INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23 - 24, 2012 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, The Council of Southeast Pennsylvania, 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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704.11(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 personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that staff persons and volunteers received 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.
The findings include:
On February 23, 2012 five personnel records requiring documentation of HIV/AIDS and TB/STD training were reviewed.
The facility failed to provide documentation of the required 4 hours of tuberculosis and sexually transmitted diseases training using a Department approved curriculum in one of five records, specifically # 7.
Employee # 7, support staff, was hired 9/2006 and would have been required to complete 4 hours of TB/STD training using a Department approved curriculum by 9/2008.
Based on a review of employee # 7's personnel record and training certificates, the facility documented 3 hours of TB/STD training on 1/2/09.
The documented training's for employee # 7 failed to comply with the required 4 hours of TB/STD training using a Department approved curriculum.
In addition, the Staffing Requirements Facility Summary Report as completed by the facility on February 22, 2012 indicated 3 hours of TB/STD training for employee # 7.
The facility confirmed the findings.
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Plan of Correction
The human resources director will indicate which staff need the minimum trainings, in this case employee #7. The administrative assistant will locate the needed training; tuberculosis/STD and notify staff of training dates. The staff will attend the trainings and will submit their usual training completed form to the human resources director. This will be completed by 7/1/2012.
Moving forward, the Human Resources director will ensure new employees will be required to complete the minimum hours of training for HIV/AIDS, STD's and tuberculosis within the 1st year of employment for counselors and within 2 years for all other staff.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on an interview with the clinical supervisor, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
On February 24, 2012 the facility's fire drill log was reviewed.
The fire drill log indicated that the fire alarm was set off during the fire drills. However, during an interview with the clinical supervisor it was determined that neither the fire alarm nor the smoke detector was set off during the fire drills.
The clinical supervisor confirmed the findings.
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Plan of Correction
705.28 (d) (1-8)
Licensing:
Because our agency shares a professional building with other departments, we are requesting an exception from the standard monthly fire drill procedure because setting of the fire alarm would disturb the other departments and their clients. As an alternative we will conduct monthly fire drills by blowing a whistle and exiting the office via the different exit routes on a random, monthly basis.
For inspection, we will provide an inspection report that the building's fire alarm is in working order.
Fire drills will be conducted by the administrative assistants(s).
This written exemption has been completed and mailed 4/19/2012 by the clinical supervisor.
Council of SEPA
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709.91(b)(6) LICENSURE Intake and admission
709.91. 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 and a review of the facility's policy and procedure manual, the facility failed to document a psychosocial evaluation per policy.
The findings include:
The facility's policy title "Psychosocial Evaluation" states:
Within thirty days of first contact, a psychosocial examination, including history, will be administered by the therapist assigned to the client.
On February 24, 2012, eight client records requiring documentation of a psychosocial evaluation were reviewed.
The facility failed to document a psychosocial evaluation per policy in five of eight records reviewed, # 1, 2, 3, 6, and 8.
Client # 1 was admitted to the program on 10/25/11.
The psychosocial evaluation was to be documented within 30 days of first contact by 11/25/11. The psychosocial evaluation was documented; however it did not indicate a completion date.
Client # 2 was admitted to the program on 7/22/11.
The psychosocial evaluation was to be documented within 30 days of first contact by 8/22/11. However, at the time of review on 2/24/12 the facility failed to document a psychosocial evaluation for client # 2.
Client # 3 was admitted to the program on 10/4/11.
The psychosocial evaluation was to be documented within 30 days of first contact, by 11/4/11. The psychosocial evaluation was documented; however it did not indicate a completion date.
Client # 6 was admitted to the program on 11/15/11.
The psychosocial evaluation was to be documented within 30 days of first contact by 12/15/11. However, at the time of review on 2/24/12 the facility failed to document a psychosocial evaluation for client # 6.
Client # 8 was admitted to the program on 10/13/11, and is still an active client.
The psychosocial evaluation was to be documented within 30 days of first contact by 11/13/11. However, at the time of review on 2/24/12 the facility failed to document a psychosocial evaluation for client # 8.
The clinical supervisor reviewed the records and confirmed the findings.
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Plan of Correction
A signature/date line was added by the clinical supervisor to the bottom of psychosocial evaluation template. The addition of the signature/date line will prompt the individual completing the psychosocial to sign and date it. This signature/date line will be examined during chart reviews, which are completed by the clinical supervisor. This occurred on 2/29/2012.
The clinical supervisor will check to ensure all psychosocial evaluations are present when signing off on individualized treatment plans. The clinical supervisor is responsible for signing off on all individualized treatment plans this will ensure that each treatment file will be checked for the presence of the psychosocial evaluation. This occurred on 2/29/2012.
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