INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 8 - 9, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conemaugh Valley Memorial Hospital 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 January 3, 2011.
|
Plan of Correction
|
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
|
Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to provide documentation that the project director met the educational qualifications for the position.
The findings included:
Four personnel records were reviewed on December 8, 2010. One personnel record pertained to the project director. Per regulation, the facility must provide documentation that the project director meets the educational and experiential qualifications for the position. The facility failed to provide this documentation in employee record # 1.
Employee # 1 has been the project director since April of 2010. The facility director reported that the project director has a Master of Business Administration degree and a Masters of Arts degree in Public Health. There was no documentation of college transcripts or degrees in employee record # 1. Review of the resume for employee # 1; confirmed that the project director meets the experiential qualifications for the position. It was not possible to determine if employee # 1 meets the educational requirements for the position; as there were not any college transcripts or degrees to review.
The facility director was interviewed on December 8 - 9, 2010. The facility director confirmed the project director did not have a copy of his transcripts or degrees available for review; as of the date of this inspection.
|
Plan of Correction
The Facility Director will provide verification of the documentation needed for the Project Director's Master of Business Administration degree and his Master of Arts degree in Public Health. The Facility Director will request copies of transcripts and degrees from the Project Director to meet the regulation for educational qualifications for the position of Project Director. |
705.27 (5) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(5) Notify the Department within 48 hours of a fire, other disaster or situation which affects the continuation of services.
|
Observations
Based on a review of administrative materials and an interview with the facility director, the facility failed to document emergency procedures that included the notification of the Department within 48 hours of a fire, other disaster or situation which affects the continuation of services.
The findings included:
Administrative policies and procedures were reviewed on December 8, 2010. Per regulation, general safety and emergency procedures shall include that the nonresidential facility shall notify the Department within 48 hours of a fire, other disaster or situation which affects the continuation of services. The facility failed to provide documentation of this procedure.
On December 8 - 9, 2010, the facility director was interviewed. The facility director confirmed that the emergency procedures did not include that the Department shall be notified within 48 hours of a fire, other disaster or situation which affects the continuation of services.
|
Plan of Correction
The Facility Director will update the facility's policy in the policy and procedure manual. The Facility Director will be the person responsible to contact the Department within 48 hours of a fire, other disaster or situation which affects the continuation of services. The Facility Director will be responsible to disseminate the updated policy to all staff and appoint a designee in the event that the Facility Director is off site and unavailable to notify the Department in a situation which affects the continuation of services. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
|
Observations
Based on a review of client records and an interview with the facility director, the facility failed to document that follow-ups were completed within 30 days of discharge, as per facility policy, in two of four client records.
The findings included:
Twelve client records were reviewed on December 8 - 9, 2010. Eight client records pertained to the outpatient program. Four outpatient client records required the completion of follow-up information. Per facility policy, follow-up will be completed with clients within 30 days of discharge. The facility failed to document that follow-ups were completed within 30 days of discharge in client records # 10 and 11.
Client # 10 was admitted into treatment on August 13, 2010 and discharged on October 22, 2010. Follow-up was due to be completed no later than November 22, 2010. Follow-up was not completed until December 2, 2010.
Client # 11 was admitted into treatment on July 2, 2010 and discharged on September 20, 2010. Follow-up was due to be completed no later than October 20, 2010. Follow-up was not completed until October 28, 2010.
|
Plan of Correction
The Facility Director will review the requirement of documentation that follow-ups were completed within 30 days with all staff at the next scheduled staff meeting. Documentation will be reflected in the staff meeting minutes. The Program Secretary will send a follow up letter to all discharged clients. Staff members will follow up with a phone call to all successful discharges in addition to the letter within the 30 days. The Facility Director will provide direct supervision with the individual counselor whose records did not reflect the follow up within 30 days. The Facility Director will monitor the Quality Assurance checklist for closed charts to ensure the follow up within 30 days is sustained by all staff. |