INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 9 - 11, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Coatesville Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on a review of staff training records, the facility failed to show documentation of staff feedback in seven of eleven records reviewed.
The findings include:
Eleven staff training records were reviewed on May 11, 2012. The training year reviewed January 1, 2011 through December 31, 2011. Per the agency policy, feedback forms are to be turned in after the completion of training. The facility failed to document the submission of feedback forms after the completion of employee training in records, #2, 3, 4, 5, 6, 7 and 8.
An interview with the facility director on May 11, 2012 confirmed the findings.
|
Plan of Correction
Feedback forms will be completed for all attended trainings internal and external by all employees. Clinical Supervisor and Clinic Director will collect all feedback forms after all attended trainings and they will be maintained in the training binders. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of personnel records, the facility failed to have updated CPR certifications.
The findings include:
Eleven personnel records were reviewed on May 10, 2012. During the review of personnel records it was observed that the CPR cards expired April 2012.
An interview with the facility director on May 9, 2012 confirmed the findings.
|
Plan of Correction
Ten out of the 13 Counselors onsite were porvided with CPR training by a certified trainer through the American Heart Association on 5/5/12 along with Clinic Director, Clinical Supervisor, and Front Office staff. Medical staff - four nurses, Director of Nursing, Physician Assistant, and Medical Director - will also be trained by 7/9/2012.
Clinic Director will track all CPR trainings and maintain in the training binder to ensure staff our retrained prior to the two year expiration date. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project director in one of two personnel records.
The findings include:
Eleven personnel records were reviewed on May 10, 2012. One personnel record pertained to the project director. One personnel record required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 was hired May 1, 2006. The facility training year is from January 1 through December 31, 2011. Employee # 1 had documentation of only 1 hr training documented for the 2011 training year.
A discussion with the facility director on May 11, 2012 confirmed the findings.
|
Plan of Correction
Clinic Director will request a copy trainings attended by Project Director by 7/30/2012 for year 2012 to verify the amount of training hours completed for the year. If Project Manager has not met 12 hours, Clinic Director will send out reminder to Project Manager to register and send Clinic Director a copy of the registration. After 12/30/2012, Clinic Director will begin contacting Project Manager by June 1st of each year to obtain status of trainings attended. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to ensure that the clinical staff received at least 25 hours of training for the 2011 training year in one of four personnel records reviewed.
The findings include:
Eleven personnel records were reviewed on May 10, 2012. Six personnel records represented the clinical staff and of the six, four were required to show 25 hours of training for training year 2011, #5, 6, 7 and 8. Employee #7 was hired January 4, 2010 and for the 2011 training year they only showed 13.45 hours. The training year was from January 1, 2011 through December 31, 2011.
A discussion with the facility director on May 11, 2012 confirmed the findings.
|
Plan of Correction
Employee was short hours due to medical issues during her pregnancy. By 7/2/2012, Clinical Supervisor will obtain a status of all trainings completed by couseling staff and send out a reminder of hours that are still needed as well as required trainings. Staff will need to send Clinical Supervisor proof of all training registration. Starting 7/2/2012, staff will be asked to complete the required 25 hours by Novemeber 1st of each year to ensure there is time to registered for any hours missed. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
|
Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills were conducted at different times of the day.
The findings include:
The fire drill records were reviewed on May 11, 2012. There were only two entries of drills that were conducted on the afternoon shift, occurring in the months of February 2012 and March 2012. All other drills were conducted in the morning. The following months were reviewed May 2011, June 2011, July 2011, August 2011, September 2011, October 2011, November 2011, December 2011, January 2012, February 2012, March 2012 and April 2012. The facility's hours are Monday through Friday 5:30 am to 3 pm and 5 pm to 7 pm, Saturday 5:30 am to 10:30 am and Sunday 5:30 am to 7:30 am.
An interview with the facility director on May 11, 2012 confirmed the findings.
|
Plan of Correction
On 5/29/2012, Health and Safety officer began scheduling fire drills during varying times of the day including after 12:00p. Health and Safety Officer will be responsible for ensuring that all required fire drills are completed ontime and during varying timeframes, including late afternoon. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
|
Observations
Based on a review of the facility's administrative documentation , the facility failed to document a financial statement of income and expenses for the facility.
The findings include:
Based on a review of the facility's 2011 annual report on May 10, 2012, the facility failed to document a financial statement of income and expenses for the facility.
An interview with the facility director on May 11, 2012 confirmed the findings.
|
Plan of Correction
An annual report notification was run in an ad that was displayed in the Daily Local News on 5/12/2012. Clinic Director will ensure that the notification of the annual report is published as soon as the report is made available. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
|
Observations
Based on a review of the facility's 2011 annual report, the facility failed to document a statement disclosing the names of officers, director and principal shareholders.
The findings include:
Based on a review of the facility's 2011 annual report on May 10, 2012, the facility failed to document a statement disclosing the names of officers, director and principal shareholders.
An interview with the facility director on May 11, 2012 confirmed the findings.
|
Plan of Correction
Clinic Director emailed a copy of the 2011 annual report after audit visit that contained the namesn of the officers, director and principal shareholders. Clinic Director will ensure that hardcopies of the report are made available prior to the licensing review. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
|
Observations
Based on observation, the facility failed to secure active client records within locked storage containers.
The findings include:
During the on-site licensing inspection on May 9, 2012, it was observed that the room identified for client records contained painting supplies. Interviews with staff confirmed that that the facility permitted painters to utilize this room for storage other than client files while the offices were being painted. This room was permitted to be open for the painters to have access to their supplies.
On May 10, 2012, it was observed that the door to the active client records room was wide open; no staff was in the room and the client records were available for anyone to review.
|
Plan of Correction
On May 11, 2012, all paint supplies were removed from the file room. Paint was moved back into the room by staff after the painting was completed. All charts were removed during the renovations. Staff have been informed that the file room is not to be used as storage. All contractors will by informed by Clinic Director that all supplies must not be left in nonstorage areas. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include a composite picture, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and client's attitude toward treatment of the client in twelve of twelve client records.
The findings include:
Sixteen client records were reviewed on May 11, 2012. A psychosocial evaluation was required in six client records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.
The psychosocial evaluations in client records #4, 5 and 7 did not include a composite picture of the client.
The psychosocial evaluations in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 11 and 12 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records # 1, 2, 3, 4, 6, 7, 8, 9, 10 and 11 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 11 and 12 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records #1, 2, 4, 5, 6, 9 and 12 did not included an evaluation of the client's attitude towards treatment and how it would impact treatment.
Also, per the facility's policy psychosocial evaluations are to be completed within 30 days of the client's admission date.
Client #2 was admitted on December 7, 2011 and their psychosocial evaluation was to be completed by January 7, 2012. As of the date of the inspection, there was no documentation of the client's psychosocial evaluation in client record #2.
Client #7 was admitted on November 29, 2011 and their psychosocial evaluation was to be completed by December 29, 2011. Their psychosocial evaluation was completed on January 4, 2012, 6 days after the required time for the completion of the evaluation, December 29, 2011.
Client #12 was admitted on November 29, 2011 and discharged on March 22, 2012. Their psychosocial evaluation was to be completed by December 29, 2011. Their psychosocial evaluation was completed on January 16, 2012, 18 days after the required time for the completion of the assessment, December 29, 2011.
An interview with the facility director on May 11, 2012 confirmed the findings.
|
Plan of Correction
By 8/31/2012, Clinical Supervisors will contact a training with clinical staff on how to properly complete a psychosocial evaluation to ensure that it provides a clear picture composite picture, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and client's attitude toward treatment of the client in twelve of twelve client records. The training will be broken up into two sessions.
All psychosocial evaluation will be reviewed and signed off by Clinical Supervisors on a weekly basis. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
|
Observations
Based on a review of client records, the facility failed to document treatment plans within the facility's time frame in seven of twelve client records.
The finding includes:
Sixteen client records were reviewed on May 11, 2012. Treatment plans were reviewed in twelve client records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12. Per the facility's policy, treatment plans will be completed within 30 days of the client's admission date, following the completion of the client's biopsychosocial history and evaluation. A discussion with facility director on May 11, 2012 confirmed the findings.
Client #2 was admitted on December 7, 2011 and their treatment plan was completed on December 5, 2011. Client record #2's treatment plan was completed on December 5, 2011 before the completion of the client's psychosocial evaluation which was not completed as of the date of the licensing inspection.
Client #5 was admitted on December 11, 2011 and their treatment plan was completed on February 2, 2012. Client record #5's treatment plan was completed on February 2, 2012 before the completion of the client's psychosocial evaluation which was completed but did not indicate the date it was developed.
Client #6 was admitted on February 28, 2012 and their treatment plan was completed on March 27, 2012. Client record #6's treatment plan was completed on March 27, 2012 before the completion of the client's psychosocial evaluation which was completed on March 28, 2012.
Client #7 was admitted on November 29, 2011 and their treatment plan was to be completed by December 29, 2011. Client #7's treatment plan was completed on January 23, 2012, 27 days of their initial date of completion of December 29, 2011.
Client #9 was admitted on December 29, 2011 and discharged on March 1, 2012. Their treatment plan was to be completed by January 29, 2011. As of the date of client #9's discharge there was no documentation of their comprehensive treatment plan.
Client #12 was admitted on November 29, 2011 and discharged on March 22, 2012. Their treatment plan was to be completed by December 29, 2011. Client #12's treatment plan was completed on January 16, 2012, 19 days of their initial date of completion of December 29, 2011.
The therapist signed the treatment plan on February 5, 2012 and the client did not sign the treatment plan as of February 12, 2012 their discharge date, couldn't determine if it was developed with the client. The standard stated an individual treatment and rehabilitation plan shall be developed with a client.
A discussion with facility director on May 11, 2012 confirmed the findings.
|
Plan of Correction
By 06/29/2012, Clinical Supervisors will conduct a training with clinical staff to review the facility policy pertaining to the timeframes in which the psychosocial evaluation and treatment plans must be completed. Clinical Supervisors will track all new patients coming in to ensure the psychosocial is completed and signed off on prior to the treatment plans. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document follow-up information in seven of eight discharge client records.
The findings include:
Eighteen client records were reviewed on May 11, 2012. Per the facility policy, the counselor will complete the follow-up documentation with 30 days for successful completions, 14 days for unsuccessful completions and 7 days if being referred. Follow-up documentation was required in seven discharge client records, # 9, 11, 12, 13, 14, 15 and 16. The facility did not document a discharge summary in client records, # 9, 11, 12, 13, 14, 15 and 16.
Client #9 was admitted December 29, 2011 and was discharged on March 1, 2012. The follow-up was to be done by March 15, 2012. There was no documentation of a follow-up in client record #9.
Client #11 was admitted on December 14, 2011 and was discharged on March 22, 2012. The follow-up was to be done by April 5, 2012. There was no documentation of a follow-up in client record #11.
Client #12 was admitted on November 29, 2011 and was discharged on March 22, 2012. The follow-up was to be done by April 5, 2012. There was no documentation of a follow-up in client record #12.
Client #13 was admitted on November 11, 2011 and was discharged on February 14, 2012. The follow-up was to be done by March 13, 2012. There was no documentation of a follow-up in client record #13.
Client #14 was admitted on November 3, 2011 and was discharged on December 28, 2011. The follow-up was to be done by January 28, 2012. There was no documentation of a follow-up in client record #14.
Client #15 was admitted on August 27, 2010 and was discharged on December 6, 2011. The follow-up was to be done by December 13, 2011. There was no documentation of a follow-up in client record #15.
Client #16 was admitted on March 3, 2005 and was discharged on March 1, 2012. The follow-up was to be done by April 2, 2012. There was no documentation of a follow-up in client record #16.
An interview with facility director on May 11, 2012 confirmed the findings.
|
Plan of Correction
Clinical Supervisor has begun to complete all discharge follow-ups fpr patients that have completed successfully, have not completed successfully, and referred. There is a manual that is being maintained in Clinical Supervisor's office that contains all discharge follow-ups. |