INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2008 through July 10, 2008 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. The following deficiencies were identified during this inspection and a plan of correction is due on August 1, 2008.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility was required to have the clinical supervisor, personnel record #3, obtain the core curriculum training in clinical supervision. Employee #3 was promoted to the position of clinical supervisor in 2006 and did not have any prior experience as a supervisor before that time and therefore was required to obtain the core curriculum training. Employee #3 had not obtained the training at the time of the inspection.
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Plan of Correction
The clinical supervisor will complete the core curriculum cinical supervisor training if the 25 hour clinical supervisor training which he attended, conducted by David Powell is not approved. All information submitted to DOH for approval. Clinic Director spoke with Tom Brown 8/11/08 and he approved the 25 hr Clinical supervision training by David Powell for the clinical supervisor. |
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.
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Observations
Based on a review of personnel records on July 8, 2008, the facility was required to document six months of direct observation weekly and weekly clinical supervision in three personnel records. The facility failed to document the direct observation in one personnel record, #10 and both the direct observations and clinical supervision in one personnel record, #11. Personnel record #10 did not have any documented direct observations from 5/14/08 to 6/9/08. Personnel record #11 did not have any documented direct observations from 12/6/07 to 12/20/07, 1/8/08 to 1/21/08, 2/6/08 to 2/27/08 and 2/27/08 to 3/31/08; additionally, there was no documentation of clinical supervision from 12/13/07 to 1/7/08, 1/12/08 to 1/31/08, 2/27/08 to 3/12/08, 3/12/08 to 3/26/08, 3/26/08 to 4/9/08 and 4/9/08 to 4/23/08.
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Plan of Correction
Staff #10 will have weekly direct observations conducted through the second week of October 2008. Clinical supervision for staff #11 will be conducted weekly through the second week in August. Direct observations for staff #11 will be conducted weekly through the second week in October 2008. Clinic Director will review supervision manuals on a bimonthly basis to ensure compliance. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill records on July 8, 2008, the facility was required to have a complete fire drill record. The facility failed to include the following information in the fire drill records: the exit route(s) used during the drill, number of persons in the facility at the time of the drill, and whether the fire alarm or smoke detector was operative.
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Plan of Correction
CTC will utilize fire drill forms previously utilzed by August 1, 2008 which include exite routes used during the drill, number of persons in the facility at the time of the drill, and whether the fire alarm or smoke detector was operative. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill records since the last inspection, the facility was required to document alternate exit routes used during a fire drill from January 2008 to June 2008. The facility failed to document the alternate exit routes in all fire drills except for the drill conducted in June 2008.
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Plan of Correction
CTC will utilize previous fire drill forms which document alternativ exit routes beginning August1, 2008. |
709.22(e) 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:
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Observations
Based on a review of administrative documentation on July 8, 2008, the project needed to notify the general public of the availability of the annual report for the year ending 2007. The facility failed to provide documentation that the project notified the general public of the availability of the annual report.
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Plan of Correction
The clinic director will run an advertisement in the Philadelphia Inquirer the week of August 3, 2008. The clinic Director will document in calendar to run advertisement prior to 6/30/08 of each year to assure this is donein a timely manner and will maintain documentation confirming advertisement was run in the newpaper. |
709.26(f)(3) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
(3) The requisite skills, knowledge and experience.
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Observations
Based upon a review of 5 personnel records on July 8, 2008, the facility was required to have job descriptions that included the requisite skills, knowledge and experience for counselors in 5 personnel records. The facility failed to include the required knowledge and experience for a counselor as identified in Chapter 704.7(b)(1) - (6) in four of five personnel records, #5, 6, 8 and 9. The job description only indicated that a candidate had to be a "Certified Counselor" and did not address the required number of years experience.
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Plan of Correction
Counselor job descriptions will be amended to include specific requirements for the position including knowledge and experience for a counselor as well as years of experience for a counselor. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of 12 client records on July 9 - 10, 2008, the facility was required to document complete psychosocial evaluations in 11 records reviewed. The facility failed to document complete psychosocial evaluations in 6 of 11 records, #5, 7, 8, 10, 11 and 12. The psychosocial evaluations did not include the counselor's assessment of the client's assets/strengths, the negative factors that may inhibit treatment, the client's attitude towards and ability to participate in treatment, and the section for the counselor's conclusions and impressions. The documents were summary repeats of the client's historical information and the client's own statements.
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Plan of Correction
A training will be conducted by the clinical supervisor for all counselors to address how to write a psychosocial evaluation by August 25, 2008. The clinical supervisor will monitor for compliance in monthly chart reviews. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of 12 client records on July 9 - 10, 2008, 11 records were required to document complete comprehensive treatment plans. The facility failed to document the short and long-term goals of the comprehensive treatment plans in terms of individual and measurable criteria in 10 of 11 client records, #1, 3, 4, 5, 6, 7, 8, 9, 10 and 12.
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Plan of Correction
A training was conducted by the clinical supervisor on July 18, 2008 which reviewed how to write a comprehensive treatment plan, treatment plan review and short and long term goal documentation. The clinical supervisors will review treatment plans on a weekly basis and sign them. When a treatment plan is identified as out of compliance this will be addressed in 1 on 1 supervision. The counselor will have 48 hours to make corrections. When the corrections are made the counselor and clinical supervisor will review the treatment to ensure it meets compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records on July 9 - 10, 2008, the facility was required to document complete treatment plan updates with an assessment of the client's progress in relationship to the stated goals of the treatment plans in 10 client records. The facility failed to document treatment plan updates with an assessment of progress and instead provided reviews of progress that were repeated from one update to the next in six of 10 client records, # 7, 8, 9, 10, 11 and 12. Additionally, 60-day treatment plan updates were missing in two client records, #2 and 5.
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Plan of Correction
A training was conducted by the clinical supervisor on writing treatment plan reviews including progress assessment on the reviews on July 18,2008. The treatment plans are reviewed and signed by the clinical supervisors on a weekly basis. When the clinical suprevisors identify a treatment plan that is out of compliance this will be addressed in 1 on 1 supervision. The counselor will have 48 hours to make corrections. When the corrections are made the counselor and clinical supervisor will review the treatment plan to ensure compliance. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based upon a review of client records on July 9 - 10, 2008, the facility was required to document complete group progress notes in 12 client records. The facility failed to document group notes that included an assessment and plan that were unique to each client from that treatment session and were repeated from one group to the next in 9 of 12 client records, #3, 4, 5, 6, 7, 8, 9, 10 and 11. The group progress notes utilize a checkbox system to provide the assessment of the client from that treatment session, but there was no other information provided by the counselor.
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Plan of Correction
A brief staff mtg with the counselors will be held by the clinical supervisor to review the assessment portion of the group progress note by August 25, 2008. Group notes will be reviewed by the clinical supervisors on a weekly basis as they are distributed to the counselors. If out of compliance this will be addressed in 1 on 1 supervision and the counselor given 48 hours to correct the notes and submit to the clinical supervisors for review. |