INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 6, 2007 through June 7, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 5, 2007.
|
Plan of Correction
|
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.
|
Observations
Employee #3 did not meet the educational requirements for the position of counselor.
|
Plan of Correction
Clinical supversion will be provided for all counselor assistants hired. Documentation will include 3 months direct supervision; 6 months close supergvision; and, 3 month evaluation.
Employee #3 will be removed from the counsleing roster and placed under supportive staff due to MH Counselor status.
Person Responsible: Program Director and Clinical Supervisor
Timeframe for Completion: Immediate |
704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
|
Observations
A positive assessment was not documented for employee #2 who was assigned a full caseload.
|
Plan of Correction
Employee #2 has been removed to support staff status. A Clinical Supervisor has been hired and will be starting 7/23/07. Also, a qualified PRN Social Worker will be hired toprovide additional clinical support
Person Responsible: Program Director
Timeframe for completion: Immediate egarding #2, and within two weeks for the hiring of the Social Worker |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
|
Observations
Employee #2 was not supervised by a full-time clinical supervisor or counselor.
|
Plan of Correction
Clinical supervision will be provided for all counselor assistants hired. Documentation will include 3 months direct supervision; 6 months cloase supervision; and, a 3 month evluation.
Person(s) Responsible: Prgram Director and Clinical Supervisor
Timeframe for completion: Immediate |
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.
|
Observations
The facility failed to document a semiannual performance evaluation for employee #2.
|
Plan of Correction
All counselor assistants hired will receive a semianual evaluation in addition to 3 months direct supervision and 6 months close supervison.
Person(s) responsible: Clinical Supervisor
Timeframe for completion: Immediate |
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.
|
Observations
The project failed to provide documentation of supervision for employee #2.
|
Plan of Correction
All counselor assistants hired will receive 3 months direct supervision; 6 months close supervison; and, a semiannual evluation. Person(s) responsible: Clinical Supervisor Timeframe for completion: Immediate |
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
|
Observations
The facility failed to provide a policy and procedure for the annual evaluation of the overall training plan.
|
Plan of Correction
The language in the policy and procedure will be more specific in outlining and detailing the step-by-step process that results in the Annual Evaluation of the Training Year.
Person(s) Responsible: Program Director
Timeframe for completion: Immediate
|
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
|
Observations
The counselor to client ratio was 1:16.
|
Plan of Correction
The ratio will change with the addition of the Clinical Director; a newly hired qualified counselor; and the one-year requirement expiring for the bachelor level counselor. The new configuration will change the ratio to 1:7.
Person(s) responsible: Program Director and Clinical Supervisor
Timeframe for completion: Within 30 days |
705.2 (3) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(3) Keep exterior exits, stairs and walkways lighted at night.
|
Observations
The exit on the third floor did not have an exterior light.
|
Plan of Correction
An internal monthly fire tower and exit light checklist will be developed and implemented.
Person(s) responsible: Residential Director and Maintenance Worker
Timeframe for completion: 7 days |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
|
Observations
The eating and cooking utensils were not stored in an enclosed area.
|
Plan of Correction
A cover has been obtained for the cooking and eating utensils
Person(s) repsonsible: Chef
Timeframe for completion: Immediate |
705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
|
Observations
The project failed to have the written procedures for the evacuation and transfer of residents impaired by alcohol or other drugs.
|
Plan of Correction
Language will be added to the "General Safety and Emergency Procedures" that addresses this regulation under a serious emergency evacuation of the building.
Person (s) responsible: Program Director and Residential Director
Timeframe for completion: Within 7 days |
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.
|
Observations
The basement was not equipped with a fire alarm for the hearing impaired.
|
Plan of Correction
A strobe light will be installed in the basement to address the regulation. Program is currently soliciting bids.
Person(s) responsible: Program Director and Residential Director
Timeframe for completion: With 60 days |
705.11 (2) (ii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(ii) Maintain security screens or safety locks for all operable windows.
|
Observations
The safety screens in client bedroom number 10 and in the client bathroom on the third floor were broken.
|
Plan of Correction
Safety screens will be installed in the bathroom and in Room #10.
Person responsible: Program Director and Maintenance Worker
Timeframe for completion: Within 7 days |
711.14(b)(5) LICENSURE Subchapter B.Approval Procedures.Restrictions
711.14. Restrictions on certificate of compliance.
(b) Utilizing appropriate Department forms, the holder of a certificate shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
|
Observations
The facility had 23 client beds for the residential non-hospital drug free activity which exceeded the authorized maximum capacity of 22.
|
Plan of Correction
The bed is being used for a child and has been desginated, by signage, as such.
Peron(s) repsonsible: Program Direcotr, Residential Director and Lead Hous Manager
Timeframe for completion: Completed
|
711.52(c)(2) LICENSURE Type/Frequency of TX
711.52. Treatment and rehabilitation services.
(c) 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.
|
Observations
The type and frequency of treatment and rehabilitation services was not documented in three of five records reviewed, #3, 4 and 6. The frequency was not documented in one of five client records reviewed, #1.
|
Plan of Correction
A temporary Clinical Supervisor Consultant has been hired to provide interim supervisory sessions and documentation review for the clinical staff.
The supervision would include a weekly audit, on a case-by-case basis of the clinical charts.
Following each weekly audit, the intensive training would include twice weekly individual sessions, reviews of timelines for documention, emphasis on goals, objective, action plan, frequency of services, staff responsible.
All supervisory sessions will be documented, and areas of concern will be discussed with the Program Director.
The fulltime Clinical Director wil be starting on 7/23/07. However, the Consultant will remain at MSP for approximately one month in order for a smooth the transition to occur and eliminate the progress being made.
Person(s) responsible: Program Director
and interim Clinical Supervisor Consultant
Timeframe for completion: Within 2 weeks |
711.51.(g)(6) LICENSURE Vocational Support Services
711.52. Treatment and rehabilitation services.
(g) The project shall assist the client in obtaining the following supportive services when necessary:
(6) Vocational.
|
Observations
The facility failed to provide documentation that vocational supportive services were obtainable.
|
Plan of Correction
The Referral Agreement language has been modified to include description and reciprocity of services for vocational supportive services.
Peron(s) responsible: Program Director, Administrative Secretary, and the Administrative Operations Secretary.
Timeframe for completion: In process...awaiting signed referrals. Expected date of return: two weeks. |
711.53(a)(6) LICENSURE Aftercare Plan
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes all information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plan, if applicable.
|
Observations
The aftercare plans did not include goals with time frames or the criteria for re-entry in four of four records reviewed, # 7, 8, 9 and 10.
|
Plan of Correction
A temporary Clinical Supervisor Consultant has been hired to provided interim supervisory sessions and documentation review (Tx Plans, Aftercare, etc) for the clinical staff.
Person(s) responsible: Program Director and interim clinical Supervisor Consultant
Timeframe for completion: Within 2 weeks |
711.53(c)(2)(ii) LICENSURE Specific Information Disclosed
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(ii) The specific information disclosed.
|
Observations
Consent to release information forms did not include the specific information to be released in two of five client records reviewed, #1 and 4.
|
Plan of Correction
A temporary Clinical Supervisor Consultant has been hired to provided interim supervisory sessions and documentation review, up to and icnluding all clinical documents and releases of informaiton, for the clinical staff.
Person(s) responsible: Program Director and interim clinical Supervisor Consultant
Timeframe for completion: Within 2 weeks |
711.53(c)(2)(iii) LICENSURE Purpose of Disclosure
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(iii) The purpose of disclosure.
|
Observations
The purpose of consent forms did not coincide with the individual(s) and/or agencies to whom the information was released to in five of five client records reviewed, #1, 2, 3, 4 and 6.
|
Plan of Correction
A temporary Clinical Supervisor Consultant has been hired to provide interim supervisory sessions and documentation, particularly emphasizing the critical importance of properly executed releases matching the receiving agencies and/or individual(s), with the clinical staff.
Person(s) responsible: Program Director and interim clinical Supervisor Consultant Timeframe for completion: Within 2 weeks |
711.56(a) LICENSURE Written Termination Notice
711.56. Notification of termination.
(a) The project director 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
A notice of termination was missing in one of one client record reviewed, #7.
|
Plan of Correction
A temporary Clinical Supervisor Consultant has been hired to provided interim supervisory sessions and documentation, up to and including the purpose of Termination Letters, review for the clinical staff.
Person(s) responsible: Program Director and interim clinical Supervisor Consultant
Timeframe for completion: Within 2 weeks |