INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 5 and 6, 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 March 13, 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 #8 did not meet the qualifications for the position of counselor based upon a review of their degree.
|
Plan of Correction
Employee #8's position, as of February 8, 2007, has been changed from counselor to counselor assistant until she meets the qualifications for counselor.
Persons Responsible: Division Director and Inpatient Program Director
Timeframe for Completion: February 8, 2007
|
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 documentation provided for both employee #5 and #6 was not sufficient to verify that the two counselor assistants had received direct observation and close supervision as required.
|
Plan of Correction
Employee #5 and #6 will be supervised by the Inpatient Clinical Supervisor per DOH Regulatory 704.9. These supervision sessions will be documented weekly and forwarded to the Human Resource Department for inclusion in the employee personnel file. The Program Director & Human Resource Administrator will monitor counselors' files to ensure continued compliance via the monthly Continuous Quality Improvement (CQI) process.
Persons Responsible: Division Director, Inpatient Program Director and Human Resource Administrator.
Timeframe for Completion: April 15, 2007 and ongoing.
|
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
|
Observations
The assessment of staff training needs lacked signatures and dates to verify when they were completed.
|
Plan of Correction
The yearly Training Needs Assessment Form will be revised to include signatures and dates to verify when they were completed. Program Directors will be responsible for securing these signatures and dates during yearly training evaluation needs sessions.
Persons Responsible:
Inpatient Program Director and Human Resource Administrator
Timeframe for Completion: May 22, 2007
|
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
Feedback forms were not completed for all training attended.
|
Plan of Correction
After each internal and external training attended by the Inpatient personnel, feedback forms will be distributed by the Human Resource Department. These forms will be completed and given to the Human Resource Staff person responsible for the training. Certificates will not be given to the trainee until these forms are filled out. The Inpatient Program Director will be given copies of the trainings attended and the accompanying feedback forms to monitor this process. Copies of Certifications and Training Feedback Forms will be placed in the personnel files.
Persons Responsible:
Inpatient Program Director and Human Resource Manager
Timeframe for Completion: May 22, 2007
|
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
There was a portable space heater located in the kitchen office.
|
Plan of Correction
The portable space heater has been removed from the kitchen office.
Persons Responsible:
Director of Operations.
Timeframe for Completion: March 1, 2007
|
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
A visual alarm for the hearing impaired was not in the common area on the second floor.
|
Plan of Correction
A visual alarm for the hearing impaired will be installed in the common area on the second floor.
Persons Responsible:
Director of Operations.
Timeframe for Completion: March 31, 2007
|
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
|
Observations
Medications were not documented as per facility policy.
|
Plan of Correction
On March 19, 2007 training will be provided to the inpatient staff on "Medication Control" by the Gaudenzia-DRC Medical Department Nurse Manager (LPN). By March 31, 2007 the Medical Department will review every medication chart to ensure that medications were documented as per facility policy.
The Program Director in cooperation with the Medical Department will monitor clients' medication charts to ensure continued compliance via the Monthly Continuous Quality Improvement (CQI) process.
Persons Responsible:
Inpatient Program Director and Nurse Manager
Timeframe for Completion: March 31, 2007.
|
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Psychosocial evaluations did not include a composite picture of the client in five of six records reviewed, #1, 3, 4, 7 and 8. Coping mechanisms were not identified in four of six client records reviewed, #1, 2, 4 and 8. Support systems were not addressed in four of six client records reviewed, #1, 2, 3 and 4.
|
Plan of Correction
On March 12, 2007 training will be provided to the Inpatient Counselors followed by regular supervision on "Psychosocial Evaluations" and the "composite picture". The Program Director and Clinical Supervisor will review charts on a regular basis to ensure that there is a composite picture to include addressing client problems, strengths and weaknesses, coping mechanisms, and identifying client support systems of the individual client in the evaluation. The Program Director will monitor clients' charts to ensure continued compliance via the monthly Continuous Quality Improvement (CQI) process.
Persons Responsible:
Inpatient Program Director
Timeframe for Completion: March 31, 2007
|
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Treatment plan updates were not completed within the timeframe identified in the facility's policy in five of five records reviewed, #1, 2, 3, 4 and 8.
|
Plan of Correction
On March 19, 2007 training will be provided to the Inpatient Counselors on effective "Treatment Planning". By March 31, 2007 the Program Director will review every chart to ensure that treatment plan updates are completed within the timeframes identified in the facilities policy. The Program Director will randomly monitor clients' charts to ensure continued compliance via the monthly Continuous Quality Improvement (CQI) process.
Persons Responsible:
Inpatient Program Director
Timeframe for Completion: March 31, 2007
|
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Counseling services for group sessions were not being consistently provided in accordance with the individual treatment plans in six of six records reviewed, #1, 2, 3, 4, 7 and 8.
|
Plan of Correction
The Inpatient Director and the Clinical Supervisor will meet with counseling staff to review the provision of counseling services regulations and insure that group sessions are being provided as stated on the client's treatment plan and documented in client file.
Persons Responsible:
Inpatient Program Director
Timeframe for Completion: March 31, 2007
|
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
|
Observations
Work conducted by the clients while at the facility was not documented on treatment plans.
|
Plan of Correction
The Inpatient Director will meet with counseling staff to review the client records regulations and insure that all work being provided by clients while in treatment will be documented on the client's treatment plan. Work therapy will be incorporated as part of the Preliminary Treatment Plan.
Persons Responsible:
Inpatient Program Director
Timeframe for Completion: March 31, 2007
|