INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from November 29, 2011 to December 1, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, St. Joseph's Institute 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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704.7(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.
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Observations
Based on a review of the agency self reporting staffing form and the employee personnel records the facility failed to employ counselors who met one of the requirements specified at Chapter 704. 7(b).
The findings included:
Six clinical staff records were reviewed during the onsite inspection. Five of these staff were designated as counselors. Employee # 5 did not have documentation of an approved degree and therefore was not qualified for the designation as a counselor. The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
The Counselor's training plan has been updated to include education to become a Certified Addiction Counselor.
A written assessment of her skill level was prepared and placed in the personnel file.
Supervision for 3 months was documented including daily clinical team review and weekly individual supervision with the Clinical Director. Ongoing supervision by the Clinical Director will be provided to meet the requirements.
All documentation has been completed as of Jan. 1, 2012
The Humnan Resources staff have been advised of the list of approved degrees and will use this information to confirm that the qualifications of future applicants meet the requirements set forth in the regulations.
The Project Director will review and document compliance on a quarterly basis to ensure that all action steps have been implemented. |
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 the review of the facility training manuals and administrative materials which included the facility annual training plan, the facility failed to document an assessment for the current 2011 training year.
The findings included:
During the annual onsite licensing renewal inspection, all facility training materials were reviewed. This included the facility training manual and various facility training documents addressing the training plan process. Individual employee assessment forms were documented for all employees in the sample. No documentation was presented to Division staff which demonstrated the facility's efforts to compile the data obtained from the annual training assessment questionnaires for the purpose of determining which topics were most relevant for the annual facility training plan.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
A survey of all staff will be conducted each December concerning the training needs and interests of the employees. This information, in combination with the training feedback gathered during the annual employee reviews, will be used in the preparation of the Institute's Master training plan and each individual plan. The training plan for each New Year will be completed early in the first quarter, and reviewed with the staff. The individual training plans will be signed by the employee and their supervisor, and represent a commitment between both parties.
The employee survey has been completed and the master training plan for 2012 prepared as of Jan 3, 2012. The individual plans will be finalized before the end of January.
The Project Director has responsibility for ensuring that a strong training program is developed and implemented. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of the facility policies and procedures manual and administrative reports, the facility failed to document the Project's goals and objectives which addressed available resources to be utilized in goal achievement.
The findings include:
The facility goals and objectives for 2010 and 2011 were reviewed during the November 29 to December 1, 2011 annual licensing inspection. The goals for 2011 were not comprehensive, and failed to take into account all areas of project operations. The goals that were presented did not include identification resources to aid in the implementation of the stated goals.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
The Institute will prepare a comprehensive plan for 2012 that will address all areas of operation. Goals and objectives will be delineated with corresponding timeframes and budgets. This plan will be completed each year by the end of January. The Project Director is responsible for ensuring that the plan is devleoped, approved and implemented.
The first draft of the plan is being reviewed as of January 3, 2012 |
709.24(a)(4) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(4) Written procedures for referral outlining cooperation with other service providers.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to have a well organized, up to date manual that is consistent with current practices.
The findings included:
During the annual onsite licensing inspection held from November 29 through December 1, 2011, the facility policy and procedure manual was reviewed. The manual was not well organized and contained conflicting and/or vaguely stated policies and procedures specifically related to the frequency and timelines for required documentation components in the client record, including but limited to: preliminary treatment planning, documentation of treatment plan updates and case consultations.
The findings were reviewed with the Project Director and Clinical Supervisor and were not disputed.
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Plan of Correction
The manual has been reviewed for policies that are inconsistent or where greater detail is appropriate. A new draft has been provided for review by the Department of Health in conjunction with a licensing application for a detox unit. Upon approval of this manual, which has been reorganized, a common manual will be prepared for both licensed programs, identical in all respects except for the policies specific to detox treatment and residential care.
The Clinical Team, under the direction of the Clinical Director, will take responsibility for reviewing the policies every six months to ensure compliance by the staff and determine if new policies or changes are required. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of fiscal records presented to Division staff during the inspection, the facility failed to document an annual audit for the Fiscal Year ended December 31, 2010.
The findings included:
During the annual onsite licensing inspection of November 29 to December 1, 2011, the fiscal records were reviewed. A document submitted for review was a report by a Certified Public Accountant on the facility's financial activities for the Fiscal Year ended December 1, 2011. The report indicated in the text that it was not an audit . No opinion was expressed by the accountants submitting the report.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
The Institute's Certified Public Accountant has been instructed to perform a comprehensive audit for fiscal year 2011.
The letter of engagement will detail this requirement.
The Project Director is responsible for ensuring that the audit meets the specified requirements. The work of the audit team has begun for the fiscal year ending December 31, 2011. |
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, the facility released specific information to funding entities which exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b).
The findings included:
Five full client records were reviewed during the onsite annual inspection of November 29- December 1, 2011. Information released from client record # 4 exceeded the limitations on information that could be released as specified at 4 Pa. Code subsection 255.5(b). A disclosure of information released from client record # 4 was documented on October 27, 2011. The information released to the third party payer included psychiatric symptoms the client was experiencing, clinical impressions of therapy staff and details from the client's history.
The Clinical Supervisor confirmed that a record of the information disclosed by the Intake Worker to third party payers was not documented, but that information routinely released included medications taken by the client, clinical impressions, client history including drugs of abuse and symptomology and relationship history with family and significant others.
The findings were reviewed with the Clinical Supervisor and Project Director and were not disputed.
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Plan of Correction
The Institute's confidentiality policy has been expanded to include a detailed explanation of PA Code 255.5(b) The "Interpretive Guideline" for this policy has been provided to the Admissions and Clinical staff with an explanation of the concern re the inappropriate release of information. Meetings on this topic have been held with all appropriate staff. A training program will be offered to all staff to ensure understanding and compliance with this regulation and the broader concerns of confidentiality and professional ethics.
A training program with an approved external trainer is being finalized for the first quarter of 2012.
The Project Director has assumed responsibility for ensuring that the staff are well trained with respect to confidentiality. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of the medication area and the documentation contained therein and an interview with nursing staff, the facility failed to document inspections of the medication storage area.
The findings included:
An inspection of the medication room was conducted on December 1 , 2011. There was no documentation of monthly inspections of the medication storage area. Facility policy stated that the nurse is to inspect the medication area monthly. The nurse on duty was interviewed and indicated that she had no knowledge of any inspection records.
The findings were reviewed with the Clinical Supervisor and the Project Director and were not disputed.
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Plan of Correction
A form has been prepared to document monthly inspections of the medication room. The staff have been trained in its use, and regular inspections have begun.
The Clinical Director will undertake an internal audit of the nursing protocols on a quarterly basis to ensure there is full compliance. |
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 the review of the facility policy and procedure manual and client records, the facility failed to document preliminary treatment plans in two of five client records.
The findings included:
The annual licensing renewal inspection was conducted onsite form 11/29/2011 to 12/1/2011. The client record review process was conducted from 11/30/11 to 12/1/11. The facility manual was reviewed and a sample of five client records was reviewed. Three of five records had the treatment plans documented within one day of admission and did not require a preliminary treatment plan. Documented facility policy indicated that a treatment plan was to be documented in the client record within 72 hours.
Record #4- This individual was admitted on 11/4/11 and last treated on 11/28/11. There was no preliminary treatment plan documented in the record and the comprehensive treatment plan was not developed until 11/9/2011. The treatment plan was not documented within 72 hours.
Record # 5- This client was admitted on 9/14/11 and discharged on 10/13/11. No preliminary treatment plan was documented. The comprehensive treatment plan was documented on 9/26/11. The treatment plan was not documented within 72 hours.
The findings were reviewed with the clinical supervisor and Project Director and were not disputed.
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Plan of Correction
The policies and procedures concerning the development of treatment plans were reviewed with the counseling staff. The importance of completing the preliminary treatment plan within 72 hours was reinforced. A review was conducted of the items that need to be documented.
Internal audits will be conducted by the Clinical Director on a regular basis to ensure compliance. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records during the annual inspection, the facility failed to document the type and/or frequency of services to be provided to the client on the treatment plans in five of five client records.
The findings included:
The annual onsite licensing renewal inspection was conducted from 11/29/2011 to 12/1/2011. Five client records were reviewed from 11/30/2011 to 12/1/2011. The treatment plans in five of five client records failed to include documentation of the type and/or frequency of treatment services.
Record # 1 - This client was admitted on 11/10/11 and last treated on 11/18/11. The comprehensive treatment plan was documented on 11/11/11. There was no documentation of the frequency of services on the treatment plan.
Record # 2- This client was admitted on 11/1/11 and last treated on 11/28/11. The comprehensive treatment plan was documented on 11/1/11. There was no documentation of the frequency of services on the treatment plan.
Record # 3- This client was admitted on 11/27/11 and last treated on 2/23/11 . The comprehensive treatment plan was documented on 11/27/11. There was no documentation of the frequency of services on the treatment plan.
Record # 4- This client was admitted on 11/4/11 and last treated on 11/28/11. The comprehensive treatment plan was documented on 11/9/11. There was no documentation of the frequency of services on the treatment plan.
Record #5 - This client was admitted on 9/14/11 and last treated on 10/10/11 . The comprehensive treatment plan was documented on 9/26/11. There was no documentation of the frequency of services on the treatment plan.
The findings were reviewed with the project director and clinical supervisor and were not disputed.
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Plan of Correction
New documentation forms have been developed that list the frequency of services provided by the Institute in the 3 major program areas: psycho-education, counseling, holistic services. This new process has been reviewed with the clinical staff and will be implemented on 1/9/2012. These documents include: Summary of therapeutic concerns, Treatment goals fulfilled by the educational program, and treatment goals fulfilled by the holistic program.
The Clinical Director is responsible for monitoring compliance. |
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 the review of the facility policy and procedure manual and client records during the annual inspection, the facility failed to document treatment plan updates which addressed progress on the stated goals of the treatment plan. Treatment plan updates were not completed in timeframes required by facility policy.
The findings included:
The annual onsite licensing renewal inspection was conducted from 11/29/2011 to 12/1/2011. Five client records were reviewed on 11/30/2011 and 12/1/2011. Four of the five records failed to include documentation of treatment plan updates within timframes established by facility policy and/or failed to address progress made on the stated goals of the treatment plan.
Client record # 1 - This client was admitted on 11/10/11 and last treated on 11/18/11. The comprehensive treatment plan was documented on 11/11/11. One treatment plan update was documented on 11/16/2011. The content of the update failed to include the client's progress on each of the stated goals of the previous treatment plan.
Client record # 2- This client was admitted on 11/1/11 and last treated on 11/28/11 . The comprehensive treatment plan was documented on 11/1/11. One treatment plan update was documented on 11//9/11. The content of the update failed to include the client's progress on each of the stated goals of the previous treatment plan.
Client record # 3- This client was admitted on 1/27/11 and last treated on 2/23/11 . The comprehensive treatment plan was documented on 1/27/11. The content of the update documented on 2/3/11, failed to include the client's progress on each of the stated goals of the previous treatment plan.
Client record # 4- This client was admitted on 11/4/11 and last treated on 11/28/11. The comprehensive treatment plan was documented on 11/9/11. A treatment plan update was documented on 11/12/11. The content of the update failed to include the client's progress on each of the stated goals of the previous treatment plan.
The findings were reviewed with the project director and clinical supervisor and were not disputed.
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Plan of Correction
Reviewed with all clinical staff the timeframes for updates on the treatment plans and the importance of completing documentation in a timely manner. Created and reviewed with staff new forms that document the therapeutic concerns. Provided training on the identification of the 2-3 primary goals that should be highlighted in the treatment plan. Imposed deadlines on counselors to develop therapeutic treatment goals in a timely manner. Training was completed on 12/28. Full implmentation scheduled for 1/9/2012.
The Clinical Team will be reviewing the plans on a regular basis to ensure that the system is being effectively implemented. The Clinical Director will monitor to ensure compliance. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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:
(8) Case consultation notes.
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Observations
Based on the review of the facility policy and procedure manual and client records during the annual inspection, the facility failed to document case consultations within time frames required in facility policy.
The findings included:
The annual onsite licensing renewal inspection was conducted from 11/29/2011 to 12/1/2011. Five client records were reviewed on 11/30/2011 and 12/1/2011. Facility policy stated that case consultations were to be documented weekly. Five of the five client records failed to include documentation of case consultations which were completed on a weekly basis.
Client record # 1 - This client was admitted on 11/10/11 and last treated on 11/18/11 . The comprehensive treatment plan was documented on 11/11/11 .One case consultation was documented on 11/14/11. There was no case consultation for the week of 11/21/11.
Client record # 2- This client was admitted on 11/1/11 and last treated on 11/28/11 . The comprehensive treatment plan was documented on 11/1/11. No case consultations were documented in this client record.
Client record # 3- This client was admitted on 1/27/11 and last treated on 2/23/11 . The comprehensive treatment plan was documented on 1/27/11. One case consultation was documented on 2/3/11. There were no case consultations documented for the weeks of 2/7/22 and 2/14/11.
Client record # 4- This client was admitted on 11/4/11 and last treated on 11/28/11. The comprehensive treatment plan was documented on 11/9/11. No case consultations were documented in this client record.
Client record # 5- This client was admitted on 9/14/11. The treatment plan was formulated on 9/26/11. The last recorded treatment date was on 10/10/11. One case consultation was documented on 10/3/11. There were no case consultations documented for the week of 9/19/11 and 9/26/11.
The findings were reviewed with the project director and clinical supervisor and were not disputed.
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Plan of Correction
The policy was revised to indicate that only one case consultation would be required during the course of treatment (30-days). The policy manual is being reviewed and all inconsistencies will be corrected. The policy in effect has been reviewed with all members of the clinical staff.
Members of the Clinical Team have undertaken this work with guidance from the Clinical Director.
A comprehensive review of the policy manual will occur on an annual basis. |