personnel records # 1, 2 and 4. There was no training feedback forms documented in any of the three personnel records.
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Plan of Correction
Freedom Healthcare already has a training evaluation form that had not been used. The director reviewed with all management staff that the evaluation must be completed after each of the trainings. The director has documented in the personnel files that the training evaluation for the previous training was not completed. Any training attended after site inspection for 3/5/09 will have training evaluation forms completed afterwards, and they will be filed in the employees personnel file. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the results of a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen outside the counseling room.
Findings:
A physical plant inspection was completed on March 6, 2009. The first floor is to be used as the methadone maintenance area. This area includes individual counselor offices, examination rooms, a group room and a waiting room. The are windows in each of the areas which are not covered by blinds or curtains. The windows are tinted but this does not provide total privacy. There is a sidewalk that runs along the building as well as park benches where individuals could gather. These individuals would have direct access to the individuals on the first floor on the building.
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Plan of Correction
The director has ordered custom made blinds, as of 4/6/09, for both of the doctor exam rooms. They shall be installed as soon as they come in or no later than 30 days from 4/6/09. The director will have the other windows on the first floor tinted or made opaque by window treating up to 7 ft from the bottom of the window in order to ensure that someone cannot see inside the windows from the outside either with or without the lights on. This shall also be completed as soon as possible but no later than 30 days from 4/6/09. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of the fire drill log and an interview with the clinical supervisor, the facility failed to document that unannounced fire drills were conducted at least once a month.
Findings:
Fire drills logs were reviewed on March 6, 2009. There was no documentation that the facility had conducted a fire drill during the months of November and December 2008, nor for the months of January and February of 2009.
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Plan of Correction
As of 4/1/09, the director will conduct unannounced fire drills on a monthly basis. All fire drills will be documented and filed in a fire drill log showing who was present during the fire drill, the exits used to evacuate the building and the time of evacuation. |
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, the facility failed to document the results of reference investigations in five of six personnel records.
Findings:
Six personnel records were reviewed on March 5-6, 2009. Six personnel records were required to have the results of reference investigations. The facility did not document the results of reference investigations in personnel records # 1, 3, 4, 5 and 6.
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Plan of Correction
As of 3/5/09, the director documented those employees that their references were called and filed in the employees' personnel charts. As of 3/5/09, it was implemented, prior to a potential employees hire date, that they submit their references. Those references are be contacted and the documentation of the phone call or attempted contact with the reference will be documented in the employee's personnel file. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of the job descriptions and an interview with the clinical supervisor, the facility failed to document a job description for project positions that included the current job title, tasks and responsibilities and the requisite skills, knowledge and experience of the position in three of six personnel records.
Findings:
Six personnel records were reviewed on March 4-5, 2009. Six personnel were required to have job descriptions. The facility did not document current job descriptions that included tasks and responsibilities and the requisite skills, knowledge and experience of the position in personnel records # 1, 2 and 3.
In record # 1, the job description documented in the file indicated that the project director was also served as the clinical supervisor. The project director in no longer serving as the clinical supervisor. The job description was not updated to reflect this change.
In record # 2 the the job description documented in the file indicated that the position held by this employee was that of a counselor. This employee is currently serving in a supervisory position. The job description for this employee was not updated to reflect this change.
In record # 3, there was no documentation of a job description for the employee.
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Plan of Correction
As of 3/5/09, the director revised the job description form for the project director and the clinical supervisor (record #1 and record #2). The director and the clinical supervisor have both signed off on new job descriptions that specify their job title, tasks and responsibilities and the requisite skills, knowledge and experience of the position. These updated job descriptions will be filed in each of their personnel charts.
As for record #3, the director developed a job description for the employee that did not have a job description specifying his job title, tasks and responsibilities and requisite skills, knowledge and experience of the position, and it was signed as of 3/6/09.
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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client records, the facility failed to document that the client was informed of the right that a project director may temporarily remove portions of their record prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file in six of six records.
Findings:
Six client records were reviewed on March 5, 2009. Six were required to have documentation that the client was informed of the rights. The facility failed to document that the client was informed that a project director may temporarily remove portions of their record prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client in client records # 1, 2, 3, 4, 5 and 6.
In records #1, 2, 3, 4, 5 and 6, there was no documentation that the client had been informed of this right.
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Plan of Correction
The director has revised the clients rights' form, as of 4/1/09, that the clients sign at intake. It now includes the documentation that the client was informed of the right that the project director may temporarily remove portions of their record prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Clients that have previously been accepted will be given the new form. It will be reviewed with their primary counselor and they will be asked to sign off on the amended client rights form. |