INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 27-28, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD / New Start II 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(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's staff development records, the facility failed to document an overall training plan to address agency staff training needs.
The findings include:
On June 26, 2012, the facility's training records were reviewed for documentation of an overall agency training plan. The facility did not document an overall training plan for the 2012 training year.
An interview with the facility director on June 26, 2012 confirmed the findings.
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Plan of Correction
The Facility Director in conjunction with the Residential Counselor Supervisor and Clinical Director will set up an annual training program for all employees. The training program will include
(1) All trainings mandated by BDAP
(2) Trainings identified by the management team that will support the employee in their professional development and growth
(3) Trainings identified by each individual staff that they feel will support them in their professional development and growth.
The Clinical Director and Residential Aide Supervisor will be responsible for ensuring that each employee has taken all mandatory trainings in addition to (10) additional training hours. The staff development plan will be reviewed during individual supervision in addition to on the employee annnual performance review.
The annual training plan will be reviewed bi-annually in December and May by the Facility Director.
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the facility's staff development records, the facility failed to document an annual evaluation of the overall training plan.
The findings include:
On June 26, 2012, the facility's staff development records were reviewed for documentation of an annual evaluation of their overall training plan. The facility did not document an annual evaluation of their 2011 training program.
An interview with the facility director on June 26, 2012 confirmed the findings.
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Plan of Correction
The Facility Director in conjunction with the Residential Counselor Supervisor and Clinical Director will set up an annual training program for all employees. The training program will include:
(1) All trainings mandated by BDAP.
(2) Trainings identified by the management team that will support the employee in their professional development and growth.
(3) Trainings identified by each individual staff that they feel will support them in their professional development and growth.
The Clinical Director and Residential Aide Supervisor will be responsible for ensuring that each employee has taken all mandatory trainings in addition to (10) additional training hours. The staff development plan will be reviewed during individual supervision in addition to the employee's annnual performance review.
The annual training plan will be reviewed bi-annually in May and December. The Program Director will use the training feedback forms from the staff to assess the training program for the year and to develop the training program for the upcoming year in conjunction with the corporate office. |
705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to store all eating, drinking and cooking utensils in a clean enclosed area.
The findings include:
A physical plant inspection was conducted on June 28, 2012 between approximately 9:00 A.M. to 10:00 AM. The facility did not store all eating and drinking utensils in a clean enclosed area.
The kitchen cabinets had noticeable food particles, dust and dirt. Additionally, five of the cabinets were lined with a white powery substance.
An interview with the facility director on June 28, 2012 confirmed the findings.
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Plan of Correction
Immediatley after the cititation was noted the cabinets identified as having the white powdery substances were cleaned. In addition the area where all eating and drinking utensils are kept were cleaned and inspected to ensure dryness before all eating and drinking utensils were placed in them. Moving forward Facility Director has assigned a designee to inspect the kitchen on a weekly basis to ensure that all corrective actions are being constantly implemented and followed thru with to prevent further citations. |
705.7 (b) (4) 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:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that storage areas for foods are free of food particles, dust and dirt.
The findings include:
A physical plant inspection was conducted on June 28, 2012 between approximately 9:00 A.M. to 10:00 AM. The facility did not maintain food storage areas free of food particles, dust and dirt.
The kitchen cabinets used to store food had noticeable food particles, dust and dirt. Additionally, five of the cabinets were lined with a white powery substance.
An interview with the facility director on June 28, 2012 confirmed the findings.
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Plan of Correction
Immediately after the inspection Facility Director had the storage area where the food is kept cleaned and all food particles, dust and dirt was removed. In addition, Facility Director has assigned a designee who will inspect the kitchen on a weekly basis. The assigned designee will inspect the kitchen cabinets for food particles, dust and dirt. The checklist will be kept and be available for review. Also Facility Directory will conduct random inspections of the kitchen to ensure that the kitchen is free |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill log, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
On June 27, 2012, the facility's fire drill log was reviewed. The fire drill log did not contain fire drill reports for the entire year of 2011.
The findings were confirmed by the facility director on June 27, 2012.
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Plan of Correction
The Facility Director has developed a fire drill schedule for the site for the next 12 months. The fire drill schedule is only available to the administrative staff and includes (4) fire drills that will take place during sleeping hours. All fire drill reports will be kept in a fire drill log and be available upon review. The Residential Aides on the assigned shift that the fire drill is scheduled to tak place will be responsible for ensuring that the drills are conducted and documentated. The Residential Supervisor will be responsible for ensuring that all fire drills take place as scheduled and rescheduling any missed drills. The Residential Supervisor will review the fire drill log book on a monthly basis to ensure compliance. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's fire drill log, the facility failed to document a fire drill during sleeping hours at least every six months.
The findings include:
On June 27, 2012, the facility's fire drill log was reviewed. The fire drill reports for the entire year of 2011 were missing from the fire drill log, so it was not possible to determine if the facility conducted fire drills during sleeping hours at least every six months.
An interview with the facility director on June 27, 2012 confirmed the findings.
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Plan of Correction
The Facility Director has developed a fire drill schedule for the site for the next 12 months. The fire drill schedule is only available to the administrative staff and includes (4) fire drills that will take place during sleeping hours. All fire drill reports will be kept in a fire drill log and be available upon review. The Residential Aides on the assigned shift that the fire drill is scheduled to tak place will be responsible for ensuring that the drills are conducted and documentated. The Residential Supervisor will be responsible for ensuring that all fire drills take place as scheduled and rescheduling any missed drills. The Residential Supervisor will review the fire drill log book on a monthly basis to ensure compliance. |
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 and the client handbook, the facility failed to inform clients of their rights.
The findings include:
The client handbook and seven client records were reviewed on June 28, 2012. The facility did not document a complete list of client rights in the client handbook or on the client rights sign-off form in records # 1, 2, 3, 4, 5, 6 and 7.
The facility did not inform the clients of the following rights:
(1) A client has the right to inspect his own records. The project director may temporarily remove portions of the records 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.
(2) The client has the right to appeal a decision limiting access to his records to the project director.
(3) The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
(4) The client has the right to submit rebuttal data or memoranda to his own records.
An interview with the facility director on June 28, 2012 confirmed the findings.
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Plan of Correction
The Clinical Director has developed a new "Client Rights" form which will replace the old form in the client handbook. The new client handbook will be available upon review. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to document a personal history that included historical and current legal, employment, and/or sexual data.
The findings include:
On June 28, 2012, seven client records requiring personal histories were reviewed, specifically records # 1, 2, 3, 4, 5, 6 and 7. The facility did not document a personal history to included historical and current legal, employment and/or sexual data in records # 1, 2, 3, 4, 5, 6 and 7.
Client # 1 was admitted on 3/8/12. The personal history in client # 1's record, dated 3/12/12 did not include historical and current legal, employment and sexual data.
Client # 2 was admitted on 1/2/12. The personal history in client # 2's record, dated 1/26/12 did not include historical and current legal and employment data.
Client # 3 was admitted on 4/23/12. The personal history in client # 3's record, dated 4/23/12 did not include historical and current legal and employment data.
Client # 4 was admitted on 5/7/12. The personal history in client # 4's record, dated 5/7/12 did not include historical and current legal and employment data.
Client # 5 was admitted on 9/8/11. The personal history in client # 5's record, dated 9/8/11 did not include historical and current legal and employment data.
Client # 6 was admitted on 9/14/11. The personal history in client # 6's record, dated 9/14/11 did not include historical and current legal and employment data.
Client # 7 was admitted on 12/9/11. The personal history in client # 7's record, dated 12/12/11 did not include historical and current legal, employment and sexual data.
An interview with the facility director on June 28, 2012 confirmed the findings.
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Plan of Correction
The Clinical Director has revised the form (Biopsychosocial Assessment) that includes the personal history to include historical, current legal, employment and sexual data. The clinical staff has been notifed of the changes and trained. All of the previous forms will be removed and shredded to ensure that the incorrect form is no longer in use. The Intake therapist will have the responsibility of collecting the data that sufficiently obtains the proper information. The Clinical Director will conduct chart audits on a monthly basis. In addition, the utilization review specialist assigned by the corporate office will also conduct random chart audits at his/her discretion. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of client records, the facility failed to document treatment plan updates to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
The findings include:
On June 28, 2012, six client records requiring treatment plan updates were reviewed, specifically records # 1, 2, 3, 5, 6 and 7. The facility did not document a treatment plan update to include an assessment of the client's progress in client records # 2, 5, and 6.
Client # 2 was admitted on 1/2/12. The treatment plan updates in client # 2's record documented on 3/23/12 and 4/23/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 5 was admitted on 9/8/11. The treatment plan updates in client # 5's record documented on 11/11/11, 1/6/12, 2/3/12, 3/29/12, and 4/27/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 6 was admitted on 9/14/11. The treatment plan updates in client # 6's record documented on 12/1/11, 12/30/11, 1/27/12, 2/24/12, 3/23/12, and 4/20/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
An interview with the clinical supervisor on June 28, 2012 confirmed the findings.
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Plan of Correction
The Clinical Director has updated the treatment plan to include the assessment of progress from the previous treatment period. The Clinical Staff has been notified of the changes to the treatment plan and trained on how to accurately update client progress or lack of. In addition, the previous forms has been removed and shredded to ensure that the correct treatment plan template is being used. The Clinical Director will conduct chart audits on a monthly basis to ensure a clinical record deficiency does not recur. In addition, the Utilization Review Specialist assigned by the corporate office will also conduct random chart audits at his/her discretion to ensure further compliance with this deficiency.
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709.53(a)(9) LICENSURE Aftercare plans
709.53. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document aftercare plans to include future goals with time frames and/or the criteria for re-entry into the project.
The findings include:
On June 28, 2012, three client records requiring aftercare plans were reviewed, specifically records # 5, 6 and 7. The facility did not document an aftercare plan to include future goals with time frames and/or criteria for re-entry into the project in client records # 4, 5, and 6.
Client # 5 was admitted on 9/8/11 and discharged on 6/11/12. The aftercare plan in client # 5's record documented on 4/24/12 did not include the criteria for re-entry into the project.
Client # 6 was admitted on 9/14/11 and discharged on 6/8/12. The aftercare plan in client # 6's record documented on 6/8/12 did not include future goals with time frames and the criteria for re-entry into the project.
Client # 7 was admitted on 12/9/11 and discharged on 3/9/12. The aftercare plan in client # 7's record documented on 3/9/12 did not include future goals with time frames and the criteria for re-entry into the project.
An interview with the clinical supervisor on June 28, 2012 confirmed the findings.
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Plan of Correction
The Clinical Director has developed an aftercare plan that includes future goals with time frames and/or the criteria for re-entry into the project. All clients who are either being discharged from the program or who will be receiving a different level of care will have a completed aftercare plan along with a follow up care sheet to assess their progress in the community and compliance with aftercare plan. All of the Clinical Staff has been notified that a new form is being introduced into the clinical chart. They have also been trained on how to use the form. The Clinical Director will conduct chart audits on a monthly basis to ensure that aftercare plans are being completed correctly. In addition, the utilization review specialist assigned by the corporate office will also conduct random chart audits at his/her discretion to ensure further compliance with this plan of correction. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in three out of three client records.
The findings include:
On June 28, 2012, three client records requiring follow-up information were reviewed, specifically records # 5, 6 and 7. The facility did not document follow-up information in client records # 5, 6 and 7.
Client # 5 was admitted on 9/8/11 and discharged on 6/11/12. Client # 5's record did not contain follow-up information at the time of review.
Client # 6 was admitted on 9/14/11 and discharged on 6/8/12. Client # 6's record did not contain follow-up information at the time of review.
Client # 7 was admitted on 12/9/11 and discharged on 3/9/12. Client # 7's record did not contain follow-up information at the time of review.
An interview with the clinical supervisor on June 28, 2012 confirmed the findings.
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Plan of Correction
All clients who are either being discharged from the program or who will be receiving a different level of care will have a completed aftercare plan along with a follow up care sheet to assess their progress in the community and compliance with aftercare plan. The client's Therapist will ensure that the client has a completed Aftercare Plan. The Clinical Director will monitor for completion via individual supervision and chart auditing. The Case Manager will be responsible for following up on all discharged residents for (30) days after discharge for continutiy of care. The Case Manager has been assigned to follow up on records #5, 6 & 7 to assess reintegration into the community and connect with any identified community based services if needed. |