INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 11, 2013 to December 12, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WES Corporation 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:
|
Plan of Correction
|
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
|
Observations
Based on an interview with the Senior Director of IT and QA/Medical Records, the facility failed to document an assessment of staff training needs, an overall plan for addressing assessment of staff training needs, and an annual evaluation of the overall training plan.
The findings include:
On December 11, 2013 and December 12, 2013, the Licensing Specialist asked to see the facility's assessment of staff training needs, overall plan for addressing assessment of staff training needs, and annual evaluation of the overall training plan. An assessment of staff training needs, an overall plan for addressing assessment of staff training needs, and an annual evaluation of the overall training plan was not presented for review.
The findings were confirmed during an interview with the Senior Director of IT and QA/Medical Records on December 12, 2013 at approximately 11:50 A.M.
|
Plan of Correction
- The assessment of staff training needs, overall plan for addressing assessment of staff training needs, and annual evaluation of the overall training plan have been completed by the Quality Assurance Manager.
* In conjunction with the Training Department, PD/FD will ensure that the comprehensive staff development program is completed annually and readily available at the time of the site visit.
- It will include: the assessment of staff training needs, overall plan for addressing assessment of staff training needs, and annual evaluation of the overall training plan.
* The agency's training coordinate will provide oversight for ensuring that the aforementioned is completed. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of a personnel record, the facility failed to document an individual training plan annually for each employee in one of one personnel record reviewed.
The findings include:
From December 11, 2013 to December 12, 2013, one personnel record requiring documentation of an individual training plan was reviewed. The facility failed to document an individual training plan in one of one personnel record reviewed, specifically, personnel record # 1.
Employee # 1 is the project director and was hired for her current position May 16, 2011. The individual training plan for employee # 1 was due December 31, 2012. However, personnel record # 1 did not include documentation of an individual training plan as of December 12, 2013.
The findings were confirmed during an interview with the Senior Director of IT and QA/Medical Records on December 12, 2013 at approximately 11:50 A.M.
|
Plan of Correction
- In conjunction with the Training Department, PD/FD will ensure that the Individual Training plan is completed for all staff within the program. The plan will be appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor. Employee #1 will have a completed training plan. The training coordinator for WES Health System will ensure that all employees will receive their necessary trainings. The training coordinator will also monitor the on-going schedule to ensure that trainings are always up to date. |
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.
|
Observations
Based on a review of a personnel record, 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 STD/TB training and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff in one of one personnel record reviewed.
The findings include:
From December 11, 2013 to December 12, 2013, one personnel record was reviewed to verify that employees had HIV/AIDS and STD/TB training. The facility failed to ensure that persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of STD/TB training in one of one personnel record reviewed, specifically, personnel record # 1.
Employee # 1 is the project director and was hired for her current position May 16, 2011. Employee # 1 was due to complete a minimum of 6 hours of HIV/AIDS training and at least 4 hours STD/TB training by May 16, 2013. However, personnel record # 1 did not include documentation of HIV/AIDS and STD/TB training as of December 12, 2013.
The findings were confirmed during an interview with the Senior Director of IT and QA/Medical Records on December 12, 2013 at approximately 11:50 A.M.
|
Plan of Correction
- In conjunction with the Training Department, PD/FD will ensure that staff receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of STD/TB training and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff
- Employee #1 will complete the required training by June 30, 2014. Director of QA will ensure that Employee #1 completes the trainings.
|
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of personnel records, first aid cards and Cardio Pulmonary Resuscitation (CPR) certifications, and the facility's staff work schedule from November 12, 2013 to December 12, 2013, the facility failed to ensure that a sufficient number of staff persons trained in first aid and CPR skills were present during all the project's hours of operation.
The findings include:
From December 11, 2013 to December 12, 2013, the facility's personnel records were reviewed. Also, on December 12, 2013, the facility's first aid cards, CPR certifications, and staff work schedule from November 12, 2013 to December 12, 2013 were reviewed.
The facility is open Monday through Friday from 8:00 A.M. to 8:00 P.M. The facility failed to ensure that at least one person trained in first aid and having current CPR certification was onsite during the following hours on the following dates:
1)From 6:00 P.M. to 8:00 P.M. on 11/12/13, 11/14/13, and 11/27/13.
2)From 7:00 P.M. to 8:00 P.M. on 11/13/13, 11/25/13, 12/2/13, 12/4/13, and 12/9/13.
3)From 5:00 P.M. to 8:00 P.M. on 11/15/13, 11/19/13, 11/22/13, 11/26/13, 12/3/13, 12/5/13, 12/6/13, 12/10/13, 12/11/13, and 12/12/13.
4)From 7:30 P.M. to 8:00 P.M. on 11/18/13 and 11/20/13.
5)From 5:30 P.M. to 8:00 P.M. on 11/21/13.
|
Plan of Correction
- PD/FD will ensure that the program has proper coverage of at least one staff with current CPR/FA training during hours of operation.
- Training Department and the PD/FD will ensure that CPR/FA training is scheduled for all staff on the unit. CPR/FA training needs are reviewed quarterly by the Training Department.
|
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
|
Observations
Based on observations on December 11, 2013, the facility failed to ventilate bathrooms by exhaust fan or window in two of four bathrooms.
The findings include:
A physical plant inspection was conducted on December 11, 2013, 2 men's public restroom and 2 women's public restroom were inspected. The following restrooms were not ventilated by an exhaust fan or window:
1)The women's public restroom on the first floor at approximately 1:58 P.M.
2)The men's public restroom on the first floor at approximately 2:01 P.M.
The findings were confirmed during an interview with the Senior Director of IT and QA/Medical Records on December 11, 2013 at approximately 2:02 P.M.
|
Plan of Correction
- Ventilate bathrooms by exhaust fan or window: Ventilation system now works in the Men's and Ladies restrooms on the first floor.
- Housekeeping staff will ensure that the exhaust fans are "on" when they perform daily restroom cleaning duties.
* The Chief Administrative Officer oversees housekeeping and will ensure that the exhaust fans are turned on when they perform their daily cleaning routine.
- Effective Immediately
|
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
|
Observations
Based on observations on December 11, 2013, the facility failed to maintain protective caps over each electrical outlet in the facility's childcare area.
The findings include:
A physical plant inspection was conducted on December 11, 2013. It was observed during the inspection from approximately 2:20 P.M to 2:22 P.M., that there was no protective cap over one of the electrical outlets near the front entrance of the childcare area and no protective cap over one of the electrical outlets below the television in the childcare area.
The findings were confirmed during an interview with the Senior Director of IT and QA/Medical Records on December 11, 2013 at approximately 2:22 P.M.
|
Plan of Correction
- After the physical plant inspection on 12/12/13, the one electrical outlet near the front entrance of the childcare area and the one electrical outlet below the television in the childcare area were covered with protective caps.
* PD/FD will ensure that protective caps are maintained over each electrical outlet that is not in use.
- All Staff will be reminded to maintain the safety feature.
* The Director of the program will ensure that the electrical safety caps cover the outlets at all times.
- Effective Immediately
|
709.22(b) LICENSURE Governing Body
709.22. Governing body.
(b) If a project is publicly funded, not more than one staff member of the project may sit on the governing body at a designated time.
|
Observations
Based on a review of the facility's current list of Board of Directors, the facility failed to not have more than one staff member of the project on the governing body at a designated time.
The findings include:
The list of the facility's Board of Directors that was presented by the facility and reviewed on December 11, 2013 included the Chief Executive Officer and the Chief Financial Officer of the facility's project as members of the Board of Directors.
The findings were confirmed during an interview with the Senior Director of IT and QA/Medical Records on December 11, 2013 at approximately 12:17 P.M.
|
Plan of Correction
- PD/FD will ensure that not more than one staff member of the project may sit on the governing body at a designated time.
- One staff member, The Chief Financial Officer, will be removed from the board by the President of the Board.
|
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
|
Observations
Based on a review of personnel records and interview with the Senior Director of IT and QA/Medical Records, the facility failed to demonstrate the project's efforts toward informing staff on employee rights in one of three personnel records reviewed.
The findings include:
From December 11, 2013 to December 12, 2013, three personal records requiring the facility to demonstrate that the project made an effort toward informing staff on employee rights were reviewed. The facility did not demonstrate that the project made an effort toward informing staff on employee rights were reviewed, specifically, personnel record # 2.
Employee # 2 is the facility director and was hired April 29, 2013. The facility's project was required to demonstrate that the project made an effort toward informing employee # 2 on employee rights by April 29, 2013. However, the facility could not provide verification or documentation that the project demonstrated an effort toward informing employee # 2 on employee rights. Additionally, the facility was unable to provide documentation that the project made an effort toward informing employee # 2 through a policy statement on employee rights posted in the facility.
The findings were confirmed during an interview with the Senior Director of IT and QA/Medical Records on December 12, 2013 at approximately 11:50 A.M.
|
Plan of Correction
- In conjunction with our Human Resources Department, the PD/FD will ensure that documentation is present in the employee file to demonstrate the project's efforts toward informing staff on employee rights.
- Employee #2 is not currently employed. All current and future-hired staff will review employee rights and sign to confirm receipt.
* The Director of Human Resources will ensure that all staff, current and future, will have employee rights signed and by all staff.
- Effective Immediately
|
709.92(a)(3) 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:
(3) Proposed type of support service.
|
Observations
Based on a review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in seven of seven client records reviewed.
The findings include:
From December 11, 2013 to December 12, 2013, seven client records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in seven of seven records reviewed, specifically, client records # 1, 2, 3, 4, 5, 6, and 7.
Client # 1 was admitted September 3, 2013. The individual treatment and rehabilitation plan was completed September 22, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 12, 2013.
Client # 2 was admitted July 19, 2013. The individual treatment and rehabilitation plan was completed July 24, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 12, 2013.
Client # 3 was admitted April 16, 2013. The individual treatment and rehabilitation plan was completed September 11, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 12, 2013.
Client # 4 was admitted September 6, 2013. The individual treatment and rehabilitation plan was completed September 9, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 12, 2013.
Client # 5 was admitted March 27, 2013. The individual treatment and rehabilitation plan was completed May 10, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 12, 2013.
Client # 6 was admitted April 9, 2013 and discharged December 4, 2013. The individual treatment and rehabilitation plan was completed May 14, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 12, 2013.
Client # 7 was admitted April 23, 2013 and discharged December 3, 2013. The individual treatment and rehabilitation plan was completed June 11, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 12, 2013.
The findings were presented to the Senior Director of IT and QA/Medical Records on December 12, 2013 at approximately 3:30 P.M.
|
Plan of Correction
- PD/FD will train the staff to incorporate support services that extend beyond the families.
- Community supports and resources will be discussed and documented on the treatment plans for clients # 1, 2, 3, 4, 5, 6, and 7 by the respective therapists.
* The Director of the program will audit the charts to ensure that the aforementioned services will be documented on the treatment plans. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan update and/or subsequent individual treatment and rehabilitation plan update in three of seven client records reviewed. Also, based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan update and/or subsequent individual treatment and rehabilitation plan update at least every 60 days in three of seven client records reviewed.
The findings include:
From December 11, 2013 to December 12, 2013, seven client records requiring documentation of an individual treatment and rehabilitation plan were reviewed. The facility did not document an individual treatment and rehabilitation plan update and/or subsequent individual treatment plan update in three of seven records reviewed, specifically, client records # 1, 3, and 6. Also, the facility did not document an individual treatment and rehabilitation plan update and/or subsequent individual treatment and rehabilitation plan update at least every 60 days in three of seven records reviewed, specifically, client records # 2, 4, and 5.
Client # 1 was admitted September 3, 2013 and the individual treatment plan was completed September 22, 2013. The individual treatment plan update was due November 21, 2013. However, client record # 1 did not include documentation of an individual treatment plan update as of December 12, 2013.
Client # 2 was admitted July 19, 2013 and the individual treatment plan was completed July 24, 2013. The individual treatment plan update was due September 22, 2013. However, the individual treatment plan update was not completed until November 8, 2013.
Client # 3 was admitted April 16, 2013 and the individual treatment plan was completed September 11, 2013. The individual treatment plan update was due November 10, 2013. However, client record # 3 did not include documentation of an individual treatment plan update as of December 12, 2013.
Client # 4 was admitted September 6, 2013 and the individual treatment plan was completed September 9, 2013. The individual treatment plan update was due November 8, 2013. However, the individual treatment plan update was not completed until December 9, 2013.
Client # 5 was admitted March 27, 2013. The individual treatment plan was completed May 10, 2013 and the individual treatment plan update was completed July 22, 2013. The subsequent individual treatment plan update was due September 20, 2013. However, the subsequent individual treatment plan update was not completed until November 7, 2013.
Client # 6 was admitted April 9, 2013 and discharged December 4, 2013. The individual treatment plan was completed May 14, 2013 and the individual treatment plan update was completed June 10, 2013. However, client # 6 did not include documentation of a subsequent individual treatment plan update as of December 12, 2013.
The findings were presented to the Senior Director of IT and QA/Medical Records on December 12, 2013 at approximately 3:30 P.M.
|
Plan of Correction
- PD/FD in conjunction with the Quality Management Department will ensure that Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days
- Treatment plan updates will be documented for client records #1, 2, 3, 4,5, and 6 during each clients upcoming visit.
- Effective Immediately
|
709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
|
Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which include information relative to the client's involvement with the project regarding documentation of a case consultation in five of five client records reviewed and an aftercare plan in two of three client records reviewed.
The findings include:
From December 11, 2013 to December 12, 2013, eight client records requiring documentation of a complete client record on an individual which includes information relative to the client's involvement with the project were reviewed. The facility did not document a case consultation in five of five records reviewed, specifically, client records # 2, 3, 5, 6, and 7. Also, the facility did not document an aftercare plan in two of three records reviewed, specifically, client records # 6 and 7.
Client # 2 was admitted July 19, 2013. The case consultation was due October 31, 2013. However, client record # 2 did not include documentation of a case consultation as of December 12, 2013.
Client # 3 was admitted April 16, 2013. The case consultation was due July 31, 2013. However, client record # 3 did not include documentation of a case consultation as of December 12, 2013.
Client # 5 was admitted March 27, 2013. The case consultation was due June 30, 2013. However, client record # 5 did not include documentation of a case consultation as of December 12, 2013.
Client # 6 was admitted April 9, 2013 and discharged December 4, 2013. The case consultation was due July 31, 2013 and the aftercare plan was due December 4, 2013. However, client record # 6 did not include documentation of a case consultation and an aftercare plan as of December 12, 2013.
Client # 7 was admitted May 23, 2013 and discharged December 3, 2013. The case consultation was due August 31, 2013 and the aftercare plan was due December 3, 2013. However, client record # 7 did not include documentation of a case consultation and an aftercare plan as of December 12, 2013.
The findings were presented to the Senior Director of IT and QA/Medical Records on December 12, 2013 at approximately 3:30 P.M.
|
Plan of Correction
- PD/FD will ensure that case consultations are completed for every participating client within 90 days of admission and every 90 days following.
* The case consultations will include the therapist and the Director of the program.
* The Director of the program will audit the records to ensure that the case consultations and after care plans are documented timely.
- Clients 2, 3, 5, 6, and 7 will receive case consultations.
|