INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the July 26,2012 licensure renewal inspection. The follow-up inspection was conducted on March 1, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Little Creek Lodge 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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704.8(a) LICENSURE Qualifications-Counselor Assistant
704.8. Qualifications for the position of counselor assistant.
(a) A person who does not meet the educational and experiential qualifications for the position of counselor may be employed as a counselor assistant if the requirements of at least one of the following paragraphs are met. However, a project may not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.
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Observations
Based on a review of supervisory documentation and an interview with the clinical supervisor, the facility failed to ensure that no more than one counselor assistant for each employee who meets the requirements for counselor was employed at one time.
The finding includes:
An unannounced plan of correction follow up inspection was conducted on March 1, 2013. During the inspection Division staff asked to review the documentation of supervision for the counselor assistants. Documentation for three counselor assistants was noted in the supervision documentation. There are two staff employed at the facility who meet the Chapter 704 requirement for counselor . One is employee # 1 and one is employee # 2.
Employee # 1 acts as project director and was hired 8/1/07.
Employee # 2 acts as clinical supervisor and was hired 3/21/12.
Employee # 3 was hired 9/13/10 and was identified as a counselor assistant.
Employee # 4 was hired 4/18/11 and was identified as a counselor assistant.
Employee # 5 was hired on 11/6/09 and was identified as the second shift supervisor and also as a counselor assistant.
These staff were identified as counselor assistants by the clinical supervisor and documentation of counselor assistant supervision notes were presented on each of the employees.
The finding was not disputed by the clinical supervisor.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an unannounced follow-up Inspection in the application of Regulation 704.8(a).
Employee #5 who was identified as a Counselor's Assistant has been moved to 2nd shift supervisor only as of March 11, 2013, changing the ratio of certified counselors to counselor's assistants to 1:1 in the facility.
To ensure that this does not recur, the Project Director will ensure going forward that the certified counselors to counselor's assistants ratio does not exceed 1:1 in the facility. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations. If a counselor's assistant is hired, they will only be placed in the facility with a 1:1 Counselor to CA ratio to ensure appropriate supervision time is available to them.
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of employee records and an interview with the clinical supervisor, the facility failed to document feedback on training sessions attended as required by facility policy.
The finding includes:
An unannounced plan of correction follow up inspection was conducted on March 1, 2013. The clinical supervisor was interviewed at that time and verified that staff are to document training feedback forms after each training session in accordance with facility policy. Five employee records were reviewed . Three of these attended training sessions during the current training year ( 2012-13). Feedback forms were not documented for training sessions attended in three of three applicable records.
Employee record # 2 contained documentation of a training session attended 2/13/13. No training feedback was documented for this training session.
Employee record # 3 contained documentation of two training sessions attended, one on 11/15/12 and one on 1/17/13. No documentation of training feedback was documented for these training sessions.
Employee record # 4 contained documentation of two training sessions attended, one on 11/15/12 and one on 1/17/13. No documentation of training feedback was documented for these training sessions.
The findings were reviewed with the clinical supervisor and were not disputed.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an unannounced follow-up Inspection in the application of Regulation 704.11(a)(3).
Training Feedback Forms for Employee's #2, #3, #4, were completed at the time of the Survey and placed in the employee's onsite training file.
Ongoing compliance will be maintained by Clinical Director.
All Training Feedback Forms will be completed within 48 hours of training. |
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 employee records, the facility failed to document an individual training plan on each employee for the current (2012-13) training year.
The finding includes:
An unannounced plan of correction follow up inspection was conducted on March 1, 2013. Three of five records failed to include documentation of a training plan for the 2012-13 training year.
Employee record #1 - The employee was hired on 8/1/07. No documentation of an individual training plan was documented in the record at the time of the inspection.
Employee record #4 - The employee was hired on 4/18/11. No documentation of an individual training plan was included in the record at the time of the inspection.
Employee record # 5 - The employee was hired on 3/21/12. No documentation of an individual training plan was documented in the record at the time of the inspection.
The finding was reviewed with the clinical supervisor and was not disputed.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an unannounced follow-up Inspection in the application of Regulation 704.11(b)(1).
Training Plans will be completed and signed on all existing employees no later than April 15, 2013 . All new hires will have a Training Plan completed, signed and in place within 30 days of hire. As for Employee's #1, #4, #5, these Plans were completed at the time of the Survey and placed in the employee's onsite training file.
Ongoing compliance will be maintained by Clinical Director.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that space heaters are prohibited in the facility.
The finding includes:
An onsite plan of correction follow up inspection was conducted on March 1 , 2013. A Lasko ceramic portable space heater was observed in the residential director's office.
The finding was verified by the clinical supervisor and was not disputed.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an unannounced follow-up Inspection in the application of Regulation 705.8 (2) Heating and Cooling.
On March 11 2013 the moveable heaters located in a Residential Director's office was removed from facility.
As of March 11, 2013, Resident Director will be responsible for ensuring compliance of moveable heaters by conducting a periodic search of the facility. Memo's were also given to all staff to inform staff that portable heaters are not permitted in the facility.
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that fire extinguishers were inspected at least annually by a local fire company or fire extinguisher company.
The finding includes:
An onsite plan of correction follow up inspection was conducted on March 1 , 2013. Inspection tags on fire extinguishers mounted throughout the facility documented the most recent inspection of the fire extinguishers as August of 2011.
The clinical supervisor confirmed this finding by inspecting the fire extinguisher inspection tag and it was not disputed..
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an unannounced follow-up Inspection in the application of Regulation 705.10(c)(3).
On March 4, 2013, Mander Fire & Safety Inc. came to inspect all fire extinguishers and updated all fire extinguishers. All extinguishers are good until March 1, 2014.
Little Creek Lodge will ensure that this does not recur by Having Mander Fire & Safety Inc. checking all fire extinguishers on a yearly basis .
Person Responsible: Mander Fire & Safety Inc.
Person Responsible for Monitoring: Program Director
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709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of employee personnel records, the facility failed to document reference investigations on each employee
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an unannounced follow-up Inspection in the application of Regulation 709.26(d)(2) Licensure Personnel Management.
All personal files have been updated to include at least three (3) reference investigations.
To prevent recurrence, all newly hired employees will have Reference Investigation History's placed in personal files on start date by the CFO.
The Chief Financial Officer will monitor this area for compliance.
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709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based on a review of employee personnel records, the facility failed to document salary histories in five of five personnel records.
The finding includes:
An unannounced plan of correction follow up inspection was conducted on March 1, 2013. Five of five records reviewed did not include documentation of salary history.
Employee # 1 was hired 8/1/07. No salary history was documented at the time of the inspection.
Employee record # 2 was hired 3/21/12. No salary history was documented for this employee at the time of the record inspection.
Employee record # 3 was hired on on 9/13/10. No salary history was documented on this employee.
Employee record # 4 was hired on 4/18/11 . No salary history was documented on this employee.
Employee record # 5 was hired on 3/21/12. No salary history was documented on this employee.
The finding was reviewed with the Clinical Supervisor and was not disputed.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an unannounced follow-up Inspection in the application of Regulation 709.26(d)(4) Licensure Personnel Management.
At the time of inspection, Employee's #1, #3, #4, #5 had no documentation of Salary History in personnel file. All these files have been update to include Salary History's and all personal files will include Salary History by April 15, 2013
The Chief Financial Officer will monitor this area for compliance.
To prevent recurrence, all newly hired employees will have Salary History's placed in personal files on start date by the CFO.
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709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, the facility failed to document job descriptions which contained the requisite skills, knowledge and experience in two of three employee records. No job description was documented in the third record.
The finding includes:
An unannounced plan of correction follow up inspection was conducted on March 1, 2013. Two of five employee records had job descriptions which failed to include the requisite skills knowledge and experience. One personnel record was missing a job description altogether.
Employee record # 1- The employee was hired on 8/1/07. The job description did not contain the requisite skills, knowledge and experience.
Employee record # 2- The employee was hired on 3/21/12. The job description did not contain the requisite skills , knowledge and experience.
Employee record # 5- The employee was hired 3/21/12. No job description was documented in the record at the time of the inspection .
The findings were reviewed with the clinical supervisor and were not disputed.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an unannounced follow-up Inspection in the application of Regulation 709.26(f) Licensure Personnel Management.
On date of inspection, Employee #1, #2, #5's did not have the requisite skills knowledge and experience. on March 11, 2013 requisite of skills knowledge and experience were placed in these employee's files. all personal files will include requisite skills knowledge and experience by April 15, 2013
The Chief Financial Officer will monitor this area for compliance.
To prevent recurrence, all newly hired employees will have requisite of skills knowledge and experience placed in personal files on start date by the CFO. included in personnel file prior to date of hire.
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709.51(b)(3)(iii) LICENSURE Personal History
709.51. 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 , the facility failed to document a complete personal history on each client in two of three applicable records.
The finding includes:
An unannounced plan of correction follow up inspection was conducted on March 1, 2013. Two of three client records failed to include documentation of a detailed personal history on the client.
Client #1 was admitted on 1/23/13 and last treated on 2/22/13. The personal history failed to include documentation of details on family interrelationships, employment held and the educational history. The sexual history failed to include detail on whether the client had ever been the victim or perpetrator of sexual abuse.
Client record # 2 was admitted on 1/19/13 and last treated on 2/22/13. The personal history failed to include documentation of details on family interrelationships, employment held and the educational history.
The finding was reviewed with the clinical supervisor and was not disputed.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an unannounced follow-up Inspection in the application of Regulation 709.51(b)(3)(iii) Licensure Personnel History.
By April 15, 2013 the Clinical Director will complete in-house training with clinical staff, which is focused on the required information specific to Personal History section of our Biopsychosocial intake. This training will emphasize information to be included in Family System, Vocational and Educational histories.
It is anticipated that this data will begin to be fully integrated into patient records by 5/01/2013.
Clinical Director will be responsible to initiate and maintain chart monitoring to ensure compliance
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation on each client which provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
The finding includes:
An unannounced plan of correction follow up inspection was conducted on March 1, 2013. Three of three client records failed to include documentation of an evaluation that contained documentation of a psychosocial evaluation which provided a composite picture of the individual in relationship to the collected historical information
Client record #1 was admitted on 10/4/12 and last treated on 1/1/13 . The psychosocial evaluation did not contain a composite picture of the client and failed to identify negative factors which may impact treatment, client needs, the client's attitude toward treatment or the impressions and conclusions of the counselor.
Client record # 2 was admitted on 1/23/13 and last treated on 2/22/13 .The psychosocial evaluation did not contain a composite picture of the client and failed to identify negative factors which may impact treatment, client needs, potential support systems, the client's attitude toward treatment or the impressions and conclusions of the counselor.
Client record # 3 was admitted on 2/7/13 and last treated on 2/17/13. The psychosocial evaluation did not contain a composite picture of the client and failed to identify negative factors which may impact treatment, client needs, the client's attitude toward treatment or the impressions and conclusions of the counselor.
The finding were reviewed with the clinical supervisor and were not disputed.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an unannounced follow-up Inspection in the application of Regulation 709.51(b)(6)Licensure Psychosocial evaluation.
Psychosocial evaluations have been edited to require counselors to specifically evaluate and require inclusion of assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment. By April 15, 2013 the Clinical Director will complete in-house training with clinical staff, which is focused on the required information specific to developing a composite picture of client in 2nd part of psychosocial history.
It is anticipated that this data will begin to be fully integrated into patient records by 5/01/2013. Clinical Director and CQI will be responsible to initiate and maintain chart monitoring to ensure compliance
This was edited effective March 15, 2013 and the Clinical Director is responsible to insure that this deficiency does not recur.
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709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client records , the facility failed to document an individualized treatment plan on each client in two of three client records.
The finding includes:
An unannounced plan of correction follow up inspection was conducted on March 1, 2013. Two of three client records failed to document an individualized treatment plan.
Client record #1 was admitted on 10/4/12 and last treated on 1/1/13. The treatment plan formulated on 1/23/13 was not individualized based on the assessed needs of the client. Goals were written generically.
Client record # 2 was admitted on 1/23/13 and last treated on 2/22/13. The treatment plan formulated on 1/19/13 was not individualized based on the assessed needs of the client. Goals were written generically.
The finding were reviewed with the clinical supervisor and were not disputed.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an unannounced follow-up Inspection in the application of Regulation 709.52(a) Licensure Individual TX and Rehab Plan.
The Clinical Director will schedule staff training addressing documentation of individual sessions and individualizing of treatment plans.
The Clinical Director will review treatment charts on monthly basis. The Director will meet to review documentation of individual sessions and treatment planning.
The training will take place May 15, 2013 in the use of Psychosocial evaluations in development of Individualized treatment planning.
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709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of service in three of three client records reviewed.
The finding includes:
An unannounced plan of correction follow up inspection was conducted on March 1, 2013. Three of three client records failed to include documentation of a record of service..
Client #1 was admitted on 10/4/12 and last treated on 1/1/13. No record of service was documented in the record at the time of inspection.
Client # 2 was admitted on 1/23/13 and last treated on 2/22/13. No record of service was documented in the record at the time of inspection.
Client record # 3 was admitted on 2/7/13 and last treated on 2/17/13. No record of service was documented in the record at the time of inspection.
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The finding were reviewed with the clinical supervisor and were not disputed.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an unannounced follow-up Inspection in the application of Regulation 709.53(a)(3) Licensure Records of Service.
The Clinical Director will provide oversight and management to ensure that all Individual, Family, and Group counseling sessions are accurately documented on the record of service.
The Clinical Director will review the record of service on a monthly basis to ensure that Individual, Family, and Group counseling sessions are accurately documented on the record of service, and will provide supervision and training to the Residential Care Worker about accurate and timely documentation of services rendered on the record of service.
The Residential Care Worker will complete the record of service to accurately reflect all Individual, Family, and Group counseling sessions by the end of each week and will file the record of service in the client's chart.
It is anticipated that this data will begin to be fully integrated into patient records by 5/01/2013.
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709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document progress notes which addressed the client's progress on stated treatment goals in three of three client records reviewed.
The finding includes:
An unannounced plan of correction follow up inspection was conducted on March 1, 2013. Three of three client records failed to include documentation of progress notes which tracked progress on the client's treatment plan goals.
Client # 1 was admitted on 10/4/12 and last treated on 1/1/13. Progress notes failed to track progress on the stated goals of the treatment plan. Notes lacked depth regarding the counselor's analysis of and conclusions regarding the client's current situation or status.
Client # 2 was admitted on 1/23/13 and last treated on 2/22/13. Progress notes failed to track progress on the stated goals of the treatment plan. Notes lacked depth regarding the counselor's analysis of and conclusions regarding the client's current situation or status.
Client # 3 was admitted on 2/7/13 and last treated on 2/17/13. Progress notes failed to track progress on the stated goals of the treatment plan. Notes lacked depth regarding the counselor's analysis of and conclusions regarding the client's current situation or status.
The finding were reviewed with the clinical supervisor and were not disputed.
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Plan of Correction
Clinical staff is receiving continuing education for the proper documentation required for the progress notes in regards to counselor assessment and conclusions regarding the client's current situation or status.
The Clinical Director is responsible to insure that content is accurate and correct as pertaining to the standards put forth by the DDAP.
To prevent recurrence, Audits will be conducted every 15-21 days to insure that information is being properly documented.
It is anticipated that this data will begin to be fully integrated into patient records by 5/01/2013.
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