INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, TREHAB 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document annual staff work performance evaluations in the record of employee #7.
Employee #7 was hired as a counselor on 05/26/2014 and was still in the position as of the date of the inspection. The last documented work performance evaluation was signed and dated by the employee on 7/15/2015 and there was no annual work performance evaluation documented for 2016 at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor has developed a checklist that will be completed at the time of annual review. This coversheet will list all supervisees and indicate if an annual performance review has been completed by clinical supervisor, reviewed by supervisee, signed by facility director, copied for supervisee and filed in supervisee's personnel file. The completed checklist will be placed on file in clinical supervisor's office along with a copy of each supervisee's annual review. Clinical supervisor completed the annual performance review paperwork that was missing from identified staff person's personnel file and reviewed it with staff person on 3/10/17. Clinical supervisor obtained all necessary signatures and filed it in staff person's personnel file along with a memo explaining why paperwork was dated outside of the typical deadline for annual review submission. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
On February 23, 2017, it was discovered that since the previous licensing inspection the facility had 1 client death while they were an active patient. Client #5 was admitted on 12/04/2015. The facility learned of client #5's death in July 2016 and subsequently discharged client #5 on 07/20/2016. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory timeframe.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
At the time of inspection clinical supervisor and licensing agent reviewed the Unusual Incident Regulation to ensure understanding by clinical supervisor, specifically reporting death(s) of clients participating in the outpatient program. As a result of this technical assistance, clinical supervisor completed an Unusual Incident Report and submitted it to the Department of Drug and Alcohol Programs on 2/27/17 to correct oversight. Additionally, on 3/2/17 clinical supervisor reviewed the Unusual Incident licensing regulation with clinical staff to ensure understanding of the regulation and understanding of their responsibility to report unusual incidents ? such as death of a client ? to clinical supervisor; staff was provided with an updated Unusual Incident Reporting Form Non-NTP. Clinical Supervisor and clinical staff person reporting the incident are responsible for completing all necessary forms and clinical supervisor will ensure all incidents are reported to DDAP within the 72 hour timeframe. |