INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 2, 2013 to December 3, 2013 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:
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Plan of Correction
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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.
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Observations
Based on a review of personnel records, the facility failed to ensure that a counselor assistant satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) when promoted to the position of counselor in two of two personnel records reviewed.
The findings include:
From December 2, 2013 to December 3, 2013, two personnel records were reviewed for documentation that a counselor assistant satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) when promoted to the position of counselor in two of two personnel records reviewed, specifically, personnel records # 3 and 4.
Employee # 3 is a counselor and was hired as a counselor assistant May 15, 2012 and promoted to the position of counselor November 16, 2012. A review of the personnel record for employee # 3 indicated that the documentation for work experience requirements for the position was insufficient when the facility promoted employee # 3 to the position of counselor. The documentation indicated that employee # 3 had an Associates of Arts in Liberal Arts in Social Science Behavioral Option but only had one year and ten months of clinical experience when the facility promoted employee # 3 to the position of counselor.
Employee # 5 is a counselor and was hired as a counselor assistant February 16, 2012 and promoted to the position of counselor January 2, 2013. A review of the personnel record for employee # 5 indicated that the documentation for work experience requirements for the position was insufficient. The documentation indicated that employee # 5 had a Bachelor of Arts in Psychology but only had eleven months of clinical experience when the facility promoted employee # 5 to the position of counselor.
The findings were confirmed during an interview with the project director on December 3, 2013 at approximately 9:30 A.M.
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Plan of Correction
Deficiency 0051
It is the responsibility of the program director and clinical supervisor to discuss with applicant previous employment pertaining to years of clinical experience in a health or human service agency. At this time it will be determined the length of time needed to be a counselor assistant per chapter 704.7 qualifications before advancing to the position of counselor. The program director met with the clinical supervisor on 12/5/13 to review 704.7 and licensing alert 4/02 Staffing Regulation Requirements for Direct and Close supervision of Counselor Assistant.
Employee #3 and #4 will be demoted from the position of counselor back to the position of counselor assistant. Employees #3 and #4 will receive supervision from the clinical supervisor according to the regulations for supervision of counselor assistants.
Employee #3 and #4 were demoted back to counselor assistants on 12/3/13. When employees #3 and #4 completes one of the sets of qualifications in 704.7 they will be promoted back to the position of counselor and the clinical supervisor will be responsible for making sure that the promotion happens.
Moving forward it is the responsibility of the clinical supervisor and program director will make sure that all new and existing counselor assistants are only promoted to the position of counselor when they have completed one of the sets of qualifications in 704.7
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on observations on December 3, 2013, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on December 3, 2013. It was observed during the inspection at approximately 8:47 A.M., that there was a dumpster located in the facility's parking lot. The dumpster was overflowing with trash and was partially covered with lids.
The findings were confirmed during an interview with the project director on December 3, 2013 at approximately 1:30 P.M.
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Plan of Correction
The dumpster in the facility's parking lot was emptied on 12/3/13 after the physical plant inspection and the lids were closed on the dumpster. It is the responsibility of the maintenance coordinator or staff on duty to check the dumpsters daily for trash overflow. A noncombustible, covered container will be purchased and placed by dumpsters on 12/17/13 to hold excess trash.
During client house meeting held on 12/16/13, clients will be informed that if the dumpster is full to use the trash can provided and report that the dumpster is full to staff on duty. This will be announced weekly at this house meeting.
It is the responsibility of the maintenance coordinator and staff on duty to check dumpster daily for overflow.
It is the responsibility of the program director to ensure overall compliance.
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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 personnel records, the facility failed to document results of reference investigations in two of two personnel records reviewed.
The findings include:
From December 2, 2013 to December 3, 2013, two personnel records requiring documentation of reference checks were reviewed. The facility failed to document results of reference investigations in two of two personnel records reviewed, specifically, personnel records # 6 and 7.
Employee # 6, a residential program worker, was hired March 29, 2013. However, personnel record # 6 did not include documentation of reference checks as of December 3, 2013.
Employee # 7, a residential program worker, was hired July 15, 2013. However, personnel record # 7 did not include documentation of reference checks as of December 3, 2013.
The findings were confirmed during an interview with the project director on December 3, 2013 at approximately 9:30 A.M.
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Plan of Correction
It is the responsibility of the hiring supervisor to call and document three reference checks for new hires and give the documentation to the program director to place in employee file.
The hiring supervisors were trained on this procedure on 12/4/13 and given the form to be completed at the time call is made to check the reference.
It is the responsibility of the hiring supervisors to ensure this procedure is followed.
It is the responsiblity of the program director to ensure that three reference checks are completed upon all staff being hired. This will ensure overall compliance.
Employee #6 - three reference checks will be completed for this employee by 12/31/2013
Employee #7 ? three reference checks will be completed for this employee by 12/31/13.
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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, the facility failed to document a physical examination that included documentation of a date of completion, vital signs, physician's impression, and/or documentation verifying that the physical examination was completed by a physician in eight of ten client records reviewed. Also, based on a review of client records, the facility failed to document a physical examination in one of ten client records reviewed.
The findings include:
From December 2, 2013 to December 3, 2013, ten client records requiring documentation of a physical examination were reviewed. The facility did not document a physical examination that included documentation of a date of completion, vital signs, physician's impression, and/or documentation verifying that the physical examination was completed by a physician in eight of ten client records reviewed, specifically, client records # 1, 2, 4, 5, 6, 7, 8, and 10. In addition, the facility did not document a physical examination in one of ten client records reviewed, specifically, client record # 3.
Client # 1 was admitted November 6, 2013. The physical examination was due November 16, 2013. However, the physical examination did not include a date of completion and physician's impressions. Also, the physical examination was not signed by a physician and did not include any other documentation verifying that the physical examination was completed by a physician as of December 3, 2013.
Client # 2 was initially admitted May 31, 2013, discharged July 30, 2013, and re-admitted August 30, 2013. The physical examination was due June 10, 2013. However, the physical examination did not include a date of completion and physician's impressions. Also, the physical examination was not signed by a physician and did not include any other documentation verifying that the physical examination was completed by a physician as of December 3, 2013.
Client # 3 was initially admitted June 5, 2013, discharged August 12, 2013, and re-admitted September 12, 2013. The physical examination was due June 15, 2013. However, client record # 3 did not include documentation of a physical examination as of December 3, 2013.
Client # 4 was admitted October 8, 2013. The physical examination was due October 18, 2013. However, the physical examination did not include a date of completion and physician's impressions. Also, the physical examination was not signed by a physician and did not include any other documentation verifying that the physical examination was completed by a physician as of December 3, 2013.
Client # 5 was admitted September 3, 2013 and the physical examination was completed July 11, 2013. However, the physical examination did physician's impressions, was not signed by a physician, and any other documentation verifying that the physical examination was completed by a physician as of December 3, 2013.
Client # 6 was admitted September 18, 2013. The physical examination was due September 28, 2013. However, the physical examination did not include a date of completion and physician's impressions. Also, the physical examination was not signed by a physician and did not include any other documentation verifying that the physical examination was completed by a physician as of December 3, 2013.
Client # 7 was admitted April 23, 2013 and discharged July 21, 2013. The physical examination was due May 3, 2013. However, the physical examination did not include a date of completion, vital signs, and physician's impressions. Also, the physical examination was not signed by a physician and did not include any other documentation verifying that the physical examination was completed by a physician as of December 3, 2013.
Client # 8 was admitted April 26, 2013 and discharged July 29, 2013. The physical examination was due August 8, 2013. However, the physical examination did not include a date of completion as of December 3, 2013.
Client # 10 was admitted July 10, 2013 and discharged August 28, 2013. The physical examination was completed April 24, 2013. However, the physical examination was completed by a nurse and did not include physician's impressions as of December 3, 2013.
The findings were confirmed during an interview with the project director on December 3, 2013 at approximately 3:30 P.M.
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Plan of Correction
It is the responsibility of the clinical supervisor to review all physicals of referrals prior to interview process. If physicals do not include date of completion, vital signs, review of organ systems, general appearance, physician's impressions and signature, staff will notify referral source that the physical is incomplete and request a new physical. Interview will not be completed without proper documentation from referral source.
The program director met with the clinical supervisor to discuss this procedure on 12/5/13. On 12/16/13 counselors will be informed of this procedure and given a copy of information needed on a physical.
It is the responsibility of the clinical supervisor to ensure all physicals are reviewed prior to interview.
It is the responsibility of the program director to ensure overall compliance.
Client # 3,7,8,10 ? discharged from treatment so Harwood is not able to complete a new physical for client #3, 7, 8, and 10.
Client # 1, 4 ? Harwood will obtain a new physical for client within 45 days
Client # 2 ? completing treatment 12/21/13 ? will not need another physical
Client # 5 ? completing treatment 12/27/13 ? will not need another physical
Client #6 - possible completion the week of 12/23/13 ? will not need another physical. If completion extends through December, Harwood will obtain a new physical.
The clinical supervisor will be responsible for making sure that all new clients' physicals are completed on time and properly in accordance with the regulations and the facility's policies and procedures.
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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 that included documentation of coping mechanisms, client's attitude toward treatment, and/or counselor's conclusion/impressions in three of ten client records reviewed.
The findings include:
From December 2, 2013 to December 3, 2013, ten client records requiring documentation of a complete psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation that included documentation of coping mechanisms, client's attitude toward treatment, and counselor conclusion/impressions in three of ten client records reviewed, specifically, client records # 2, 3, and 9.
Client # 2 was initially admitted May 31, 2013, discharged July 30, 2013, and re-admitted August 30, 2013. The psychosocial evaluation was completed June 10, 2013. However, the psychosocial evaluation did not include documentation of coping mechanisms, client's attitude toward treatment, and counselor's conclusions/impressions as of December 3, 2013.
Client # 3 was initially admitted June 5, 2013, discharged August 12, 2013, and re-admitted September 12, 2013. The psychosocial evaluation was completed September 18, 2013. However, the psychosocial evaluation did not include documentation of coping mechanisms, client's attitude toward treatment, and counselor's conclusions/impressions as of December 3, 2013.
Client # 9 was admitted June 19, 2013 and discharged August 28, 2013. The psychosocial evaluation was completed June 24, 2013. However, the psychosocial evaluation did not include documentation of coping mechanisms, client's attitude toward treatment, and counselor's conclusions/impressions as of December 3, 2013.
The findings were confirmed during an interview with the project director on December 3, 2013 at approximately 3:30 P.M.
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Plan of Correction
It is the responsibility of the counselor to complete a new psychosocial evaluation on newly admitted clients and re-admission clients.
It is the responsibility of the clinical supervisor to check that all psychosocial evaluations are complete, not an addendum of re-admission, before signing the paperwork.
Program director met with clinical supervisor and counselors to inform them of proper documentation on psychosocial evaluations on 12/9/13.
It is the responsibility of the clinical supervisor to ensure that all evaluations are written in their entirety.
It is the responsibility of the program director to ensure overall compliance.
Client #2 ? counselor will write a complete evaluation by 12/13/13 properly and in accordance to the regulations.
Client #3and 9 ? client discharged from treatment so the facility is not able to complete a new psychosocial evaluation for clients #3 and 9.
The clinical supervisor will audit client records weekly at staff meeting to make sure that psychosocial evaluations are completed on time and properly in accordance with the regulation and the facility's policies and procedures for all new and existing clients.
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709.52(a)(1) LICENSURE Short/Long term TX Goals
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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document the long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan in ten of ten client record reviewed.
The findings include:
From December 2, 2013 to December 3, 2013, ten client records requiring documentation of short-term and long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan were reviewed. The facility did not document the long-term goals for treatment in ten of ten records reviewed, specifically, client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.
Client # 1 was admitted November 6, 2013. The individual treatment and rehabilitation plan was completed on November 21, 2013, but it did not include documentation of the long-term goals for treatment as of December 3, 2013.
Client # 2 was initially admitted May 31, 2013, discharged July 30, 2013, and re-admitted August 30, 2013. The individual treatment and rehabilitation plan was completed on July 10, 2013, but it did not include documentation of the long-term goals for treatment as of December 3, 2013.
Client # 3 was initially admitted June 5, 2013, discharged August 12, 2013, and re-admitted September 12, 2013. The individual treatment and rehabilitation plan was completed on June 19, 2013, but it did not include documentation of the long-term goals for treatment as of December 3, 2013.
Client # 4 was admitted October 8, 2013. The individual treatment and rehabilitation plan was completed on October 21, 2013, but it did not include documentation of the long-term goals for treatment as of December 3, 2013.
Client # 5 was admitted September 3, 2013. The individual treatment and rehabilitation plan was completed on September 16, 2013, but it did not include documentation of the long-term goals for treatment as of December 3, 2013.
Client # 6 was admitted September 18, 2013. The individual treatment and rehabilitation plan was completed on October 1, 2013, but it did not include documentation of the long-term goals for treatment as of December 3, 2013.
Client # 7 was admitted April 23, 2013 and discharged July 21, 2013. The individual treatment and rehabilitation plan was completed on May 7, 2013, but it did not include documentation of the long-term goals for treatment as of December 3, 2013.
Client # 8 was admitted April 26, 2013 and discharged July 29, 2013. The individual treatment and rehabilitation plan was completed on June 6, 2013, but it did not include documentation of the long-term goals for treatment as of December 3, 2013.
Client # 9 was admitted June 19, 2013 and discharged August 28, 2013. The individual treatment and rehabilitation plan was completed on July 2, 2013, but it did not include documentation of the long-term goals for treatment as of December 3, 2013.
Client # 10 was admitted July 10, 2013 and discharged August 28, 2013. The individual treatment and rehabilitation plan was completed on July 22, 2013, but it did not include documentation of the long-term goals for treatment as of December 3, 2013.
The findings were confirmed during an interview with the project director on December 3, 2013 at approximately 3:30 P.M.
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Plan of Correction
It is the responsibility of the counselor to document long term goal established by the client on the individual treatment plan.
It is the responsibility of the clinical supervisor to check plans for long term goal before signing the plan.
On 12/5/13 program director met with clinical supervisor and counselors to train on documenting long term goal on treatment plan.
A new treatment plan template was designed to include long term goal and be incorporated to plan by 12/20/13.
client #1,2,4,5,6 - counselor and client will identify long term goal on treatment plan by 12/20/13. Client #1, 2,4,5, and 6 will be amended to include documentation of long-term goals.
client #3,7,8,9,10 - are no longer in treatment so the facility is unable to amend or complete new treatment plans for clients #3,7,8,9,and 10.
it is the responsibility of the program director to ensure overall compliance.
it is the responsibility of the clinical supervisor to audit all client records monthly to ensure that the treatment plans are completed on time and include documentation of short term and long term goals on the treatment plans for all clients. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project regarding verification that any work done by the client at the project is an integral part of his or her comprehensive treatment plan and/or treatment plan update in seven of ten client records reviewed.
The findings include:
From December 2, 2013 to December 3, 2013, ten client records requiring documentation of a complete client record on an individual which includes information relative to the client's involvement with the project regarding verification that any work done by the client at the project is an integral part of his or her comprehensive treatment plan and/or treatment plan update were reviewed. The facility did not document verification of work therapy in the comprehensive treatment plan and/or treatment plan update in seven of ten records reviewed, specifically, client records # 1, 2, 3, 4, 5, 8, and 10.
Client # 1 was admitted November 6, 2013. The comprehensive treatment plan was completed November 21, 2013. The facility was required to document work therapy on the comprehensive treatment plan. However, client record # 1 did not include documentation of work therapy in the comprehensive treatment plan as of December 3, 2013.
Client # 2 was initially admitted May 31, 2013, discharged July 30, 2013, and re-admitted August 30, 2013. The comprehensive treatment plan was completed July 10, 2013 and the treatment plan updates were completed October 3, 2013 and November 27, 2013. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan updates. However, client record # 2 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of December 3, 2013.
Client # 3 was initially admitted June 5, 2013, discharged August 12, 2013, and re-admitted September 12, 2013. The comprehensive treatment plan was completed June 19, 2013 and the treatment plan updates were completed October 25, 2013 and November 25, 2013. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan updates. However, client record # 3 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of December 3, 2013.
Client # 4 was admitted October 8, 2013. The comprehensive treatment plan was completed October 21, 2013 and the treatment plan update was completed October 21, 2013. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan update. However, client record # 4 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of December 3, 2013.
Client # 5 was admitted September 3, 3013. The comprehensive treatment plan was completed September 16, 2013 and the treatment plan updates were completed October 15, 2013 and November 14, 2013. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan updates. However, client record # 5 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of December 3, 2013.
Client # 8 was admitted April 26, 2013 and discharged July 29, 2013. The comprehensive treatment plan was completed June 6, 2013 and the treatment plan update was completed July 29, 2013. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan update. However, client record # 8 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan update as of December 3, 2013.
Client # 10 was admitted July 10, 2013 and discharged August 28, 2013. The comprehensive treatment plan was completed July 22, 2013 and the treatment plan update was completed August 20, 2013. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan update. However, client record # 10 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan update as of December 3, 2013.
The findings were confirmed during an interview with the project director on December 3, 2013 at approximately 3:30 P.M.
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Plan of Correction
It is the responsibility of the counselor to include work therapy on all initial and updated treatment plans.
It is the responsibility of the clinical supervisor to check that work therapy is on all treatment plans before signing the plan.
The program director trained clinical supervisor and counselors on 12/9/13 to include work therapy on all plans throughout the client treatment stay.
The program director designed a template for work therapy on all plans and will be distributed to staff by 12/20/13.
It is the responsibility of the clinical supervisor to ensure that work therapy is included on all treatment plans. The clinical supervisor will audit all client records every 30 days to ensure all treatment plans include work therapy for all clients.
It is the responsibility of the program director to ensure overall compliance that treatment plans include work therapy.
Client #1,2,4,5 - work therapy will be included on next treatment plan by 12/20/13 for clients #1, 2, 4 and 5.
Client #3, 8, 10 - the facility is unable to complete a new treatment plan with work therapy for clients #3,8, and 10 because they have been discharged from treatment. clients discharged from treatment.
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