INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 30 through 31, 2006 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 November 22, 2006.
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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
Employee # 3 did not meet the requirement of one year clinical experience to qualify for the position of counselor.
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Plan of Correction
Employee # 3 is a recent graduate and did not have the required one year experience required. Employee #3, who has a Bachelor's degree, will receive weekly close, documented supervision for 6 months.
Timeframe for Compliance: 6 months
Person(s) Responsible: Clinical Director, Residential Operations Director, and Program Director
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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.
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Observations
The client/staff ratio was 13 to 1.
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Plan of Correction
Ratio is skewed due to Counselor Assistant compliance issues, and recent vacancy of fulltime therapist.
A fulltime therapist was hired on 10/30/06, but did not start at My Sister's Place until 10/31/06. The first week is orientation, and caseloads have been redistributed.
Counselor Assistant - 1:4
Two Counselors: 1:7 each
Clinical Director - 1:4
Timeframe for completion: 11/7/06
Person(s) Responsible: Clinical Director
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711.51(b)(3)(ii) LICENSURE D&A History
711.51. 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
The drug and alcohol history was missing in one of five records reviewed, # 5. Histories received from other treatment programs, that were less than six months old, were not reviewed and updated in three of five records reviewed, # 2, 3 and 4.
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Plan of Correction
Due to the high clincial staff turnover, all clinical staff will receive a copy of the DOH 711's as part of orientation and on-going training. Current charts missing the updates will be amended. Also, a CBE update form will be developed specific to the program.
Timeframe for completion: 30 days
Person(s) Responsible: Prgram Director and Residential Operations Director
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711.51(b)(3)(iii) LICENSURE Personal History
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The personal history was missing in one of five records reviewed, # 5. Histories received from other treatment programs, that were less than six months old, were not reviewed and updated in three of five records reviewed, # 2, 3 and 4.
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Plan of Correction
Due to the high clincial staff turnover, all clinical staff will receive a copy of the DOH 711's as part of orientation and on-going training. Current charts missing the updates will be amended. Also, a CBE update form will be developed specific to the program.
Timeframe for completion: 30 days
Person(s) Responsible: Prgram Director, Residential Operations Director, and Clinical Director |
711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluation was missing in one of five records reviewed, # 5. Evaluations by this treatment facility were not completed as required in three of five records reviewed, # 2, 3 and 4.
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Plan of Correction
Missing psychosocial evaluation will be completed. Record reviews will be completed on a monthly basis to ensure compliance to regulatory issues and appropriate treatment planning.
Timeframe for completion: #5 will be completed within one week. Record reviews will be on-going.
Person(s) responsible: Clinical Director |
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
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:
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Observations
Two consent to release information forms were blank, but signed by a client in one five records reviewed, # 6.
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Plan of Correction
The proper execution of Consents Forms will be incorporated into a clinical and case manager staff training.
Timeframe for completion: Consents that are in non-compliance will be corrected immediately. Staff training will occur within one month.
Person(s) Responsible: Program Director and Residential Operations Director |
711.53(c)(2)(vi) LICENSURE Consent's Expiration Date
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:
(vi) The expiration date of the consent.
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Observations
The expiration date of the consent was missing in five of five records reviewed, # 1, 2, 3, 4 and 5.
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Plan of Correction
The proper execution of Consents Forms will be incorporated into a clinical and case manager staff training.
Timeframe for completion: Consents #1,2,3,4, and 5 that are in non-compliance will be corrected immediately. Staff training will occur within one month reviewing proper execution.
Person(s) Responsible: Program Director and Residential Operations Director |
711.53(c)(3) LICENSURE Copy of Client Consent
711.53. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Whether or not the client was offered a copy of the consent was not identified in four of five records reviewed, # 2, 3, 4 and 5.
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Plan of Correction
The proper execution of Consents Forms will be incorporated into a clinical and case manager staff training.
Timeframe for completion: Consents for #2, 3, 4 and 5 that are in non-compliance will be corrected immediately. Staff training will occur within one month.
Person(s) Responsible: Program Director and Residential Operations Director |
711.58(a)(3) LICENSURE Inspection of Storage Area
711.58. Medication control.
When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding medications used by clients, which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
During this review period, two medication inspection reports were due, but only one was documented.
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Plan of Correction
A fulltime nurse has been hired replacing the Temp Nurse. The required documentation has been reviewed and explained to her. The nurse has the form and the record book. Nurse will receive a copy of the DOH 711's.
Timeframe for completion: Immediate
Peron(s) Responsible: The Residential Operations Director will monitor on a quarterly basis. |