INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15, 2009 and December 16, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, York Hospital Behavioral Health Services 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 16, 2009.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of facility policy and procedure for assessments of staff training needs, a staff interview, and employee training records, the facility failed to provide documentation of the assessment of staff training needs for the current training year.
The findings include:
The policy and procedure for conducting assessments of staff training needs and six employee training records were reviewed on December 16, 2009. An interview was also conducted with the Operations Manager at 10:35 AM and it was determined that the facility does not keep copies of the training needs assessments that the employee's complete, to evaluate the annual training needs. The operations manager confirmed that the forms are disposed of once the overall evaluation has been completed. The facility failed to document training needs assessments in employee records # 1, 2, 3, 4, 5, and 6.
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Plan of Correction
On or before 1/29/10, the Facility Director will coordinate with WellSpan Education Services to assure that the following changes occur: (1) A needs assessment will be conducted annually for all substance abuse staff. Staff will be asked to put their names on the needs assessment so that it can be maintained in the individual training files; (2) A post-training year evaluation of the overall effectiveness of the past-year's training will be conducted annually. Staff will be asked to put their names on the needs assessment so that it can be maintained in the individual training files; (3) Staff will be required to provide feedback on each training that is completed throughout the training year that is specific to that particular training. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the "staffing requirements facility summary report" self report form completed by the facility and based on employee records, the facility failed to ensure that staff to client caseloads remained at or under 35:1.
The findings included:
during the annual onsite licensing inspection
During the annual onsite licensing inspection of December 15 through December 16, 2009, the staffing report form completed by the agency was reviewed to determine client to counselor caseloads. The facility failed to ensure that the caseloads remained at or under 35:1.
Employee # 6 was assigned a caseload that exceeded the 35:1 limitation. According to the calculations this employee had a caseload that was at 40:1.
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Plan of Correction
As of 12/21/09, the schedule for employee #6 has been revised to accommodate 15 hours of activity for D&A clients, 7 hours of activity for non-D&A clients, and 18 hours of activity for "other." Employee #6 continues to carry a caseload of 7 active D&A clients. Facility Director will continue to monitor schedules to assure that a 35:1 patient to client caseload ratio is maintained. |
711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
Based on a review of six client records on December 15 through 16, 2009, the facility failed to document short and long-term goals for treatment on the individualized treatment plans in three of six client records reviewed.
Findings:
Six client records were reviewed for individualized short-term and long term goals on December 16, 2009. In client records, #1, 4, and 6, the short and long-term goals for treatment were identical and did not address specific individual needs as identified by both staff and the client on the psychosocial evaluation.
An interview with the Operations Manager was conducted on December 16, 2009 and the Operations Manager confirmed that the staff had photocopied treatment plans.
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Plan of Correction
During staff meeting on 1/6/10, Operations Manager will advise clinical staff that all participants in substance abuse treatment should have both short-term and long term treatment goals documented on their treatment and rehabilitation plan and these treatment goals should be individualized (not templated) and should address specific, individual needs as identified by both staff and the client on the psychosocial evaluation.. Compliance with this regulation will be monitored via quarterly audits of the records. |
711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies 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:
(i) Confidentiality of client identity and records.
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Observations
Based on a review of the facility's policy and procedure on the confidentiality of client identifying information and a physical tour of the facility, the facility failed to document policies and procedures that were consistent with the current practice of storing active client records.
The findings include:
The facility failed to follow facility policy and procedure on storing active client records. According to the policy and procedure, the facility will store active client records in a locked file cabinet. During the facility tour on December 15, 2009 at 9:30 AM, it was observed that the active client records have been moved and are now being stored on open shelves in an office. The facility failed to update the policy and procedure to reflect the current practice of storing active records and indicating who, by job title, has access to those records.
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Plan of Correction
As of 12/28/09, the Project's policy and procedure Client and Record Confidentiality has been revised to read as follows:
"All client records will be kept under lock and key. All active client records will be kept under lock and key in one of the following manners:
- In a locked filing cabinet in the administrative area;
- In a locked section of the chart storage area;
- In a specified chart-storage room that can be accessed only by the project director, the facility director, clinical supervisors, counselors and administrative support staff (i.e. practice managers, office managers, physician office assistants) who have direct involvement with the substance abuse project."
Staff was made aware of this revision to the policy on 12/28/09 and will be reminded in subsequent staff meetings throughout January 2010. Compliance with this policy and procedure will be monitored by the facility director, practice managers, and office managers at the respective outpatient locations.
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