INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19, 2022 through September 20, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Self Help Movement, 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors who have not functioned for 2 years as a supervisor in the provision of clinical services completed a Department-approved core curriculum in clinical supervision in one of one applicable client record reviewed.
Employee #2 was hired as a clinical supervisor on February 10, 2021 and did not have clinical supervision experience prior to being hired. There was no documentation of a Department- approved curriculum in clinical supervision training in the record at the time of the inspection.
This is a repeat citation from the September 14, 2021-September 15, 2021 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resources Manager and/or designee will ensure that the Clinical Director attends the core curriculum for clinical supervision.
When a Clinical Director is hired and does not have prior experience, the Human Resources Manager will coordinate with the Clinical Director to get he/she signed up for the approved Department clinical supervision training as soon as possible.
The Human Resources Manager has found a training for December 2022. She will have the Clinical Director fill out the registration form immediately (10/20/22) and send in the completed form. Training will be completed by December 16, 2022. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure that each employee had a written, annual individual training plan, with input from the employee and supervisor, documented in one of thirteen employee records reviewed.
Employee #13 was hired as a counselor on February 23, 2022. The individual training plan in the personnel record was not signed or dated by the employee or the supervisor and there was no other indication that it was developed with input from both the employee and the supervisor.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resource Manager, Assistant Director of Operations and the Clinical Director will meet with each employee to ensure the the employee has input into their training plan and has a written training plan that is signed and dated by the appropriate supervisor and employee.
The Human Resources Manager and/or designee will inspect new employee files within the first month of hire to ensure that all personnel records have an updated training plan signed and dated by the supervisor of the department and the employee. The Human Resources Manager will inspect employee files by the end of January to ensure that all training plans have been signed and dated by the supervisor of the department and the employee.
If the training plan was not signed and dated by the appropriate personnel, the Human Resources will meet with the supervisor to inform them that they need to meet with the employee to develop and sign and date their training plan.
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705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure that frozen food was kept at or below 0 degrees Fahrenheit. One of the freezer chests, located in the dry food storage room in the basement, registered a temperature of 10 degrees Fahrenheit at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Food Services Director will meet with kitchen staff to reiterate that they maintain the temperature logs for all freezers and to make sure that all freezers maintain a temperature of 0 degrees or below.
The kitchen staff will check temperatures on a daily basis and record the temperature in the log book. If there is a problem with temperature maintenance, the kitchen staff will inform the Food Services Director who in turn will contact our representative for service.
The Food Services Director has now set the freezer to maintain a temperature of 0 degrees and made sure the kitchen staff is logging it into the logbook on a daily basis.
This was completed on 9/20/22 and is an ongoing process.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the September 2021 through August 2022 fire drill logs, the facility failed to identify, on their fire drill log, the exit route used.
The fire drills logs, for the drills conducted during the months of December 2021 and January 2022, failed to document the exit route used.
This is a repeat citation from the September 14, 2021-September 15, 2021 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Building and Maintenance and Director of Operations will meet with Resident Monitors to ensure that staff are trained on how to fill out fire drill logs in their entirety with all required information for all fire drills.
The Director of Operations and/or Assistant Director of Operations will be responsible for ensuring that Resident Monitors are trained properly on how to fill out fire drill logs.
The Director of Building and Maintenance will inspect the logs on a monthly basis to ensure that the logs are filled out correctly.
Training will be completed for all Resident Monitors by 11/1/22. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent form was offered to the client in two of eleven applicable client records reviewed.
Client #5 was admitted on November 5, 2021 and was discharged on February 8, 2022. There was a release of information form to an external treatment provider signed and dated by the client on February 8, 2022; however, there was no documentation that indicated a copy of the consent form was offered to the client.
Client #6 was admitted on November 1, 2021 and was discharged on February 10, 2022. There was a release of information form to an external treatment provider signed and dated by the client on November 1, 2021; however, there was no documentation that indicated a copy of the consent form was offered to the client.
This is a repeat citation from the September 14, 2021-September 15, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Admissions Director and Clinical Director will meet with admissions staff to ensure that they know to offer a copy of the release of information client consent form to every client and that it is to be signed and dated by every client.
The Admissions Director and/or Assistant Admissions Director will check each chart after each client has been admitted to ensure that all admissions forms are in the chart and have been signed and dated. This includes documentation indicating the client has been offered a copy of the consent form.
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