INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run of York 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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704.6(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.
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Observations
Based on a review of the Project ' s Staffing Requirements Facility Summary Reports (SRFSR) and a review of records, the Project failed to ensure that all clinical supervisors, with less than 2 years of supervisory experience, completed a Department approved core curriculum in clinical supervision.
The findings include:
The Project ' s SRFSR forms (16 total) completed by the Project for the 2014 inspections were reviewed on March 4, 2014. The Project ' s SRFSR forms listed 1 clinical supervisor as not having completed the core curriculum in clinical supervision. A personnel record review was conducted on March 19, 2014 and confirmed the findings on the SRFSR.
Employee # WB-22 was hired to the project on September 24, 2007 and promoted to a clinical supervisor on July 18, 2011. There was no documentation of completion on the SRFSR as well as in the personnel record.
An interview with the Clinical Supervisor confirmed the findings on March 19, 2014.
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Plan of Correction
Clinical supervisor #WB-22 will attend the required supervision training in December 2014. She is unable to attend the June 2014 training due to a prior obligation. Registration will be completed as soon as the December clinical supervision training is advertised.
Her training certificate will be submitted to QI upon completion of this training. The program director will assure completion of this training.
Facility directors and program directors have been re-educated on this requirement by QM. Facility directors and program directors will be responsible for assuring completion of this requirement for all new clinical staff through training tracking (provided by QM) and supervision sessions. |
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.
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Observations
Based on a review of the Project ' s Staffing Requirements Facility Summary Reports (SRFSR) and a review of records, the Project failed to provide documentation of annual individual training plans for all employees.
The findings include:
The Project ' s SRFSR forms (16 total) completed by the Project for the 2014 inspections were reviewed on March 4, 2014. The Project ' s SRFSR forms listed all employees as having a completed individual training plan; however a personnel record review was conducted on March 12, 2014 and it was discovered that 1 employee was found to not have an individual training plan documented.
Employee # HB-2 was hired as a counselor on October 3, 2012. There was no documentation of an individual training plan in the personnel record.
An interview with the Facility Director confirmed the findings on March 12, 2014.
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Plan of Correction
Employee #HB-2 and his supervisor completed a training plan on April 1, 2014. His training plan was submitted to the QI dept on April 1, 2014.
The QM office will continue to send to all programs a list of staff who did not turn in an annual training plan. Program directors/facility directors/managers will be responsible to use this list to assure that all employees complete the required yearly training plan.
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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 the Project ' s Staffing Requirements Facility Summary Reports (SRFSR), the Project failed to ensure that all personnel received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics training using a Department approved curriculum within the regulatory time frames.
The findings include:
The SRFSR forms completed by the Project (16 total), were reviewed on March 4, 2014. The Project ' s SRFSR forms listed 30 personnel as not having completed the mandatory training within the regulatory time frames.
Employee # WB-2 was hired as a counselor on November 16, 2009. TB/STD training was due to be completed no later than November 16, 2010. There was no documentation of TB/STD training on the SRFSR form.
Employee # WB-3 was hired as a counselor assistant on December 7, 2012. HIV/AIDS training was due to be completed no later than December 7, 2013. There was no documentation of HIV/AIDS training on the SRFSR form.
Employee # WB-4 was hired as a counselor assistant on July 23, 2012. HIV/AIDS training was due to be completed no later than July 23, 2013. There was no documentation of HIV/AIDS training on the SRFSR form.
Employee # WB-5 was hired as support staff on March 19, 2007. HIV/AIDS training was due to be completed no later than March 19, 2009. There was no documentation of HIV/AIDS training on the SRFSR form.
Employee # WB-6 was hired as support staff on January 19, 2012. HIV/AIDS and TB/STD training was due to be completed no later than January 19, 2014. There was no documentation of HIV/AIDS and TB/STD training on the SRFSR form.
Employee # WB-7 was hired as support staff on October 11, 2011. HIV/AIDS and TB/STD training was due to be completed no later than October 11, 2013. There was no documentation of HIV/AIDS and TB/STD training on the SRFSR form.
Employee # WB-8 was hired as support staff on August 1, 2011. HIV/AIDS and TB/STD training was due to be completed no later than August 1, 2013. There was no documentation of HIV/AIDS and TB/STD training on the SRFSR form.
Employee # WB-9 was hired as support staff on October 15, 2008. HIV/AIDS and TB/STD training was due to be completed no later than October 15, 2010. There was no documentation of HIV/AIDS and TB/STD training on the SRFSR form.
Employee # WB-10 was hired as support staff on October 17, 2011. HIV/AIDS and TB/STD training was due to be completed no later than October 17, 2013. There was no documentation of HIV/AIDS and TB/STD training on the SRFSR form.
Employee # WB-11 was hired as support staff on December 3, 2011. HIV/AIDS and TB/STD training was due to be completed no later than December 3, 2013. There was no documentation of HIV/AIDS and TB/STD training on the SRFSR form.
Employee # WB-12 was hired as support staff on December 29, 2011. HIV/AIDS and TB/STD training was due to be completed no later than December 29, 2013. There was no documentation of HIV/AIDS and TB/STD training on the SRFSR form.
Employee # WB-13 was hired as support staff on August 23, 2011. HIV/AIDS training was due to be completed no later than August 23, 2013. There was no documentation of HIV/AIDS training on the SRFSR form.
Employee # WB-14 was hired as support staff on January 14, 2010. HIV/AIDS training was due to be completed no later than January 14, 2012. There was no documentation of HIV/AIDS training on the SRFSR form.
Employee # WB-15 was hired as support staff on January 19, 2012. HIV/AIDS and TB/STD training was due to be completed no later than January 19, 2014. There was no documentation of HIV/AIDS and TB/STD training on the SRFSR form.
Employee # WB-16 was hired as support staff on January 3, 2012. HIV/AIDS training was due to be completed no later than January 3, 2012. There was no documentation of HIV/AIDS training on the SRFSR form.
Employee # PITT-3 was hired as a counselor on February 28, 2012. HIV/AIDS training was due to be completed no later than February 28, 2013. There was no documentation of HIV/AIDS training on the SRFSR form.
Employee # PITT-4 was hired as a counselor on May 1, 2012. HIV/AIDS training was due to be completed no later than May 1, 2013. There was no documentation of HIV/AIDS training on the SRFSR form.
Employee # ERIE-3 was hired as a counselor on June 25, 2012. TB/STD training was due to be completed no later than June 25, 2013. There was no documentation of TB/STD training on the SRFSR form.
Employee # NC-2 was hired as a counselor assistant on January 16, 2013. HIV/AIDS and TB/STD training was due to be completed no later than January 16, 2014. There was no documentation of HIV/AIDS and TB/STD training on the SRFSR form.
Employee # NC-3 was hired as a counselor on February 7, 2013. HIV/AIDS training was due to be completed no later than February 7, 2014. There was no documentation of HIV/AIDS training on the SRFSR form.
Employee # HB-2 was hired as a counselor on October 3, 2012. HIV/AIDS training was due to be completed no later than October 3, 2013. There was no documentation of HIV/AIDS training on the SRFSR form.
Employee # LEB-4 was hired as support staff on May 7, 2004. HIV/AIDS and TB/STD training was due to be completed no later than May 7, 2006. There was no documentation of HIV/AIDS and TB/STD training on the SRFSR form.
Employee # LEB-5 was hired as support staff on December 7, 2009. HIV/AIDS and TB/STD training was due to be completed no later than December 7, 2011. There was no documentation of HIV/AIDS and TB/STD training on the SRFSR form.
Employee # LEB-6 was hired as support staff on October 7, 2010. HIV/AIDS training was due to be completed no later than October 7, 2012. The training was not documented until February 8, 2014.
Employee # YK-4 was hired as a counselor on December 22, 2009. HIV/AIDS and TB/STD training was due to be completed no later than December 22, 2010. The HIV/AIDS training was not documented until November 9, 2012. Additionally, there was no documentation of TB/STD training on the SRFSR form.
Employee # YK-5 was hired as support staff on February 18, 2011. HIV/AIDS and TB/STD training was due to be completed no later than February 18, 2013. There was no documentation of HIV/AIDS and TB/STD training on the SRFSR form.
Employee # YK-6 was hired as support staff on July 3, 2009. HIV/AIDS and TB/STD training was due to be completed no later than July 3, 2011. The TB/STD training was not documented until April 3, 2013. There was no documentation of HIV/AIDS training on the SRFSR form.
Employee # YK-7 was hired as support staff on January 10, 2012. TB/STD training was due to be completed no later than January 10, 2014. There was no documentation of TB/STD training on the SRFSR form.
Employee # LANC-4 was hired as support staff on July 21, 2011. HIV/AIDS training was due to be completed no later than July 21, 2013. There was no documentation of HIV/AIDS training on the SRFSR form.
Employee # LANC-5 was hired as support staff on September 24, 2005. TB/STD training was due to be completed no later than September 24, 2007. There was no documentation of TB/STD training on the SRFSR form.
The Project Director confirmed the findings during an interview on March 4, 2014.
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Plan of Correction
Each program with employees listed as not having completed their mandatory communicable disease training(s) will assure that the identified staff have the required training(s) by July 1, 2014. Facility directors/program directors/managers will be responsible for scheduling the required training(s) with their staff. Each facility has a tracking mechanism (which varies from program to program) identifying when these trainings are due. Facility directors/program directors/managers will assure timely completion of these trainings through tracking and supervision sessions. QM will continue to send out a quarterly list of trainings completed. |
704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on a review of the Project ' s Staffing Requirements Facility Summary Reports (SRFSR), the Project failed to ensure that at least one-half of all training was provided by trainers not directly employed by the project in one of thirty-two records.
The findings include:
The Project ' s SRFSR forms (16 total) completed by the Project for the 2014 inspections were reviewed on March 4, 2014. The Project ' s SRFSR forms listed 1 employee as not having obtained at least one-half of all training provided by an outside trainer during the Project ' s January 1, 2013 through December 31, 2013 training year. A personnel record review was conducted on March 5, 2014 and confirmed the findings on the SRFSR.
Employee # AW-5 received a total of 26 hours during the 2013 training year; however, 17 hours were provided by facility staff and 8 hours were provided by an outside trainer.
The Project Director confirmed the findings during an interview on March 4, 2014.
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Plan of Correction
Clinical supervisors will be responsible for assuring that ½ of all staff training hours will be provided by trainers not directly employed by the project. Clinical supervisors have been re-educated on this requirement by QM. The QM department will send out a quarterly report that lists staff and the trainings they have taken. Clinical supervisors will be responsible for assuring that staff have the appropriate type of training hours. The report will be reviewed with counselors in supervisions sessions. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Project ' s Staffing Requirements Facility Summary Reports (SRFSR) and an interview with the Project Director, the Project failed to ensure that all counselors completed at least 25 clock hours of annual training in eight of twenty seven personnel records reviewed.
The findings included:
The Project ' s SRFSR forms (16 total) completed by the Project for the 2014 inspections were reviewed on March 4, 2014. The Project ' s SRFSR forms listed 8 counselors as not having the completed the mandatory 25 clock hours of annual training.
Employee # ERIE-2 was hired as a counselor on August 23, 2010. There were only 13 hours of training documented on the SRFSR form for the January 2013 through December 2013 training year.
Employee # ERIE-3 was hired as a counselor on June 25, 2012. There were only 13 hours of training documented on the SRFSR form for the January 2013 through December 2013 training year.
Employee # WB-17 was hired as a counselor on August 21, 2011. There were only 21 hours of training documented on the SRFSR form for the January 2013 through December 2013 training year.
Employee # WB-18 was hired as a counselor on October 10, 2011. There were only 18 hours of training documented on the SRFSR form for the January 2013 through December 2013 training year.
Employee # WB-19 was hired as a counselor on November 10, 2010. There were only 8 hours of training documented on the SRFSR form for the January 2013 through December 2013 training year.
Employee # WB-20 was hired as a counselor on November 16, 2009. There were only 0 hours of training documented on the SRFSR form for the January 2013 through December 2013 training year.
Employee # WPOP-1 was hired as a counselor on July 5, 2000. There were only 14 hours of training documented on the SRFSR form for the January 2013 through December 2013 training year.
The Project Director confirmed the findings during an interview on March 4, 2014.
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Plan of Correction
Clinical supervisors will be responsible for assuring that counselors complete a minimum of 25 clock hours of training annually. Clinical supervisors have been re-educated on this requirement by QM. The QM department will send out a quarterly report that lists staff and the trainings they have taken. Clinical supervisors will be responsible for assuring that staff have the appropriate number of training hours. The training hour report will be reviewed with counselors in supervision sessions. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of administrative materials and Health Insurance Portability and Accountability Act (HIPAA) documents, the Project failed to develop a written confidentiality procedure that was compliant with 4 Pa. Code 255.5.
The findings include:
Administrative materials and HIPAA documentation were reviewed on February 19, 2014. A notice of privacy practices, dated April 2003 and revised September 2013, was posted on the project's website. This notice of privacy practices included the following statement: " The law permits CRC Health Group to use or disclose information without your written authorization for the following purposes: payment, notification of and communication with family, any administrative or judicial proceeding and to a law enforcement official for purposes such as identifying of locating a suspect, fugitive, material witness or missing person." This is in violation of federal and state substance abuse treatment laws and regulations. The project failed to provide a confidentiality procedure and HIPAA information that was in compliance with 28 Pa Code 709.28, 4 Pa Code 255.5 and 42 CFR Part II. The HIPAA documentation did not include a disclaimer indicating that releases of information permitted by HIPAA regulations, which are prohibited by federal and state confidentiality laws for substance abuse treatment, shall continue to be prohibited and will require the client's written consent prior to the disclosure of information contained in the client record.
The Project Director confirmed the findings during an interview on March 4, 2014.
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Plan of Correction
The project's website is maintained by CRC Health Group and was updated by the webmaster on 3/10/14. The website is now compliant with HIPAA and Confidentiality regulations. The project director will review the website on a quarterly basis to ensure the privacy practices statement remains in compliance with licensing regulations. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document that the preliminary treatment plans were completed as part of the intake procedures in two of eight client records reviewed.
The findings include:
Eight client records which required documentation of a preliminary treatment plan as part of the intake procedures were reviewed March 21, 2014. The facility failed to complete preliminary treatment and rehabilitation plans as part of the intake procedures in client records # 8 and 10.
Client # 8 was admitted on 7/30/13 and was discharged on 8/20/13. There was no documentation of a preliminary treatment plan in this client record as of the date of the inspection.
Client # 10 was admitted on 7/19/13 and was discharged on 7/28/13. There was no documentation of a preliminary treatment plan in this client record as of the date of the inspection.
The Facility Director confirmed the findings.
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Plan of Correction
All counselors and nursing staff will be provided training on the use of the preliminary treatment plan and required timeframes for implementation. Internal chart audits will be conducted within 48 hours of admission to ensure that the preliminary treatment plan was implemented per policy.
Responsible Party: Clinical Supervisor for rehabilitation program. Nurse Manager for detoxification program. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document a review and update of the treatment and rehabilitation plan, at least every thirty days, in one of two client records reviewed.
The findings include:
Two client records which required documentation of a treatment plan update were reviewed on March 21, 2014. The facility failed to document a treatment plan update, at least every 30 days, in client record # 9.
Client # 9 was admitted on 8/6/13 and discharged on 9/3/13. The individualized treatment and rehabilitation plan was completed on 8/15/13. A review and update of the treatment and rehabilitation plan was due to be completed by 9/15/13. The treatment plan update for this client was completed and signed by the counselor on 11/5/13.
The Facility Director confirmed the findings.
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Plan of Correction
All counseling staff will be provided training on the use of the treatment plan update according to regulation and policy. Treatment Plan updates will be reviewed with the Clinical Supervisor during weekly clinical supervision sessions. Internal chart audits will be conducted once per week to ensure treatment plan updates are completed within the required timeframe.
Responsible Party: Clinical Supervisor |