INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 17-18, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Directions Treatment Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the staffing requirements facility summary report, the facility failed to employ a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both. The staffing requirements facility summary report was reviewed on September 24, 2013. A review of the staffing requirements facility summary report indicated that the project had 18.97 full-time equivalent (FTE) counselors or counselor assistants, or both. A review of three clinical supervisory positions held by staff persons revealed that none was acting in the capacity of a full-time clinical supervisor. Each clinical supervisor had over 5 active clients on their caseload making them not working in a full-time capacity of a clinical supervisor. Bethlehem Site:Employee #3 currently has 18 active clients on their caseloadEmployee #4 currently has 14 active clients on their caseloadReading Site:Employee #3 currently has 6 active clients on their caseload
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Plan of Correction
By 10/21/2013 patient caseloads will be re-assigned by the Clinical Supervisor to ensure that Clinical Supervisors carry no more than five full-time patients on his/her caseload. Clinical Supervisor will monitor caseload weekly to ensure continued compliance with the standard.
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704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
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Observations
Based on a reviewed of personnel records, the facility failed to document a positive assessment of the counselor assistant individual skill level in one of eight personnel records reviewed.The findings include:The personnel records were reviewed on September 17, 2013. One personnel record reviewed represented a counselor assistant, #6. Per State regulations, in addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level. Employee #6's current caseload is 35 and a review of her personnel record did not show documentation of a positive assessment. An interview with the clinical supervisor on September 17, 2013 confirmed the findings.
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Plan of Correction
As of 9/30/2013, Clinical Supervisors have been advised that prior to assigning a full caseload to a counselor assistant, the supervisor's positive assessment of the counselor assistant's individual skill level will be documented. The Program Director will be responsible for monitoring Clinical Supervisors' compliance with this requirement before a counselor assistant is assigned a full caseload. Counselor Assistant #6 is no longer employed at New Directions as she has resigned.
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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 the employee personnel record, the facility failed to document the required period of close supervision for one counselor assistant. The findings include: Eight personnel records were reviewed on September 17, 2013. One of the eight personnel records reviewed were for the position of counselor assistant. The counselor assistant represented in record # 6, had a little over five months of supervision documented with weeks missing in-between those months. This employee is required to have six months of close observation. The lack of documentation was confirmed by the clinical supervisor on September 19, 2013.Employee #6 was hired on May 17, 2013 the following weeks of supervision was missing: Week of 5/20-24/13Week of 5/27-31/13Week of 6/17-21/13Week of 6/24-28/13Week of 8/8-12/13Week of 8/19-23/13
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Plan of Correction
Clinical Supervisors have been reminded of the requirement that close supervision sessions must be documented for clinical assistants' first six months' of employment. Beginning 10/01/2013, the Program Director will be responsible for reviewing documentation of supervision to ensure that the Clinical Supervisor is providing close supervision for any counselor assistant. Counselor #6 has resigned and is no longer employed at New Directions |
704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on August 30, 2013 the facility failed to ensure that staff caseloads remained at or under 35:1.The findings include: The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on September 24, 2013. The form listed two clinical supervisors and 14 counselors. Employee #3 has documented 5 hours dedicated to drug and alcohol clients and has a case load of 18 drug and alcohol clients. At the time of the inspection employee #3 exceeded the required 35:1 FTE and currently had a FTE of 53:1.Employee #7 has documented 10 hours dedicated to drug and alcohol clients and has a case load of 25 drug and alcohol clients. At the time of the inspection employee #7 exceeded the required 35:1 FTE and currently had a FTE of 46:1.
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Plan of Correction
By 10-25-2013, patients have been re-assigned to ensure that no counselor caseload will exceed the 35:1 ratio. The Clinical Supervisor will monitor each caseload to ensure that the total number of full and half time will not exceed the 35:1 ratio. Ongoing compliance with the ratio will be monitored by the Clinical Supervisor weekly.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in one of three personnel records.The findings include:Eight personnel records were reviewed on September 17, 2013. Three personnel record was required to document fire extinguisher training. The facility failed to document the completion of fire extinguisher training within seven days of staff employment in personnel record # 2.Employee # 2 was hired on August 13, 2013. The training was due upon employment. The training was documented on September 11, 2013.
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Plan of Correction
By 10/25 the administrative assistant responsible will be reminded to ensure that all new hires, including contract workers, will receive fire safety training within seven days' of hire. The Program Director will be responsible for ensuring that fire safety training has been documented within the required time-frame by review of employee orientation record within the first week of employment. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies, in one of three personnel records.The findings include:Eight personnel records were reviewed on September 17, 2013. Three personnel record required documentation of the emergency training to ensure that all personnel on all shifts were trained to perform assigned tasks . Employee # 2 was hired on August 13, 2013. The training was documented on September 11, 2013.
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Plan of Correction
By 10/25/13 the administrative assistant responsible will be reminded to ensure that all new hires, including contract workers, will receive fire safety training within seven days' of hire. The Program Director will be responsible for ensuring that fire safety training has been documented within the required time-frame by review of employee orientation record within the first week of employment. |
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 record, the facility failed to prepare alternate exit routes to be used during fire drills.The findings include:A review of the fire drill logs was conducted on September 17, 2013. The fire drills conducted from October 2012 - August 30, 2013 were reviewed. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility did not document any alternate exits used during fire drills. The exit route used during the fire drill was not documented for the drills conducted in October 2012 - August 30, 2013.An interview with facility staff on September 18, 2013 confirmed the findings.
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Plan of Correction
As of 10/14/2013, administrative staff has been instructed to ensure that alternate exits are used during monthly fire drills and to document the exit used during the fire drill. The Program Director will monitor compliance by review of the fire drill records on a monthly basis. |
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.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills were conducted during different times of the day.The findings include:The fire drill record was reviewed on September 19, 2013. Eleven months of fire drills were reviewed. The facility's hours of operation are from M-F 6am to 6pm, Sat. 6am to 10 am and Sun 8am to 9:30 am. The facility failed to document fire drills between the hours of 3pm - 6pm. An interview with facility staff on September 18, 2013 confirmed the findings.
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Plan of Correction
As of 10/14/2013, administrative staff has been instructed to ensure that fire drills are completed during all shifts, including the afternoon 3PM to 6PM shift. The Program Director will monitor compliance by review of the fire drill records on a monthly basis. |
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, the facility failed to document treatment plan updates at least every 60 days in six of eighteen client records.The findings include:Eighteen client records were reviewed on September 18, 2013. Ten of the eighteen were reviewed for treatment plan updates. Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. Treatment and rehabilitation plans were not updated at least every 60 days in client records #1, 3, 4, 6, 7 and 8.Client #1's comprehensive treatment plan was completed on May 24, 2013. The treatment plan update was completed on July 31, 2013. Client #3's comprehensive treatment plan was completed on June 5, 2013. The treatment plan update was completed on August 12, 2013. Client #4's comprehensive treatment plan was completed on April 23, 2013. The treatment plan updates were completed on June 18, 2013 and August 20, 2013. Client #6's comprehensive treatment plan was completed on May 10, 2013. The treatment plan updates were completed on July 2, 2013 and September 6, 2013. Client #7's comprehensive treatment plan was completed on December 20, 2012. The treatment plan updates were completed on February 5, 2013, April 11, 2013, June 12, 2013 and September 4, 2013.Client #8's comprehensive treatment plan was completed on April 25, 2013. The treatment plan updates were completed on June 19, 2013 and August 30, 2013.An interview with the project director, facility director and clinical supervisor on September 18, 2013 confirmed the findings.
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Plan of Correction
By 10/25/2013, Clinical Supervisor will remind counselors of the requirement to complete treatment plan updates within sixty days of the most recent treatment plan update. Clinical Supervisor will instruct staff to adhere to electronic due date tracking system to ensure compliance with the standard. Clinical Supervisor will monitor compliance through ongoing record review. |