INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 4 through 5, 2007 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 September 15, 2007.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records on September 4, 2007, the facility failed to ensure that employee #1 met the required educational requirements for the position.
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Plan of Correction
704.5 Qualifications of position of project director and facility director.
The Board of Directors is responsible for hiring a qualified program director and ensuring that the educational requirements have been met.
Time frame for compliance: This has been met as a new program director was approved and hired with a start date of 10/15/2007.
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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records on September 4, 2007, the facility failed to document a semi-annual performance evaluation for one counselor assistant. A performance evaluation was not documented for December 2006.
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Plan of Correction
704.9 Performance Evaluation.
The clinical Supervisor is responsible for completing the Semi annual review for counselor assistants. The program director will provide a training to the clinical supervisor regarding overall supervision of counselor assistants. The program director will be responsible for ensuring overall compliance of this standard.
Time frame for compliance: 9/7/07 A performance evaluation was completed on the counselor assistant after the site visit. The clinical supervisor will receive training by 10/25/07 |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel and training records and staff interviews, the facility failed to document supervision for one counselor assistant, #3. Direct observation was not documented during the months of May 14, 2007 through August 14, 2007. The facility failed to document close supervision for employee #3 starting the week of August 14, 2007 through September 4, 2007.
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Plan of Correction
704.9(C)Supervision Period of Counselor Assistant.
The Clinical Supervisor is responsible for providing supervision to the counselor assistant. Employee #3 will receive 3 months of direct observation and then 9 months of close supervision. The program director is responsible for ensuring overall compliance and will train the clinical supervisor on correct supervision of counselor assistants.
Time frame for compliance: Ongoing. Direct observation for this employee started on 9/6/07. The clinical supervisor will receive training by 10/25/07
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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.
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Observations
Based on a review of personnel and training records on September 4, 2007, the facility failed to document Department approved HIV/AIDS and TB/STD training within the required time frame in one of four records reviewed, #3
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Plan of Correction
704.11(C)(1) Mandatory Communicable Disease Training.
The program director is responsible ensuring that all staff acheive required trainings through individual training plans and training evals. The clinical supervisor will be responsible for assisting is scheduling of individual trainings.
Time frame for compliance Employee #3's verification of attending the stated training has been faxed to the state.
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705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
Based on a review of the physical plant conducted on September 5, 2007 at 4:30 pm and interview with the acting project/facility director, the facility failed to maintain a fire alarm for persons with a hearing impairment in a bedroom designated for male clients.
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Plan of Correction
The deficiency was reviewed by the department and was found to be in compliance. |
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 administrative documentation on September 4, 2007 and a discussion with the Board of Directors president on September 5, 2007, the project failed to enforce the criteria for continued membership as stated in the by-laws.
A review of the governing body by-laws revealed that the Articles of Incorporation indicated that any Director who fails to attend three (3) successive meetings of the Board of Directors shall be removed by the remaining Directors without notice.
A review of the Board meeting minutes for September 2006 through August 2007 indicated that Board member #1 failed to attend Board meetings during the months of January 2007, February 2007, March 2007 and April 2007. Board meeting minutes from May 2007 through August 2007 revealed that Board member #1 continued to be an active member on the Board of Directors.
A conversation with the president of the Board of Directors on September 5, 2007 confirmed that Board member #1 was not present for the meetings conducted between January 2007 and April 2007. In addition, the president confirmed that this member spends half the year in another state and repeatedly misses board meetings conducted during these months.
The president confirmed that no exception was presented to the Board for approval.
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Plan of Correction
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The Board of Directors have scheduled a special meeting on 10/1/07 to discuss this matter.
Board members have changed the bi-law to read if a board member is absent for more than four consecutive meetings, without an excused absence, he/she will be removed from the board. All board members will be informed of this change and they will ensure that this error will not reoccur. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility's policies and procedures on September 4, 2007, the project director failed to annually update a written manual delineating project policies and procedures. Several conflicting administrative and clinical policies and procedures were documented in the manual. The executive director and sixteen other staff members signed and dated the manual in June 2007. The signatures indicated that all staff reviewed the manual in its entirety at this time.
Two conflicting policies regarding the completion of the client's psychosocial history and assessment were documented in the manual. A policy dated 10/96 entitled "Program implementation" stated "Within five days of admission the primary counselor meets with the resident to complete the psychosocial history and assessment." A policy dated 6/07 entitled "Psychosocial history and assessment" stated "...each resident and their counselor shall complete a detailed Psychosocial History and Assessment ...within fourteen (14) days of admission." The "Initial 21-day Treatment Plan" form stated "Complete psychosocial process in the first 14 days."
A policy dated 10/96 entitled "Program Implementation" stated "Case conferences are held on a weekly basis with staff and client present ..." A second policy dated 12/96 entitled Case consultations/case conferences stated "All clients shall be the subject of a case conference every 30 days when the treatment plan is updated ..."
Two conflicting policies regarding medical emergencies were documented in the manual. A policy dated 6/03 entitled "Crisis Management - Medical Emergencies" and a policy dated 7/03 entitled "Medical Emergencies" addressed different procedures for staff in the event of a medical emergency.
Two conflicting policies regarding psychiatric emergencies were documented in the manual. A policy dated 6/93 entitled "Crisis Management - Psychiatric Emergencies" and a policy dated 7/03 entitled "Psychiatric Emergencies" addressed different procedures for staff in the event of a psychiatric emergency.
Two conflicting forms regarding the removal of possessions were included in the manual. A form dated 3/04 entitled "Resident Acknowledgement of Responsibility to remove possessions and Medications" stated "Harwood House will hold, and store, personal belongings, such as clothes, personal care items ...for no more than Seven (7) days ...After Seven (7) days Harwood House may dispose of these items as they see fit." A form dated 11/04 entitled "Client acknowledgement of resident information" stated "...I understand that any and all clothing and personal property left at Harwood for more than 14 days after my discharge becomes the property of Harwood House."
Two copies of a typed memo regarding the "List of Unapproved Medications" that was faxed from the psychiatrist to the Executive Director on May 10, 2007 contained conflicting information. The original typed memo was in the policy and procedure manual. A copy of this memo was in the staff log book with a handwritten note not on the original faxed version. The handwritten note stated "We are not going to Advertise this but if you do get a referral on these meds, we can interview them." The handwritten note was not signed. This note indicated that although a policy was in place, the facility would not abide by it.
Three conflicting policies regarding client compliance with his/her medication were documented in the manual. Three policies, "Dispensing Medications", "Clients admitted who only have prescriptions for medications" and "Taking medications", dated 7/00, 8/03 and 2/07 respectively contained inconsistencies as to whether or not a client who does not take his/her medication would or would not be discharged from the facility.
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Plan of Correction
709.23(A)
The project director is responsible for preparing and annually updating the policy and procedure manual. The Board of Directors is responsible for ensuring overall compliance.
Time frame for complaince: The policy and procedure manual will be updated, all conflicting policies will be removed and the Board and Director will sign approval by 10/25/07. |
709.23(b) 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:
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Observations
Based on a review of administrative policies, Board meeting minutes and staff interview, the project failed to document that the project director assisted or presented project goals and objectives to the governing body for the 2007/2008 fiscal year.
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Plan of Correction
709.23(B)Project Director. Goals and Objectives
The Project Director is responsible for cimpleting annual Goals and Objectives for fiscal year. The Board of Directors is responsible for overall compliance.
TIme Frame for Compliance: The goals and objectives for 2007-2008 have been formulated and approved by the Board of Directors. They were also faxed to the State upon completion.
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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 administrative documentation and staff interview, the project failed to document goals and objectives for the fiscal year of July 1, 2007 to June 30, 2008. A review of administrative documents on September 4, 2007 indicated that the annual goals and objectives for the fiscal year of July 1, 2007 to June 30, 2007 were missing. A conversation with the acting project/facility director on September 5, 2007 confirmed that the annual goals and objectives for the fiscal year of July 1, 2007 to June 30, 2007 were not developed.
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Plan of Correction
Site visit 0147
The program director is responsible for completing the annual goals and objectives and submitting to the board for approval by June 15th of each year for the next fiscal year. It is the rosponsibility of the board of directors to approve goals and objectives and sign off on them before July 1st yearly.
Time frame for compliance: Goals and objectives have been updated for 2007 and 2008. Policy has been reveiwed with president of the board for continued compliance.
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709.26(b)(4) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(4) The implementation of Federal, State and local statutes concerning fair employment practices.
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Observations
Based on a review of administrative documentation on September 4, 2007, the facility failed to document the implementation of fair employment practices. The fair employment practices document dated September 2006 was outdated and did not fairly represent the current staff composition.
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Plan of Correction
709.26(b)(4)
The Program Director is responsible for ensuring that an annual review report of staff composition is completed. The Board of Directors is responsible for ensuring full compliance.
Time Frame for compliance: Full Compliance has been achieved on 9/25/2007
The new document was updated to represent the current staff composition.
Program director will be responsible for annual update of the fair employee practices document. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the staff log book and physical plant inspection conducted on September 4 and 5, 2007, the facility failed to ensure the confidentiality of client identity.
The front door to the facility located on West Chester Pike was unsecured and did not prevent persons from entering the facility at any time. On September 4 and 5, 2007, this licensing specialist entered the building unannounced and was able to freely walk around the facility. On September 5, 2007, this licensing specialist observed a delivery person enter the building and walk around the inside of the facility looking for a staff member.
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Plan of Correction
709.28 (a) Confidentiality
The Program Director is responsible for ensuring client confidentiality. There has been a new security system placed on the front door which includes a locked door, doorbell, camera and monitors to ensure that people can not enter the facility unnanncounced.
Time frame for compliance: The new security system was put in place on 10/19/07. |
709.32(c)(4) 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:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of the facility's policies and procedures regarding medication control on September 4, 2007 and a review of two client records on September 5, 2007, the facility failed to document and ensure compliance of medication control and accountability.
The facility's policy and procedure indicated that the methods for medication control and accountability consisted of medications cards for each client with the date, time, name of medication and signature of the staff person observing the client self -administration. In addition, the primary counselor should conduct medication card checks to ensure medication compliance.
A review of client record #2 on September 5, 2007 indicated that the client was prescribed Trazodone 50 mgs. one tab at bedtime. Documentation on the medication card indicated that on July 5, 2007 the last tab was taken by the client. On July 6, 2007, the medication card indicated "none ~ 6/30". On July 13, 2007, a note on the medication card indicated "none since 7/5/07". The last note on the medication card dated August 3, 2007 stated "is the PRN or do we d/c?"
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Plan of Correction
709.32(c)(4) Medication Control
All staff who document medication will be required to fully document date, time, medication, dose and staff signature on medication cards. The clinical staff is responsible for bi-weekly medication card checks to ensure medication compliance. The clinical supervisor is responsible for ensuring that clinical staff are completing medication card checks and accountability by clients through supervision. The program director is responsible for overall compliance.
Time frame for Compliance: All staff will be trainined in policy by 11/15/07.
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709.51(a)(1) LICENSURE Criteria for Admission
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
Based on a review of facility policy and procedure on September 4, 2007 and a review of two client records, the facility failed to follow the written plan for the criteria for admission as developed by the project director.
The facility policy stated the criteria for admission included that the client was "18 years of age or older, be employed or employable, free from mood altering substances/psychotropic meds, agree to and pass drug screens, free from medical/psychiatric conditions that would preclude medical treatment, exhibit an understanding of treatment, approved for funding and completed an inpatient program." The criteria stated that "no individuals would be admitted to treatment who take tranquilizers, anti-psychotics or psychotropics."
A review of two client records, #1 and 2, indicated that both clients were on psychotropic medications for diagnosed mental health disorders.
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Plan of Correction
709.51 Intake and admission criteria
The Program Director responsible for updating policy and procedure. The policy has been changed to state that client will be admitted on approved medications.
The clinical staff who approve admission are responsible for compliance with this policy.
The program director is responsible for overall compliance.
Time frame for compliance: Compliance was achieved 9/26/07. All staff have been trained regarding the new policy. |
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.
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Observations
Based on a review of client records on September 5, 2007, the facility failed to document a complete drug and alcohol history in two of two client records reviewed, #1 and 2. Drug and alcohol histories did not include the lengths and patterns of drug and alcohol use or the client's perception of use as it related to the current treatment episode.
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Plan of Correction
709.51 Intake and Admission. Drug and Alcohol history.
The admitting staff is responsible for documenting the length and patterns of drug and alcohol use and the clients perception of use as it is related to the current episode. The clinical supervisor is responsible for ensuring that compliance by reveiwing all intake clinical documentation. The program director is responsible for overall compliance.
Time frame for compliance: All staff will be trained in proper documentation and completion of forms by 10/25/07.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records and discussion with the facility director, the facility failed to document a physical examination in one of two records reviewed, #1. The physical examination was not documented.
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Plan of Correction
709.51(b)(5)
The clinical supervisor is responsible for ensuring that all documentation regarding physical examination is in the clint chart. The facility staff is responsible for ensuring that all residents who need a physical examination receive an appointment for a physical within seven days of admit. The designated pysician is responsible for ensuring that the physical examinations are completed within seven days of admission. The program director is responsible for overall compliance.
Time frame for compliance: Policy has already been changed. All staff will be trainied on the new procedure by 11/15/07.
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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 on September 5, 2007, the facility failed to document a complete psychosocial evaluation in one of two records reviewed, #1. The psychosocial evaluation failed to include a clinical analysis of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and overall impressions.
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Plan of Correction
709.51(b)(6) Psycho Social Evaluation
The Primary Counselor is responsible for documenting a complete psychosocial evaluation. The clinical supervisor is responsible for ensuring completion through chart reveiws. The program Director is responsible for ensuring overall compliance with this standard.
All clinical staff will be trained on the proper completion of the psychosocial evaluation.
Timeframe for completion: All clinical staff will be trained by 10/31/07 |
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 a review of two client records on September 5, 2007, the facility failed to document a treatment plan update every thirty days in one of two client records, #2. A treatment plan update was not documented.
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Plan of Correction
709.52 Treatment Plan Update
The primary counselor is responsible for completing all treatment plan updates every thirty days.
The clinical supervisor will review charts monthly to ensure compliance. All clinical staff will be trained on treatment plan updates by the program director to ensure overall compliance with this standard.
Time frame for compliance: All clinical staff will be trained in treatment plan updates by 10/31/07 |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review facility policy, client records and staff interviews, the facility failed to document follow-up information based on the facilities own policy in two of two client records reviewed, #1 and 2.
The project's policy for follow-up on clients referred to another level of care stated that the clinical supervisor or assigned staff member will contact the referral source within seven days from the date of the referral appointment. Follow up information was not documented in two client records.
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Plan of Correction
709.53(a)(11)Follow up information.
It is the primary counselors responsibility to document follow up information in the clients chart. The clinical supervisor is responsible for ensuring that referral follow-ups will be done by staff in 7 days and is documented in the chart. The program director will be responsible for overall compliance with this standard.
Time frame for compliance: All clinical staff will be trained by the program director on follow up referrals and documentations by 10/31/07.
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