INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 27-29, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mainstream Counseling, Inc. 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 June 23, 2009.
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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
Based on a review of employee records and documentation on the staffing self report form provided by the Project Director during the annual onsite licensing inspection of May 27-29, 2009 the facility failed to ensure that counselors hired met one of the qualification requirements at 704.7(b) for the position of counselor.
The findings include:
During the annual licensing inspection the employee records of 8 staff were reviewed. One of these was a counselor hired in August of 2008 (#5) and the other was a counselor hired in September of 2008 ( #6). The resumes documented in their records did not demonstrate that they had the required one year of clinical experience. In addition, the staffing self report form documented that employee # 5 had 9 months of clinical experience at the time of the inspection on 5/27/09. The self report form reflected that employee # 6 had eight months experience at the time of the inspection (5/27/09) and one year of non- D&A clinical experience. The experience counted as non drug and alcohol clinical experience included a practicum and work as a Therapeutic Support Staff. Based on the information in this employee's file, the experience as documented could not be counted as meeting the one year experience requirement.
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Plan of Correction
On June 1, 2009 the administration team (Clinical Supervisor, project director and owner/executive director) decided to increase the clinical supervisor's working hours to a full time status (which is a work week of 32 hours+). Since a Full time staff member must supervise counselor assistants, once we increased the clinical supervisors hours, we became compliant with standard 704.9.
This clinical supervisor will facilitate direct supervision and observation of staff member #5 and #6's direct service with their clients, and co-sign on these clients files, as well as documentation of this close supervision. In addition to the direct supervision of client/counselor interaction, starting June 1, there will be weekly supervision with staff member #5 and 6 that will be an opportunity for educational insight re: Drug and Alcohol, therapeutic skills, clinical questions, etc. This will be an opporunity to identify the educational needs and clinical needs of staff member #5 and #6. This close monitoring will occur for six months, and the staff member #5 and #6 will need to meet the requirements on 704.10 in order to be promoted to counselor status.
In addition to these requirements above, staff member #6 will have a 2009-2010 training plan tailored to these topics: addiction 101, Co-occurring disorders training, and other topics determined by staff member #6, clinical supervisor and project director. Staff member #5 has already had the Co-occurring series in training year 2008-2009, which gives an intro to Substance use disorders, intro to mental health disorders, and many other topics. Both staff members will have trainings plans adapted to their clinical needs, and this will be determined by clinical supervisor and project director. Mainstream Counseling will be in compliance with this standard by January 2010 when both staff member #5 and 6 will have six months of supervised period. |
705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection of the facility during the annual onsite licensing inspection of May 27-28,2009, the facility failed to maintain all structures so as to be free from any danger to health or safety.
The findings included:
During the physical plan inspection on May 27, 2009 it was observed that the carpets in the second floor hallway and kitchen areas were badly worn and loose, presenting a tripping hazard.
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Plan of Correction
The Project Director will have a meeting with the owner of the Building (who is also staff member #8) regarding the need for the carpet to be replaced in second floor hallway and kitchen area. This meeting will occur by June 19th, and the options for improvements to that area will be discussed at that time. During the site visit, the inspectors made recommendations for the area, such as carpet tiles, linoleum, etc. Since this area is at the top of the stairway, it would be beneficial to get a carpet installer or contractor to make recommendations. After the initial meeting, the owner or project director will contact professionals for assistance with installation. The goal is to have the flooring as soon as possible, and no later than end of July, which is when Mainstream Counseling will be in compliance with the standard 705.22. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) 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
Based on the review of client records during the onsite licensing inspection of May 27-28, 2009, the facility failed to document an informed consent to release information for each release noted in the client record in five of eight client records.
The findings included:
Eight client records were reviewed during the annual licensing inspection. Client records # 3, 4, 5, and 7 had consent to release information forms which permitted the project to "exchange information" with other agencies. Applicable confidentiality laws only permit releases of information.
Client records # 4 and 8 documented releases of information to family members or significant others with no corresponding documentation of consent to release information to those individuals.
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Plan of Correction
On June 4, 2009, the Project Director developed a new consent to release information form, which changed the word "exchange" to "release." This change will occur on the Drug and Alcohol General Release Form, the SCA Release form, and the Probation Release form. Before the form is to be utilized at Mainstream Counseling, a copy of the consents will be sent to the inspector who completed the May 27-28, 2009 inspection for approval. This will be sent by email to the inspector by 6/5/09, and project director will make any of the recommended changes. Once that occurs, the project director will notify the staff members to replace the old forms with the new consent forms. This will be done by addressing the new consent in staff meeting on Tuesday 6/16/09. The project director will address in this staff meeting about obtaining the necessary consent to release of information prior to family sessions and prior to any family member/significant other involvement. The project director will do a thorough explanation of the new consent form at that time, and this will occur by 6/16/09. The staff members who have records of #4 and #8 will obtain the proper consents by 7/4/09. |
709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records during the annual onsite licensing inspection of May 27-28, 2009, the facility failed to ensure that specific limits on disclosures in accordance with 4
Pa. Code subsection 255.5(b) were kept in each record.
The findings included:
Eight client records were reviewed from May 27-28, 2009. A third party payer required staff to complete a level of care assessment which demanded client identifying information regarding specifics of the clients' high risk behaviors over the previous 12 month period which exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b). The specific information requested by the third party payer included: suicide attempts, homicide attempts, inability to care for self, violent/aggressive behavior, victim of sexual/physical abuse, imprisonment, homelessness, drug and alcohol abuse and social isolation. In the sample of nine client records, information released to a third party payer in three client records, specifically client records # 3, 5 and 7 exceeded the limits imposed at 4 Pa. Code Subsection 255.5(b).
One consent to release information to a government/funding entity was documented in client record # 6 and was signed by the client but failed to specify what information was to be released. The specific information to be released section on the consent to release information was left blank.
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Plan of Correction
On June 2, 2009, the Project Director presented this confidentiality issue with the third party payer that was demanding the information that exceeded the limitations imposed by 4 Pa code subsection 255.5(b) at the SCA Board meeting. The Director of the SCA encouraged Project Director to set up a meeting with the Provider Relations Representative of this Third Party Payer, and the SCA director wanted to be involved and supportive as well. This issue was addressed with the Provider Representative on 6/3/09, and she is going to contact representatives from Pittsburgh regarding this issue of confidentiality. A meeting will be set up once the appropriate representatives are notified, and the SCA director and Project Director will be present as well. Staff will be told at the Staff meeting on 6/9/09 to dsicontinue filling in the high risk behavior information on these specific forms. The Project Director will explain the reasoning for this and at that point, Mainstream Counseling will be in compliance with this standard by 6/9/09. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records during the annual onsite licensing inspection of May 27-28, 2009, the facility failed to document complete medical histories on each client four of eight client records.
The findings included:
Eight client records were reviewed during the annual onsite licensing inspection. Each record was required to have a complete medical history which included personal medical history, family medical history and symptoms and illnesses experienced by each client. Family medical histories were not documented in client records # 1, 5, 6 and 8.
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Plan of Correction
Project Director inspected client records #1,5,6,8 on 6/3/09. The counselor for record #1 had additional family medical history on the back of the psychosocial, so she transferred that information to the medical history form. By 6/4/09, the Project Director met with the counselors of chart records #5,6,8 to explore family histories and the appropriate family history information was placed onto the medical history form. Chart record #8 will explore family medical history on 6/3/09, since counselor had not obtained that information previously.
The project director and clinical supervisor will perform a training on various clinical information that was missed in charts for the 2008-2009 inspection. As of May 2009, Mainstream Counseling implemented treatment team meetings that occur after staff meetings on Tuesdays. This treatment team meeting is a time to address clinical issues and paperwork issues/questions. Family medical histories will be explored at the 6/23/09 treatment team meeting, along with the documentation of medications which is another deficiency that was found at the 2008-2009 inspection. This treatment team meeting is facilitated by clinical supervisor, project director and executive Director/owner.
Clinical supervisor will also follow up with each counselor in individual supervision regarding this documentation on the medical history form . |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. 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 during the annual onsite licensing inspection of May 27-28, 2009, the facility failed to document drug and alcohol histories on each client that addressed patterns and amounts of drug and alcohol abuse in six of eight client records.
The findings included :
Eight client records were reviewed. Each of the records was required to document a complete drug and alcohol history which included drugs used, length and patterns of use , client perception of the impact of abuse on their lives, family drug and alcohol abuse and prior treatment episodes.
The following client records did not include documentation of the amounts of drugs named that the client was using: # 3, 4, 5, 6.
Client record #8 did not address family drug and alcohol abuse, lengths or patterns of use or specific substances abused .
Client record # 1 did not address the client's perception of the impact of their drug and alcohol abuse on various areas of their life.
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Plan of Correction
Project Director reviewed records #1, 3,4,5,6,8 on 6/3/09. Project Director met with Clinical Supervisor on 6/3/09 to discuss the inconsistencies with obtaining a thorough Drug and Alcohol History. This issue will be discussed with entire staff on 6/30/09, during treatment team meeting which is designed to be a time when counselors can discuss issues with paperwork, treatment, clinical needs, in addition with their individual clinical supervision that each counselor and counselor assistant receives. The information that was missing from the files will be addressed by clinical supervisor in direct supervision. Clinical Supervisor will ensure that the appropriate information is added to the psychosocial. This will be completed by 7/31/09. The project director will do quality improvement audits every 3 weeks to ensure that psychosocials and various paperwork are being completed in a timely and competent way.
In addition, the psychosocial form will be changed to allow for more space to allow for more specifics about patterns of use, length, client perceptions, etc related to Drug and Alcohol History. This new psychosocial will be presented at treatment team meeting on 6/30/09. Staff will be required to complete new psychosocials from that point forward. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records during the annual onsite licensing inspection of May 27-28, 2009, the facility failed to document complete personal histories on each client in six of eight client records.
The findings include:
Eight client records were reviewed at the annual licensing inspection. Each was required to have a complete personal history documented. Family interrelationships were not documented in client records # 1, 2, 4, 5 or 6.
Employment histories in client records # 1 & 5 addressed only most recently held employment and did not document a complete work history.
Client record # 8 did not include documentation of a personal history.
Client record # 5 - the educational history stated that "addiction has impaired...ability to pursue education beyond GED": but did not address specifics of the impairment.
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Plan of Correction
On 6/3/09, the Project Director reviewed the client records #1,2,4,5,6,8 regarding the missing information as specified in observations #1865. Each counselor was given instruction to complete the missing information. Ths missing information will be completed by 6/30/09 and the project director will review the files at that time to determine their completion. The Project Director will also conduct quality assurance reviews of files every 3 weeks to make sure that psychosocials are being completed in a thorough and competent way.
On 7/14/09, the Project Director and CLinical Supervisor will discuss/facilitate a treatment team meeting regarding the completion of personal histories and family interrelationships, along with documentation of employment histories, and educational histories. These areas were incomplete areas of the psychosocial that was detected by inspector. The treatment team meeting on 7/14/09 will allow for staff to understand how to appropriately and thoroughly fill out these sections of the psychosocial. Clinical supervisor will also review client records in individual supervision as well to allow for a thorough inspection of files.
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709.93(a)(2) LICENSURE Client records
709.93. 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:
(2) Medication records.
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Observations
Based on a review of client records during the annual onsite licensing inspection of May 27-28, 2009, the facility failed to document complete medication records on each client in two of four client records.
The findings include:
Eight client records were reviewed during the annual licensing inspection. Four records indicated that the clients were taking medications. Client records # 1 and 2 did not include documentation of the dose and frequency taken for each of the medications listed.
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Plan of Correction
The Project Director inspected the client record #1,2 regarding documentation of medications. Project Director will address the counselor's who are responsible for client record #1, 2 to ensure that the appropriate information is added to the medication list. The counselor might need to contact the client to obtain this information in order to complete the record of medications.
On 6/23/09, The Project Director and CLinical Supervisor will have a follow up with staff regarding training on family medical history, medical form and medication records. This training will occur at the treatment team meeting which will allow for an opportunity to address this area of deficiency. If client's do not know the dosages and frequency, staff will be encouraged to have clients bring a list of medications at the following appointment. Also, coordination with the client's primary care physician (PCP) will be recommended to the staff to allow for a more comprehensive data regarding a client's medical needs. Before this coordination with the PCP can occur, the counselor will need to obtain written consent from the client before contact can be made. These options will be dsicussed at the 6/23/09 treamtent team meeting and the project director and clinical supervisor will follow up with the oversight of the client records on an ongoing basis. |
709.93(a)(3) LICENSURE Client records
709.93. 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:
(3) Record of services provided.
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Observations
Based on a review of client records during the annual onsite licensing inspection of May 27-28, 2009, the facility failed to document a complete record of service on each client.
The findings include:
Eight client records were reviewed during the annual licensing inspection. Each was required to have a complete record of service. Complete records of service must include the date of service, type of service and provider of service and must be a complete chronological listing (separate from progress notes) of the various specific services provided to the individual client.
Records of services in the following records did not document all required areas as noted below:
Record # 2 - progress notes were documented on the following dates but not included on record of service documentation: all were from 2008- 6/4, 6/9, 6/ 20, 6/ 27, 6/30, 7/ 2, 7/ 8, 7/ 16, 7/ 18, 7/ 21, 7/ 25, 7/ 28, 7/ 30, 9/12 and 9/ 24.
Record # 3 - a note was documented for 1/13/09 with no corresponding documentation on the service record.
Record # 6- No type of service was documented for entries made 12/23/08, 12/31/08 , 1/6/09 and 1/22/09.
Record # 7- type and/or duration of service was not documented for entries made 2/27, 09, 3/3/09, 4/1/09, 4/15/09 and 4/29/09.
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Plan of Correction
On 6/3/09, Project Director inspected record #2, and the progress notes for 6/4, 6/9, 6/20, 6/27, 6/30, 7/2, 7/8, 7/16, 7/18, 7/21, 7/25, 7/28, 7/30, 9/12, 9/24 are Intensive Outpatient Program notes, which have record of service in the IOP binder in the locked filing cabinet on the first floor. The Project Director retreived the record of service for those IOP treatment dates and placed it in the clients files to show the record of documentation.
Project Director will make copies of IOP record of service for all clients in IOP and get them to the appropriate individual charts for record of service for the IOP treatment dates.
Record #3, the Project Director discussed the treatment done on 1/13/09 with the appropriate counselor #8. The documentation was made that it was a crisis situation and the record of service was documented as a crisis code. The clinical documentation verified that it was a crisis situation, and counselor #8 was told to be specific with the corresponding does with treatment is provided to client.
Project Director inspected record #6 on 6/4/09 and saw the missing service codes. Due to the fact that Counselor of record #6 is on maternity leave, the code was written in the chart by the Project Director. The code placed in that category was HHSDFE for 12/23/08 (Which is a evalution for an individual in the county Jail) and HHSDFI for 12/31/08, 1/6/09, and 1/22/09 (which is individual session for an individual in jail). These changes were made on 6/4/09.
Project Director inspected record #7 and there was not an entry for 2/27 but for 2/17. Project director will clarify this with inspector by email that will be sent on 6/5/09. Project Director discussed type and duration of services with counselor #7, and counselor added the necessary information. On July 28 during the treatment team meeting, the Project Director will address the record of service sheet and educate staff about appropriately documenting a record of service. |