INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 18- 19, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Harwood House 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 April 21, 2008.
|
Plan of Correction
|
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
|
Observations
Based on a review of personnel records and staff interview, the facility failed to ensure that the counselor assistant was working toward counselor status in one of one record reviewed, #4. The counselor assistant did not document how she is working toward counselor status upon the completion of the calendar year.
|
Plan of Correction
The Clinical Supervisor is responsible for ensuring that counselor assistants are working towards full counselor status and it is documented in the chart. The Clinical Supervisor will monitor counselor assistants progress during supervisions. The Program Director is responsible for overall compliance with this standard.
Time Frame for compliance: Completed. Employee #4 has brought in documentation of continuing education and it has been placed in chart. Continued proof documentation will also be placed in the chart after each semester. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel and training records on March 18, 2008, the facility failed to ensure that staff received HIV/AIDS and TB/STD training in five of ten records reviewed, #6, 7, 8, 9 and 10.
|
Plan of Correction
The Program Director is responsible for ensuring that all staff acheive required trainings through individual training plans and training evals. The Clinical Supervisor is responsible for assisting in scheduling of individual trainings.
Time Frame for Compliance: Completed. All required employees received a 6 hour HIV/AIDS and TB/STD Training on March 27, 2008 facilitated by the Aids Care Group. |
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.
|
Observations
Based on a review of CPR certifications and first aid training on March 18, 2008, the facility failed to ensure that at least one person trained in these skills is onsite during the project's hours of operations for one of thirty days reviewed. On March 1, 2008, two staff persons on duty from 8:00 a.m. until 4:00 p.m. did not have current CPR certifications or first aid training.
|
Plan of Correction
The Program Director is responsible for ensuring that all staff receive required trainings. The Clinical Supervisor is responsible for assisting in scheduling individual employees for the trainings. The clinical supervisor is responsible for ensuring that that at least one trained residential program worker is onsight for all scheduled shifts. The Clinical Director is responsible for overall compliance and is also responsible for documenting all of her hours worked in facility to ensure proof of coverage.
Time Frame for Completion: Completed> All required staff received CPR and First aid training on 4/5/2008 facilitated by the Red Cross. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on a review of the physical plant conducted on March 18, 2008, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit. The hot water was measured at 148 and 138 degrees Fahrenheit in one male bathroom and one female bathroom, respectively.
|
Plan of Correction
The staff on duty is responsible of ensuring tht the hot water temperature does not exceed 120 degrees Fahrenheit. This will be documented on a calander in the staff area 1x daily. The Clinical Supervisor is responsible for ensuring that all staff are trained in checking the temperature and documenting it as above. The program director is responsible for overall compliance with this standard.
Time Frame for completion: Completed. All necessary staff have been trained and compliance is being acheived. |
709.32(c)(2) 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:
(2) Drug storage areas.
|
Observations
Based on a review of the drug storage area conducted on March 18, 2008, the facility failed to ensure that medication requiring refrigeration was properly stored. The refrigerator utilized for the storage of client medication was also used to store staff food and beverage items.
|
Plan of Correction
The Program Director is responsible to ensure that medication requiring refrigeration are properly stored.
Time Frame for Compliance: Completed. A seperate fridge was purchased and placed in the medication room for medication storage. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records on March 19, 2008, the facility failed to document a decision to involuntarily terminate a client's treatment at the project in one of two records reviewed, #1. Facility staff failed to notify the client, in writing, of a decision, including the reason, to involuntarily terminate the client's treatment at the project
|
Plan of Correction
The primary counselor is responsible for documenting a decision to involuntarily terminate a client's treatment in the facility. The clinical supervisor is responsible for ensuring that that the staff are trained in completing involutary discharge forms and are placing them in the charts. The program director is responsible for overall compliance with this standard.
Time Frame for Compliance: All clinical staff will be trained in completing involuntary discharge paperwork on April 28th 2008. The clinical supervisor will reveiw all discharges for continued compliance. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on a review of client records on March 19, 2008, the facility failed to document a complete drug and alcohol history in three of four records reviewed, #1, 3 and 4. Drug and alcohol histories contained incomplete and contradictory information regarding the client's lengths and patterns of drug and/or alcohol use and the client's prior treatment history. Information documented on the intake interview form was different than what was documented in the drug and alcohol history form with no clarification.
|
Plan of Correction
The primary counselor is responsible for a complete drug and alcohol history that corresponds with prior treatment history and intake form. Contradictions will be noted on progress note. The clinical supervisor will be responsible for ensuring that the primary counselor is compliant through supervision sessions and monthly chart audits. The Program Director is responsible for overall compliance.
Time Frame for Compliance: All clinical staff will be trained on May 5th in proper completion of the Drug and Alcohol history. The clinical supervisor will be trained in monitoring for compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records on March 19, 2008, the facility failed to document a complete psychosocial evaluation in three of four records reviewed, #1, 3 and 4. Psychosocial evaluations were more historical with client stated comments rather than a clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, client's attitude toward treatment and overall impressions.
|
Plan of Correction
It is the primary counselors responsibility to document a complete psychosocial evaluation in the chart. The clinical supervisor is responsible for ensuring that the primary counselor is compliant with this standard through supervision and monthly chart audits. The program director is responsible for overall compliance.
Time frame for compliance. The clinical staff will be trained in proper completion of the psychosocial evaluation and the clinical supervisor will be trained in proper review on May 12th, 2008. |
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.
|
Observations
Based on a review of client records on March 19, 2008, the facility failed to document complete progress notes in four of four client records, #1, 2, 3 and 4. Progress notes for individual sessions were missing the clinician's assessment and plan for the client. In addition, several group notes were missing a comment relative to each individual's response or participation in the group session.
|
Plan of Correction
The counselor is responsible for proper completion of progress notes in the client record. The clinical supervisor is responsible ensuring counselor compliance with this standard through supervision and monthly chart audits. The program director is responsible for overall compliance with this standard.
Time Frame for compliance: Clinical staff will be trained in proper completion of the progress note and the clinical supervisor will be trained for monitoring on May 12th, 2008. |