INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on May 15 through 17, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Retreat at Lancaster County 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 personnel records, the facility failed to ensure that each counselor met the qualifications for the position in three of four records.
Findings:
Eight personnel records were reviewed on May 15, 2012. Four personnel records were reviewed for counselor qualifications. Three of the four records did not document counselor qualifications, 5, 7 and 8.
In personnel record # 5, the counselor did not meet the qualifications for the position of counselor based on a Bachelor of Science degree in Applied Psychology with no prior clinical experience.
In personnel record # 7, the counselor did not meet the qualifications for the position of counselor based on a Master of Arts degree in the Humanities and a Bachelor of Science degree in Rehabilitation Services. The personnel record documented a hire date of January 24, 2012. A Master of Arts degree in Human Services, Marriage and Family was not documented until March 28, 2012.
In personnel record # 8, the counselor did not meet the qualifications for the position of counselor based on a high school diploma. The job description for an Addictions Counselor was signed on April 9, 2012, by the employee and the supervisor. The offer letter provided to the employee stated the position was for a Counselor Assistant.
An interview with the Project/Facility Director confirmed the the findings.
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Plan of Correction
Individuals were noted to be counselor assistants and job descriptions will reflect this change. Executive Director will ensure this change and monitor new hires going forward |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and training logs, the facility failed to ensure that all staff were instructed in the use of fire extinguishers upon employment in one of eight personnel records reviewed.
The findings were:
Eight personnel records were reviewed on May 15, 2012. All personnel were required to be instructed in the use of the fire extinguisher upon their employment. Personnel record # 4 did not have documentation that employee # 4 had this training upon employment.
Personnel record # 4 documented a hire date of September 13, 2011. The training log documented fire extinguisher training on November 10, 2011.
A discussion with the facility director confirmed the findings.
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Plan of Correction
All employees are trained on fire extinguisher upon hire now. HR is in charge of this. Is monitored by Exec Dir. Currently, all employees are trained to use the fire ext. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and training logs, the facility failed to ensure that all staff were trained upon employment to perform assigned tasks during emergencies in one of eight personnel records reviewed.
The findings were:
Eight personnel records were reviewed on May 15, 2012. Upon employment, all personnel were required to be trained to perform assigned tasks during emergencies.
Personnel record # 4 documented a hire date of September 13, 2011. The training log documented that employee # 4 did not receive training to perform assigned tasks during emergencies until November 10, 2011.
A discussion with the facility director confirmed the findings.
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Plan of Correction
all new hires will be trained within the correct time frame going forward. Executive Director will ensure and monitor HR for this. currently, all staff are now trained in emergency procedures. |
709.81(b)(6) LICENSURE Intake and admission
709.81. 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 in one of one client record.
The findings include:
Five client records were reviewed on May 17, 2012. A psychosocial evaluation was required in one client record. Per agency policy, the psychosocial is completed in 5 working days from admission. A psychosocial evaluation was not documented as per agency policy in client record #5.
Client record #5 documented an admission date of April 16,2012. A psychosocial evaluation was dated April 24, 2012. This was 6 working days after admission.
The findings were reviewed with the Project/Facility Director.
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Plan of Correction
Staff were informed and trained to ensure that all patients get their psychosical evaluation done within 5 days of admission. This will be monitored via chart checks daily by Clinical Supervisors under the direction of exec dir |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice weekly in one of five records reviewed.
The findings include:
Five client records were reviewed on May 17, 2012. One client record was reviewed for the partial program. This record was required to document individual counseling at least twice weekly, # 5.
Client record # 5 documented an admission date of April 16, 2012. The client record did not document two individual sessions per week. The weeks of 4/30/2012 and 5/7/2012 had one individual session progress note for the week.
The findings were reviewed with the Project/Facility Director and were not disputed.
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Plan of Correction
Outpatient and PHP staff were informed that there are 2 sessions per week for PHP patients and this will be monitored via chart checks on a weekly basis by the Exec Dir - documentation of these sessions must be in the record. |
709.22(c)(1) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(1) A method of selection for membership.
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Observations
Based on a review of the facility's policy and procedures and other documents produced during the inspection, including copies of the board meeting minutes, the facility failed to identify a method of selection for board members in the facility policy and did not produce a copy of the corporate bylaws for review.
The findings included:
The facility did not provide documentation of the method of selection for members of the Board of Directors. Current members of the Board were listed on the Organizational Leadership document.
The facility's policy manual was reviewed on May 15, 2012. Documentation within the policies was inconsistent with an "Organizational Leadership Document" which listed the current members of a board of directors. Initially, the facility did not list a Board of Directors and stated that the Managing Director retained 100% ownership of the facility and was responsible for overall management. A copy of the corporate bylaws was requested on May 17, 2012, after the Project/Facility Director provided a copy of the board meeting minutes.
The Project/Facility Director stated that a copy of the bylaws would be provided, but they were not presented during the inspection.
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Plan of Correction
A board meeting was held on June 13. Bylaws were presented and signed by each board member and includes how to select board members. This was carried out by the Chairman of the board and noted by this writer. They are available for review upon request. Board meetings will continued to be held on a quarterly basis. |
709.22(c)(2) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(2) Qualifications for membership.
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Observations
Based on a review of the facility's policy and procedures and other documents produced during the inspection, including copies of the board meeting minutes, the facility failed to identify qualifications for board members in the facility policy and did not produce a copy of the corporate bylaws for review.
The findings included:
The facility did not provide documentation of the qualifications for members of the Board of Directors. The qualifications can include age, residence, education, and experience. Current members of the Board were listed on the Organizational Leadership document.
The facility's policy manual was reviewed on May 15, 2012. Documentation within the policies was inconsistent with an "Organizational Leadership Document" which listed the current members of a board of directors. Initially, the facility did not list a Board of Directors and stated that the Managing Director retained 100% ownership of the facility and was responsible for overall management. A copy of the corporate bylaws was requested on May 17, 2012, after the Project/Facility Director provided a copy of the board meeting minutes.
The Project/Facility Director stated that a copy of the bylaws would be provided, but they were not presented during the inspection.
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Plan of Correction
Corporate bylaws were approved by the board members at the Board meeting held on June 13. Policy now includes selection and qualifications for board members. This was noted by the Executive Director. |
709.22(c)(3) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(3) Criteria for continued membership.
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Observations
Based on a review of the facility's policy and procedures and other documents produced during the inspection, including copies of the board meeting minutes, the facility failed to identify criteria for continued membership for board members in the facility policy and did not produce a copy of the corporate bylaws for review.
The findings included:
The facility did not provide documentation of the criteria for continued membership for members of the Board of Directors. Criteria can include required attendance at meetings, and/or participation commensurate with expertise. Current members of the Board were listed on the Organizational Leadership document.
The facility's policy manual was reviewed on May 15, 2012. Documentation within the policies was inconsistent with an "Organizational Leadership Document" which listed the current members of a board of directors. Initially, the facility did not list a Board of Directors and stated that the Managing Director retained 100% ownership of the facility and was responsible for overall management. A copy of the corporate bylaws was requested on May 17, 2012, after the Project/Facility Director provided a copy of the board meeting minutes.
The Project/Facility Director stated that a copy of the bylaws would be provided, but they were not presented during the inspection.
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Plan of Correction
Bylaws have been presented to the board and were signed on June 13 at the board meeting. This was noted by Exec Dir. This also includes criteria for continued membership for the board. |
709.22(c)(4) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(4) Frequency of meetings.
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Observations
Based on a review of the facility's policy and procedures and other documents produced during the inspection, including copies of the board meeting minutes, the facility failed to identify the frequency of meetings for board members in the facility policy and did not produce a copy of the corporate bylaws for review.
The findings included:
The facility did not provide documentation of the frequency of meetings for members of the Board of Directors. Current members of the Board were listed on the Organizational Leadership document.
The facility's policy manual was reviewed on May 15, 2012. Documentation within the policies was inconsistent with an "Organizational Leadership Document" which listed the current members of a board of directors. Initially, the facility did not list a Board of Directors and stated that the Managing Director retained 100% ownership of the facility and was responsible for overall management. A copy of the corporate bylaws was requested on May 17, 2012, after the Project/Facility Director provided a copy of the board meeting minutes.
The Project/Facility Director stated that a copy of the bylaws would be provided, but they were not.
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Plan of Correction
Bylaws were signed and reviewed by each board member on June 13 at Board Meeting. Meetings will be held quarterly and this was noted and agreed upon at the meeting. This was noted by Exec Dir |
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 patient records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in two of five patient records.
The findings included:
Five patient records were reviewed on May 17, 2012. The type and frequency of services were required in the individual treatment and rehabilitation plan in two patient records.
The patient records did not document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan, # 2 and 3.
Patient record # 2 documented an admission date of April 27, 2012, and was discharged on May 14, 2012. An individual treatment and rehabilitation plan was completed on May 1, 2012. The type and frequency of individual and group therapy services listed "detox."
Patient record # 3 documented an admission date of May 2, 2012. An individual treatment and rehabilitation plan was completed on May 7, 2012. The type and frequency of individual and group therapy services listed "detox/rehab."
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Plan of Correction
Clinical staff were informed and trained to ensure they include frequency of services on treatment plans, including group and individual sessions. This will be monitored by Clinical Supervisor via chart checks under the direction of Exec Dir |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in one of one client record.
The findings included:
Five client records were reviewed on May 17, 2012. The type and frequency of services were required in the individual treatment and rehabilitation plan in one client record. The client record did not document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan, # 4.
Client record #4 documented an admission date of December 27, 2011. An individual treatment and rehabilitation plan was dated January 10, 2012. The type and frequency of individual and group therapy services were not listed.
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Plan of Correction
Clinical staff were informed and trained to include type and frequency of treatment and rehab services including indiv and group sessions and will be monitored via chart checks by Clinical Supervisor under direction of Exec Dir |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document the support services on the individual treatment and rehabilitation plan in one of one client record.
The findings included:
Five client records were reviewed on May 17, 2012. The support services were required in the individual treatment and rehabilitation plan in one client record. The client record did not document the support services on the individual treatment and rehabilitation plan, # 4.
Client record #4 documented an admission date of December 27, 2011. An individual treatment and rehabilitation plan was dated January 10, 2012. The support services were not listed.
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Plan of Correction
Clinical staff were trained and informed to include support services on treatment plans. This will be monitored via chart checks by the Clinical Supervisor under direction of Exec Dir |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update in one of one client record.
The findings include:
Five client records were reviewed on May 17, 2012. One client record was required to have a treatment plan update. Per the facility policy, treatment plan updates are required to be completed within 60 days of the comprehensive treatment plan. The facility failed to document a treatment plan update in client record #4.
Client record #4 was admitted on December 27, 2011. An individual treatment and rehabilitation plan was dated January 10, 2012. A treatment plan update was due by March 10, 2012, and May 10, 2012. The facility failed to document the completion of a treatment plan update for either date at the time of the review.
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Plan of Correction
Staff were informed and trained to enter in treatment plans for all patients. This is monitored by clinical supervisors during daily chart checks. Exec Dir will monitor this practice going forward to ensure all patients have a treatment plan(s) |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in one of one client record.
The findings include:
Five client records were reviewed on May 17, 2012. One client record was required to have at least one quarterly case consultation at the time of the inspection. The facility failed to document a case consultation in client record #4.
Client record # 4 was admitted on December 27, 2011. There was no quarterly case consultation documented in the record at the time of the inspection.
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Plan of Correction
Executive Director will ensure case conference occurs and that they are documented in medical records on a quarterly basis. ED notified and informed staff of this matter. They understood. This will be monitored by the Exec Dir |