INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 28-30, 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 April 30, 2007.
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Plan of Correction
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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.
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Observations
Staff did not utilize the mechanism described in program policy to provide feedback for the training attended. Inconsistent documentation was noted in personnel files # 1, 3, 4 and 6.
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Plan of Correction
There are training certificates filed (for the each staff) in two places, the staff's personnel file and the "training folder". The feedback sheets accompany the certificates that are filed in the "training folder". We will make certain that the certificates are only filed in one location and all certificates have the feedback sheet applied. One staff person works in the Perevention Department and her supervisor has been notified of the new procedure and the feedback requirement. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Individual training plans were not documented in personnel files # 1, 3, 4 and 6.
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Plan of Correction
This error was an oversight on the part of the supervisor and has since been corrected.
Individual training plans have been provided to the staff in question and have been included in their "training folder". |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Documentation of mandatory communicable disease training for employees was incomplete in personnel records # 1 and 2.
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Plan of Correction
One counselor has had the mandatory communicable training at some point during the last 18 years that he has been working in this field and had requested a copy of the training certificate from a previous employer. The second employee has documentation from the training but has no certificate. Shold either counselor not sercure the certificate by May 30, 2007, both will be required to complete the training again. |
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.
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Observations
The required 25 annual training hours for counselors was not consistently documented in employee files reviewed. Employee files # 1, 6 and 7 had less than 25 hours documented for the 2005-2006 training year.
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Plan of Correction
The school based counselors who work part time (during the school year) have a difficult time sceduling training during the 9 month work period. This problem was addressed last year and all counselors will hve their required 25 hours of training before July 1, 2007 (the beginning of our new fiscal year). |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility has failed to ensure client confidentiality during treatment sessions. One counseling office has a hollow core door which allows counseling sessions to be heard from outside of the counseling room.
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Plan of Correction
The owner of the building has been notified of the need to substitute a solid door for the current hollow core one. The door is on order and will be in place on or before 6/15/2007. Until
the door is replaced the counselor has relocated his office to the small conference room across the hall from his original office. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct a fire drill for September of 2006.
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Plan of Correction
The fire drill was conducted in September, however the facility director failed to document the drill. All fire dril will be documented by the facility director immediately following each drill. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The facility failed to ensure that personal histories contained details about the client's work history, educational history , family dynamics, etc in client records # 6, 7, 8 and 9. Histories should collect as much detail as possible since they form the basis for the clinical evaluation and treatment planning processes.
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Plan of Correction
The clinical staff have been utilizing three different assessment tools duing the past year (as a result of SCA requirements). The charts in questions had, in fact, an assessment tool that was approved for the Case Management unit of the SCA and not necessarily appropiate for the agency.
We have since replaced that tool and our current tool contains much more detail regarding work history, educational history, and family dymanics. The counselors have been reminded of the need for more detail in their assessments and a periodic chart review by the Clincial Director will monitor their compliance. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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:
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Observations
Treatment plans documented in files reviewed used a template format which was not consistently individualized. Plans must be individualized to meet the assessed needs of each client.
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Plan of Correction
All counselors were addressed concerning this citation. The counselors have made the necessary changes to the treatments plans and their compliance will be monitored by the Clincal Director during monthy chart reviews. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The type and frequency of services was not consistently documented on the treatment plan. Client records # 7 and 9 had incomplete information in the treatment plans.
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Plan of Correction
The counselors were all addressed concerning this citation. The treatment plans were corrected and the counselors will be monitored during monthly chart reviews by the Clinical Director. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Individual counseling sessions were not consistently documented in client records #7 and 9. When services are provided at the partial hospitalization level of care (ten hours or more per week) two individual and two group sessions must be documented, at a minimum, for each week of treatment services provided.
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Plan of Correction
The counselors were all addressed concerning this citation. The charts'
record of treatment of service was corrected. Compliance will be monitored by the Clinical Director on a monthly basis. |
709.83(a)(7) LICENSURE Client records
709.83. 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:
(7) Referral contact.
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Observations
Referral contact information was not clearly documented in client records # 6 and 7. The need for additional services was identified in these two client records but it was not clear whether referrals were made to appropriate service providers.
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Plan of Correction
Should the client need to be referred to an ancillary service, the counselor will obtain a written release of information for the service, and, with the client, schedule an appointment.
The counselor will document the date the appointment was made and the date of the appointment. The counselor will follow the progress of the client through communication with the ancillary provider. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Work performance evaluations were not completed in accordance with agency policy in employee records # 8 and 11.
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Plan of Correction
This citation was an oversight of the Facility Director and the Clinical Director. Both employees have since received their performance reviews. In the future, all existing employees will have performance reviews once a year and all new employees will be reviewed after the initial thirty days of employment. |
709.28 (c)(1) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The specific information disclosed on the Pennsylvania Client Placement Criteria summary sheets and continued stay forms exceeds the limits imposed at 4 Pa. Code Subsection 255.5(b) in client records # 1, 6 and 9.
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Plan of Correction
The information included in the Pennsylvania Client Placement Criteria tool is provided to the SCA and utilized to determine and justify level of care. Without some of the information that exceeds 4 Pa. Code Subsection 255.5(b), level of care and treatment may be denied by the SCA. However, we have notified the Case Management Team at the SCA that we will be adhering to the confidentiality regulations. Counselors have been addressed concerning this citation. Charts will be monitored by the Clinical Director for compliance on a monthly basis. |
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
Drug and alcohol histories were incomplete in client records #1, 2, 3 and 10.
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Plan of Correction
The counselors were addressed concerning this citation. Changes were made in the charts where possible. All charts will be reviewed by the Clinical Director on monthy basis to monitor adherence of this
requirement. |
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
Personal histories were incomplete in client records # 1, 2, 3, 8, 10 and 11. Personal histories should collect as much personal information about a client as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated.
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Plan of Correction
All counselors were addressed concerning this citation. The charts were corrected wherever possible. The charts wlll be monitored on a monthly basis by the Clinical Director to assure compliance by all counslors. |
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:
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Observations
Treatment plans were not consistently individualized in files reviewed. Plans should be developed to reflect the assessed needs for each client.
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Plan of Correction
All counselors were addressed concerning this citation. The treatment plans were corrected to reflect the individual needs of the client. Compliance to this requirement will be monitired by the Clinical Director during monthly chart reviews. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Case consultations failed to address the required areas in client records # 2, 9, 10, 11 and 13. Case consultations should include the following: the date of the consultation; the names of persons attending and their disciplines; a summary of the discussion held on the client; and a disposition of cases reviewed. Each client's progress should be reviewed at least quarterly at a case conference consisting of representatives from the various client service components. Where a multi-disciplinary staff does not exist, case consultation should include the primary counselor and one other clinician.
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Plan of Correction
This citation was reviewed by the Cliniical Director with the counseling staff. A disussion was held during supervision of the purpose for and correct documentation of case consults. Compliance of this standard will be monitored by the Clinical Director during weekly treatment team meeting and during monthly chart reviews. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Verification was not in place to document that the Medical Director was approved by the Office of Medical Assistance of the Department of Public Welfare. Physician signatures were not affixed to treatment plans or updates for clients funded through Medical Assistance or the Healthchoices contractors.
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Plan of Correction
We have requested the Department of Public Welfare to forward to us a copy of the Medical Director's acceptance with their Department. It should be noted that this file was reviewed each year and found compliant.
We will have our Medical Director sign all treatment plans and updates for clients funded from Medical Assistance funding streams, including clients receiving Healthchoices funding effective immediately. |