INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 9, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tradition House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Reports, the facility failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.The findings include:The Staffing Requirements Facility Summary Reports for the 14 facilities contained within the project were reviewed on October 15, 2013. The equivalent of 105.275 full-time counselors are employed within the project. This would require at least 13 full-time clinical supervisors. The project currently employs 7 full-time clinical supervisors.
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Plan of Correction
The Vice President of Clinical Services will ensure that the ratio of Clinical Supervisors for the project is within the defined regulation of 1 fulltime clinical supervisor for every 8 fulltime counselors or counselor assistants. The Project will re-evaluate its current system and restructure the project to include the appropriate number of clinical supervisors. Human Resources coordinators will identify the number of clinical supervisors, counselors, and counselor assistants within the system on a quarterly basis. Vice President of Clinical Services will be responsible to review staffing hours quarterly to ensure that ratio is maintained. Program Directors will notify the Vice President of Clinical Services should any changes in the ratio per site occur during the quarter. Restructuring of the Clinical Supervisor ratio will begin December 1, 2013. Clinical Supervisor ratio will be in 100% compliance by January 1, 2014. |
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 the facility's staffing facility summary report, the facility failed to provide documentation of HIV/AIDS & TB/STD training in two of seven records reviewed.The findings include:The facility's staffing facility summary report was reviewed on October 4, 2013. Per regulation, staff persons shall receive a minimum of four hours of TB/STD training and six hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first two years of employment. Employee # 6 was hired September 8, 2009. This position is considered a support staff position and was required to obtain 4 hrs of TB/STD the training's by September 8, 2011. Employee # 6 failed to obtain the training's as of the date of the inspection.Employee # 7 was hired June 14, 2010. This position is considered a support staff position and was required to obtain 4 hrs of TB/STD the training's by June 14, 2012. Employee # 7 failed to obtain the training's as of the date of the inspection.
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Plan of Correction
Facility Director will ensure employees #6 and #7 will attend the next TB/STD training to be held on 11/7/2013 at Pyramid's Training Center. Facility Director will follow-up with Human Resource Coordinators and employees after said training date to ensure attendance. Human Resource Coordinators will monitor all employee files quarterly to ensure compliance with mandatory training requirements. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project directors in one of one personnel records.The findings include:Fourteen personnel records were reviewed on October 8, 2013. One personnel record pertained to the project director required the documentation of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.Employee # 1 has been the project director since July 1, 1999. The facility training year is from July through June. Employee # 1 had documentation of 10.5 hours of training for the July 2012 - June 2013 training year.
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Plan of Correction
Project Manager will complete 12 hours of training annually. Project Manager will ensure needed documentation of completed trainings is presented to Human Resources to be recorded in Personnel File. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance. |
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 the physical plant tour, the facility failed to store all food off the floor.The findings include:The physical plant tour took place on October 9, 2013. During the tour of the basement, there was a box of bananas stored on the floor. An interview with the facility director on October 9, 2013 confirmed the findings.
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Plan of Correction
Facility Director will meet with Tech Supervisor on 11/1/13 to review expectations of food preparation areas and the need to keep all food off floor as the Tech Supervisor monitors food delivery and storage. Facility Director will monitor compliance via biweekly inspection of the physical plant. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant tour, the facility failed to ensure that the facility did not store any heaters that was not permanently mounted or installed.The findings include:The physical plant tour took place on October 9, 2013. During the tour of the basement, it was noticed that the one office located in the basement had a heater that was not mounted or installed. In addition, in the based in the maintenance room there was a heater that was not mounted or installed. An interview with the facility director on October 9, 2013 confirmed the findings.
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Plan of Correction
Facility Director met with maintenance staff immediately after inspection, 10/9/13, in order to have the header removed. It was removed the same day, 10/9/2013. Facility director met with maintenance staff and risk committee members on 10/21/13 to review the importance of not having heaters in the facility that are not mounted/installed. Compliance will be monitored via monthly physical plant inspections by the risk committee members and facility director. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's fire drill record, the facility failed to documented alternate exits during fire drills.The findings include:The fire drill record was reviewed on October 4, 2013. The following months was reviewed November 2012 - August 2013. For 8 months, the facility only documented (1) exit and then 2 months (2) exit. An interview with the facility director on October 9, 2013, confirmed the findings.
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Plan of Correction
Facility Director met with maintenance staff on site on 10/21/13 to review fire drill requirements, to include alternating between both front and back exists. Maintenance staff will adhere to this standard. Facility risk committee members and facility director will ensure compliance via reviewing the fire drill log monthly during risk committee meetings. |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills were conducted during different times of the day.The findings include:The fire drill record was reviewed on October 4, 2013. Ten months of fire drills were reviewed. The facility's hours of operation are 24/7. The facility failed to document fire drills between the hours of 12 pm and 9 pm. All the drills were documented before 12 p.m.
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Plan of Correction
Facility Director met with maintenance staff on site on 10/21/13 to review fire drill requirements, to include conducting drills during different times of the day on each of the three work shifts. Facility risk committee members and facility director will ensure compliance via reviewing the fire drill log monthly during risk committee meetings. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and/or counselor conclusions and impressions in eight of ten records reviewed. The findings include:Ten client records were reviewed October 9, 2013 Eight of the ten records were reviewed for psychosocial evaluation. The psychosocial evaluations in client records # 1, 2, 3 ,4, 5, 6, 7 and 8 did not include an evaluation of the client's assets/strengths and how they would impact treatment. The psychosocial evaluations in client records # 1, 2, 3, 4, 5 6, 7 and 8 did not include an evaluation of the client's support systems.The psychosocial evaluations in client records # 1, 2, 3 , 6, 7 and 8 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment. The psychosocial evaluations in client records # 1, 2, 3 ,4, 5, 6 and 7 did not include an evaluation of the negative factors of the client.The psychosocial evaluations in client records # 1, 3 and 5 did not include an evaluation of the counselor conclusions/impressions of the client.
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Plan of Correction
Facility Director will conduct an in-service with the clinical staff by 11/06/13 to review psychosocial evaluation documentation, to include evaluation of the client's assets/strengths, coping mechanisms, support systems, negative factors towards treatment (to include how all may impact treatment), and the counselor conclusions/impressions of the client. Compliance to this standard will be met via monthly chart monitors of both open and closed charts by the Facility Director. |