INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 20, 2007 of site inspection # 677036 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 September 21, 2007.
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Plan of Correction
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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.
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Observations
Based on a review of administrative documentation it was determined that the facility failed to provide a sufficient number of staff persons for the period from the end of June, 2007 to August 17, 2007, so that at least one person trained in CPR certification and first aid training was onsite during the project's hours of operation.
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Plan of Correction
Even though the CPR instruction occurred on August 18th, 2007, there was a two-month lapse in this annual training requirement. In order to assure compliance for next year, in May 2007 the Executive director will contact the American Red Cross to reschedule this CPR refresher course by June 30th, 2008. Therefore this four-hour instruction will occur within (1) year of the previous training date of August 2007. |
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 documentation filed in employee training files it was determined that the facility did not comply with this regulation since less than half of the training provided was conducted by outside trainers.
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Plan of Correction
The monitoring of staff training hours for Clinical Staff will be converted to an automated system. Upon staff submitting evidence of trainings obtained, that information will be data entered on an ongoing basis. The training evidence, certification (and/or) training report form, will be inserted in the Annual Training report binder. The policy will be revised that will require the Executive Director to reviw a monitoring report indicating the status of staff training hours on a quarterly basis. At these quarterly reviews, Clinical Staff members will be made aware of their total training hour requiremnt; and to assure that at least half of these training hours are obtained externally. This task will be the joint responsibility of the Executive Director, Billing Supervisor,and full-time Support Staff person (Lemoyne). The programming of this new automated system will be the task of the Billing Supervisor, and will be in place by December 31st, 2007. The Executive Director and Support Staff person will be responsible for maintaining and monitoring these reports of trainings. The Executive Director will revise the policy that will clearly describe this new procedure. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on documentation reviewed in agency training files it was determined that employee #1 did not have at least 12 training hours for the prior training year.
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Plan of Correction
The Executive Director has been registered for a six (6) hour external training on September 17th, 2007. The training is titled Mastering Macromedia Dreamweaver and will provide information utilizing the Dreamweaver software to improve the design and capability of our website. The completion of this training will satisfy the requirement for (12) total hours; as well as, 1/2 of those hours would be provided externally. This workshop will take place in Frederick, Maryland and will be presented by CompuMaster. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on documentation reviewed in agency training files it was determined that employee #6 did not have at least 12 hours of training hours for the prior training year.
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Plan of Correction
The Clinical Supervisor at the York site obtained the required number of training hours (12); however, (2) two of those hours were not allowed because of the Training Evaluation Report was not signed. The training was provided by this Clinical Supervisor when training a new clinical staff member on conducting Managed Care authorizations. In other words, he did not sign-off on a training he conducted in which he was entitled to receiving credit ((1) in-service per training year). This required signature on all Training Evaluation Reports will be monitored for compliance by the full-time Support Staff person in Lemoyne when conducting the quarterly reviews with the Executive Director. |
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 documentation reviewed in agency training files it was determined that employee #4 did not at least 25 hours of training for the prior training year. Only 22 hours of appropriately documented training was found in the training file.
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Plan of Correction
All of the counselors acheived the required total of training hours, however, three staff members were deficient by 1,2 and 4 hours due to the fact that the Training Evaluation Report did not have a signature of the fellow staff member who provided the internal training or instruction, and therefore were rejected. In the future, upon counselors submitting the Training Evaluation report for any internal trainings, the full-time Support Staff person at the Lemoyne office will confirm that they are signed at the bottom by the staff member who provided the instruction in-house. If this feedback form is not signed at the bottom, the Support Staff person will forward it to the staff member who conducted the training and have them sign-off before inserting the report in the binder of annual trainings. During the quarterly review of status of staff training hours by the Executive Director, the full-time Support Staff person in Lemoyne will be responsible for reconciling the binder with the automated monitoring report and confirm that all Training Evaluation Reports have the appropriate signature. This action will be completed by December 31st, 2007. |
704.12(a)(5) LICENSURE Partial Hosp Ratio
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.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
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Observations
Based on information provided by the Project Director on the "Staffing Requirements Facility Summary Report" it was determined that the facility failed to maintain a 10:1 ratio for the partial hospital activity. The client to counselor ratio at the time of the inspection was 11:1.
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Plan of Correction
The Director will revise the Direct Service Hour weekly Operational report that is generated every Monday for both sites. The current report form, reviewed regularly for past 25 years, includes counselor total number of direct service hours which occurred and projected for upcoming week. The form will now include columns that will indicate their active client census by program - Outpatient (or) partial hospitalization. This revised report will be reviewed during staff meetings at both sites during the month of October. This revised report will be completed and integrated by November 1st, 2007. This report is reviewed by the Clinical Supervisor's at both sites every Monday. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records it was determined that the facility failed to meet this requirement based on data gathered from reviews of client records. Personal histories were incomplete in 5 of 7 client records reviewed at this level of care, specifically client records # 1, 3, 4, 5 and 8. The family history and the employment/vocational history were often missing or incomplete in those client records.
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Plan of Correction
The Clinical Supervisor will review at the (York) staff meeting on 10/10/07 New Insights Bio-psych social profile with the clinical staff and what specific details are expected in each section. The Clinical Supervisor will review the charts that were found to be in violation with the clinician as to why they were in violation. Charts that are still active files will be rectified. The Clinical Supervisor will randomly audit one chart of each counselor every two weeks during clinical supervision to monitor compliance. |
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.
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Observations
Based on a review of client records it was determined that the facility failed to meet the requirements of its own policy regarding physical exams. The policy indicated that a physical needed to be obtained prior to admission if no physical was completed within the past two years. Physicals should have been documented in client records #3, 4, 5, 6 and 7. No documentation of physical exams was found in these client records. The sample consisted of 7 records for this activity.
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Plan of Correction
The Executive Director will revise the policy that requires a physical examination prior to being admitted to our program. The revised policy will provide guidelines for counseling staff to make a recommendation to see a physician, but not mandate as a condition for admission. This policy revision will take place by September 30th, 2007. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records it was determined that the facility failed to meet the requirement for treatment plan updates in 2 of 2 applicable client records. Client records # 4 and 6 should have had updates done every sixty days. The treatment plan updates in client records # 4 and 6 were not completed within 30 days as required.
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Plan of Correction
The Clinical Supervisor will review with clinical staff at (York) staff meeting on 10/10/07 the policies and time frames for individual treatment plan updates for clients in Partial Hospitalization, and Outpatient counseling. One chart for every counselor will be randomly audited by the Clinical Supervisor every two weeks during clinical supervision to monitor for compliance with treatment plan and review time frames. |
709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of client records it was determined that the facility failed to document case consultations in 2 of 3 applicable client records. One case consultation was missing from client record # 4 and no consultation was found in client record # 6.
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Plan of Correction
The Clinical Supervisor will review with clinical staff at the (York) staff meeting on 10/10/07, the policies on time frames for case consultations. At clinical supervision every two weeks counselors will submit a spreadsheet listing all active client files to include admission date, treatment plan date, treatment plan review dates, and case consultation dates. Case consultation which are nearing 90 day due dates will be completed or scheduled. |
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.
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Observations
Based on a review of client records it was determined that the facility staff failed to comply with 4 PA. Code Subsection 255.5(b). The information identified for release on the consent to release information forms in client records # 2, 3, 4, 5, 6, 7 and 8 (seven of eight client records reviewed) was not clear and, hence, did not meet the conditions for an informed consent. Examples of the phrases used to describe the specific information to be released included: "consultation", "emergency information," evaluation" and "background information". None of these phrases meet the definition of "specific information".
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Plan of Correction
The Clinical Supervisor will review with the clinical staff at the (York) staff meeting on 10/10/07 what specific information can be released by signed consent in accordance with Code subsection 255.5. In addition, those charts that were in violation with Code subsection 255.5 will be reviewed at the staff meeting and more specific, appropriate wording for the purpose of release of information will be reviewed. Active client files will be rectified. The Clinical Supervisor will randomly review one of each clinician's charts every two weeks during clinical supervision to ensure compliance. A standardized consent specific for family members will be developed by the Clinical Supervisor by 9/28/07 and reviewed with the Executive Director. Clinical Staff will be oriented to this family member consent during the staff meeting on 10/10/07. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of a sample of client records it was determined that the facility failed to document complete personal histories. The personal histories documented lacked detail on family dynamics/interactions in client records # 3, 4, 5, 6, 7 and 8. Details were lacking on sexual histories in client records #2 and 4. Educational information was incomplete in client records # 2 and 4. Employment histories were incomplete in client records # 4 and 8. The total record sample consisted of 7 client records that were presented at this level of care.
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Plan of Correction
The Clinical Supervisor will review at the (York)staff meeting on 10/10/07 New Insights Bio-psych social profile with the clinical staff and what specific details are expected in each section. All charts that were found to be in violation will be reviewed with the clinician's by the Clinical Supervisor as to why they were in violation and active client charts will be rectified. The Clinical Supervisor will randomly audit one chart of each counselor every two weeks during clinical supervision to monitor for compliance. |
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.
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Observations
Based on a review of client records it was determined that the facility failed to meet the requirements of its own policy regarding physical exams. The policy indicated that a physical needed to be obtained prior to admission if no physical exam had been completed within the past year. Physical exams should have been documented in client records # 3, 4, 5, 6 and 7. No documentation was found in these records.
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Plan of Correction
The Executive Director will revise the policy that requires a physical examination prior to being admitted to our program. The revised policy will provide guidelines for counseling staff to make a recommendation to see a physician, but not mandate as a condition for admission. This policy revision will take place by September 30th, 2007. |
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 the review of client records it was determined that the facility failed to document complete psychosocial evaluations within the required timeframes. The psychosocial evaluation in client record #1 was not completed prior to the formulation of the comprehensive treatment plan. The psychosocial evaluations in client records # 1, 3, 4 and 8 were missing necessary components such as coping mechanisms, attitude toward treatment and detailed counselor conclusions/impressions. The deficiencies existed in 4 of 7 client records reviewed for this level of care.
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Plan of Correction
The Clinical Supervisor will review the necessary components of a psychosocial evaluation/composite with all counseling staff at the (York) staff meeting on 10/10/07. Examples of thorough psychosocial evaluations will be provided and reviewed. The charts found in violation will be reviewed with the clinician by the Clinical Supervisor as to why they were in violation and active file evaluations will be rectified. The Clinical Supervisor will randomly audit one chart of each counselor's every two weeks, during clinical supervision to monitor for compliance. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records it was determined that the facility failed to document complete aftercare plans. The after care plans reviewed were missing timeframes in client records # 7 and 8, and support services were missing in client record #7. This represents two of two records for the sample reviewed for this standard.
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Plan of Correction
The Clinical Supervisor will review the necessary components of aftercare plans including measurable goals, time frames and support services with the clinical staff at the (York) staff meeting on 10/10/07. All records will be quality assured at time of discharge for aftercare plans which are measurable, have time frames and specific support systems listed. Both files cited in the deficiency listing were authored by the same counselor. That counselor's aftercare plans are being reviewed routinely at discharge until compliance with 709.93(A)(9) is consistent |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records it was determined that the facility failed to document complete discharge summaries. The reasons for treatment and the client's response to treatment were missing or incomplete in client records # 1 and 2.
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Plan of Correction
The Clinical Supervisor will review the necessary components of discharge summaries including reasons for treatment and response to treatment in (York) staff meeting with clinical staff on 10/10/07. All records will be quality assured at time of discharge for discharge summaries, which are complete including reasons for treatment and response to treatment. |
709.14(a) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
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Observations
Based on a review of administrative documentation it was determined that the facility failed to notify the Department when it exceeded the Department approved maximum capacity. Documentation on the "Staffing Requirements Facility Summary Report", which was completed by the Project Director, reflected a census of 11 in the partial hospitalization activity. The maximum capacity authorized by the Department for this activity is 10.
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Plan of Correction
The Executive Director will formally notify the Division of Drug and Alcohol Program Licensing that the York facility's Partial Hospitalization capacity has increased from 10 to 12. This will take place by September 14th, 2007. |