INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 7-8, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Twin Lakes Center, 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 and a plan of correction is due on October 15, 2010.
|
Plan of Correction
|
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
|
Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure individual staff performance is evaluated at least annually, as required by regulation.
The findings include:
Eight personnel records were reviewed on August 8, 2010. Four personnel records were required to have documentation of an annual individual staff evaluation. Per regulation, individual staff performance shall be evaluated at least annually.
Employee #4 was hired on May 14, 2007 and was promoted to clinical supervisor on March 15, 2010. Employee #4 had not had a performance evaluation since May 2009.
An interview was conducted with the facility director on September 8, 2010 at around 9:40 AM. The inspector inquired if she knew the last time employee #4 had an evaluation, she advised all supervisors are to be evaluated in July but she knows she has not had a chance to evaluate him as of yet.
|
Plan of Correction
The medical records secretary will create a database of staff hire dates, orientation review dates and yearly review dates. She will bring the list of evaluations due for the up-coming month to the QI meeting and each supervisor will be notified. The following month, she will ensure that all of the evaluations due were completed and turned in. This will be corrected by 11/1/2010. She will monitor this list closely to ensure that they are being completed in a timely manner. |
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.
|
Observations
Based on an inspection of the physical plant, the facility failed to ensure that frozen food is kept at or below 0 degrees Fahrenheit.
The findings include:
The physical plant was inspected on September 7, 2010. The freezer in the male's lounge did not have a thermometer and therefore the inspector was unable to determine the temperature of the freezer. Additionally, the freezer in the female's lounge did not have a thermometer and the inspector was also unable to determine the temperature of the unit.
|
Plan of Correction
The Maintenance supervisor purchased two thermometers for the freezers of the female unit lounge and the male unit lounge and they were added to the freezers on 9/8/2010. He also started keeping a log of the temperatures. He will monitor these freezers quarterly to ensure that the other staff are checking the temperatures regularly. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of the inpatient client records, the facility failed to include the clients' histories and biopsychosocial evaluations during the development of the comprehensive treatment plan three of five inpatient client records reviewed.
The findings include:
Five inpatient client records were reviewed on September 8, 2010. Treatment plans were required in five client records. Client records #2, 4, 5 had treatment plans which did not include the use of client histories or evaluations in their development.
Client #2's history and biopsychosocial evaluation were completed on August 30, 2010. The comprehensive treatment plan was completed on August 25, 2010.
Client record #4's history and biopsychosocial evaluation were completed on August 21, 2010. The comprehensive treatment plan was completed on August 18, 2010.
Client record #5's history and biopsychosocial evaluation were completed on August 14, 2010. The comprehensive treatment plan was completed on August 12, 2010.
|
Plan of Correction
The supervisor will educate the staff members on paperwork due dates during their weekly supervision. They will be instructed to use the paperwork checklist to monitor these due dates closer. The staff members will be informed that they need to sign and complete the PSA form on the day that they meet with the patient. This will be completed by 10/29/2010 and will be monitored via chart audits with the supervisor checking the dates (2 per counselor per month) to ensure that it does not re-occur. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of the outpatient client records, the facility failed to include the clients' histories and biopsychosocial evaluations during the development of the comprehensive treatment plan three of five outpatient client records reviewed.
The findings include:
Five outpatient client records were reviewed on September 8, 2010. Treatment plans were required in five client records. Client records #2, 4, 5 had treatment plans which did not include the use of client histories or evaluations in their development.
Client #2's history and biopsychosocial evaluation were completed on August 30, 2010. The comprehensive treatment plan was completed on July 12, 2010.
Client record #4's history and biopsychosocial evaluation were completed on April 26, 2010. The comprehensive treatment plan was completed on April 12, 2010.
Client record #5's history and biopsychosocial evaluation were completed on April 2, 2010. The comprehensive treatment plan was completed on March 22, 2010.
|
Plan of Correction
The supervisor will educate the staff members on paperwork due dates during their weekly supervision. They will be instructed to use the paperwork checklist to monitor these due dates closer. The staff members will be informed that they need to sign and complete the PSA form on the day that they meet with the patient. This will be completed by 10/29/2010 and will be monitored via chart audits with the supervisor checking the dates (2 per counselor per month) to ensure that it does not re-occur.
|
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.
|
Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to ensure clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision.
The findings include:
On September 7, 2010 eight personnel records were reviewed. Employee #3 was promoted from a counselor to an OP clinical supervisor on March 15, 2010. After a review of employee #3's resume, it was found he had less than two years experience as supervisor in a clinical setting. Employee #3's personnel record did not have documentation of a core curriculum in clinical supervision.
On September 7, 2010 an interview was conducted with the project director who confirmed that employee number #3 had not received a core curriculum in clinical supervision.
|
Plan of Correction
The outpatient supervisor will monitor the BDAP website to see when the next training is offered. He will then register for the next training offered within traveling proximity. In order to ensure that this does not happen again, the Director will send all staff to the supervisor training prior to promotion when possible and if not, she will send them to the next available training within traveling proximity. This should be corrected by 12/31/2010. |