INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 21, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights, 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 and a plan of correction is due on March 21, 2008.
|
Plan of Correction
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on a review of employee records during the licensing inspection conducted on February 21, 2008, the facility failed to employ qualified counselors. Employee # 1 did not have the required clinical experience prior to being employed for the counselor position .
|
Plan of Correction
On 2/28/08, New Insights received the results of the staffing Qualifications Review request conducted by licensing Specialist Supervisor. The results indicated that the counselor in question (employee # 1), had the required clinical experience to be approved for "Counselor" status. |
709.81(b)(5) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
|
Observations
Based on the review of client records during the onsite inspection of February 21, 2008 the facility failed to meet the requirements of its own policy regarding physical examinations. The policy indicated that a physical examination had to be obtained prior to admission if a physical examination had not been completed within the past year. No documentation of physical examinations was found in client records # 1 and 2 ( 2 of 2 records).
|
Plan of Correction
The Executive Director will thoroughly review the entire policy regarding this standard, to assure that all the language infers a recommendation, not a requirement, for admission to both the outpatient and partial hospitalization programs. The Executive Director will distribute copies and review this revised policy at the regularly scheduled staff meetings: York, March 12th, 2008 and Lemoyne, March 19th, 2008. |
709.83(a)(10) LICENSURE Client records
709.83. 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:
(10) Discharge summary.
|
Observations
Based on the review of client records during the licensing inspection of February 21, 2008, the facility failed to document required information in the discharge summary of client record #1. The reasons for treatment and the services provided were missing from the discharge summary in the only record reviewed where such documentation was required.
|
Plan of Correction
The clinical supervisor will review nature of "presenting problem" as client's reported complaints, rather than the counselor's assessment of the reason for treatment. The clinical supervisor will review the need for specific descriptions of services provided to include number of group and individual sessions attended at each level of care as well as the length and nature of sessions. To be completed at York, April 9, 2008 staff meeting. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
|
Observations
Based on a review of administrative documentation during the licensing inspection of February 22, 2008, the project failed to make the annual report available to the public within six months of the end of the fiscal year.
|
Plan of Correction
The Executive Director will set a date on his planning calendar to place a public announcement regarding the availability of the agency's Annual Report. This action will be scheduled for December 1st, 2008. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on a review of client records during the licensing inspection of February 21, 2008, the facility failed to obtain consents to release information forms for all releases of information observed. Releases without proper consent were noted in client records #3, 7 and 8 (3 of 6 client records reviewed).
|
Plan of Correction
Confidentiality forms will be separately required for both insurance company and managed care entitity. Copies of consents will accompany all out-going documents starting at York, April 9th, 2008 staff meeting. The clinical supervisor will review use of new documents and new procedures. Copies of consents will be reviewed by clinical supervisor, in bi-weekly supervisory meeting with each counselor by reviewing one file at random. |
709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on a review of client records at the licensing inspection of February 21, 2008, the facility failed to consistently adhere to the requirements at 4 Pa. Code subsection 255.5(b) in three of six client records reviewed (# 1,2,3). The facility released information that exceeded the limitations on the amount and type of information that could be released.
|
Plan of Correction
Review of confidentiality standards will be completed by clinical supervisor at York, April 9th, 2008 staff meeting utilizing approved 4 PA Code subsection 255.5 guidelines. Quality assurance inspection of released information will be addressed during bi-weekly supervision sessions. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
|
Observations
Based on the review of client records during the licensing inspection of February 21, 2008, the facility failed to meet the requirements of its own policy regarding physical examinations. The policy indicated that a physical examination had to be obtained prior to admission if a physical examination had not been completed within the past year. No documentation of physical examinations was found in client records # 3, 4, 5, 6, 7 and 8, or in six of six client records reviewed.
|
Plan of Correction
The Executive Director will thoroughly review the entire policy regarding this standard, to assure that all the language infers a recommendation, not a requirement, for admission to both the outpatient and partial hospitalization programs. The Executive Director will distribute copies and review this revised policy at the regularly scheduled staff meetings: York, March 12th, 2008 and Lemoyne, March 19th, 2008. |
709.93(a)(5) 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:
(5) Progress notes.
|
Observations
Based on the review of client records during the licensing inspection of February 21, 2008, the facility failed to consistently document detailed individual progress notes in client records #3, 4 and 6, three of six client records reviewed.
|
Plan of Correction
The clinical supervisor will provide training on progress notes, utilizing examples of appropriately detailed DAP format at York, April 9th, 2008 staff meeting. The clinical supervisor will review one file for compliance randomly at each bi-weekly supervisory session with each counselor |