INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 29, 2013 to October 30, 2013, by staff from the Program Licensure Division. Based on the findings of the on-site inspection, Pennsylvania Care LLC DBA Miners Medical 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.
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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 the personnel and training records, the facility failed to document that a core curriculum in clinical supervision was completed in one of two records.
The findings included:
Twelve personnel records were reviewed on October 29, 2013. Two personnel records pertained to lead counselors who required the documentation of experience as supervisors or of core curriculum training in clinical supervision.
Employee # 4 was hired on June 7, 2010, and was promoted in April 2012. No documentation was provided to show the employee functioned for 2 years as a supervisor in the provision of clinical services. No documentation was provided to show the employee completed a core curriculum in clinical supervision.
The findings were reviewed and confirmed with the facility director and lead counselors.
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Plan of Correction
The facility failed to comply with regulation 704.6(C)in that the facility failed to document that a core curriculum in clinical supervision was completed for employee #4. Facility Director recently hired a new Clinical Supervisor who is registered to attend the clinical supervisor training December 9 - 13, 2013 in Williamsport. A copy of the training will be placed in the new Clinical Supervisor's personnel file by the Facility Director. Facility Director is changing job titles and assignments for staff who do not have the required training. Facility Director and Clinical Supervisor will ensure the deficiency does not recur in order to maintain compliance via implementation of a tracking system. |
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
Based on a review of the facility's Staffing Requirements Facility Summary Report (SRFSR) and personnel training files, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases (TB/STD) in 1 of 4 records reviewed.
The findings included:
The Staffing Requirements Facility Summary Report (SRFSR), completed by the facility on October 28, 2013, was reviewed on October 29, 2013. The form listed one staff as not having completed the mandatory training within the required time frames
Employee # 11, a counselor, was hired on March 27, 2012. The required trainings were to be obtained by March 27, 2013. The trainings were not documented until September 19, 2013 (HIV/AIDS) and August 22, 2013 (TB/STD).
The findings were reviewed and confirmed by the facility director.
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Plan of Correction
The facility failed to comply with
regulation 704.11 ( C )(1) requiring
clinical staff person #11 to receive 4
hours of TB/STD training and 6 hours HIV/Aids training within
their first year of employment. It
will be the responsibility of the
Facility Director and/or Senior
Counselor to ensure that all staff
receives the required training in
TB/STD and HIV/Aids within their first year of employment. A copy of the training certificate will be placed in staff persons' personnel record. Miner's
Medical will include the training completion date on the facility
Training Tracking form to be
reviewed monthly by the Facility
Director and/or Senior Counselor. |
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.
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Observations
Based on a review of the staff work hours and the Fist Aid/CPR certification cards, the facility failed to provide a sufficient number of staff persons trained in Fist Aid/CPR during the facility's hours of operation.
The findings included:
The First Aid and CPR certification cards were reviewed on October 29, 2013. The facility provided documentation of two of the three nurses having current certification. Upon review of the medication inventory, all three nurses have worked alone. Employee # 12, a nurse, does not have current CPR certification.
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Plan of Correction
The facility failed to comply with regulation 704.11 ( C )(2) requiring the facility to provide a sufficient number of staff persons trained in First Aid/CPR during the facility's hours of operation. Staff person #12 will receive their First Aid/CPR certification on 11/18/2013. It will be the responsibility of the Facility Director and/or Senior Counselor to ensure that Miner's Medical has sufficient number of staff trained in First Aid/CPR during the facility's hours of operation. A copy of Staff person #12 CPR/First Aid training certificate will be placed in staff person #12 personnel record. Facility Director and/or Senior Counselor will review staff work schedules to ensure compliance with this regulation ongoing and that staff CPR/First Aid trainings are current. This is will be monitored by the facility's Training Tracking form and will be reviewed monthly by Facility Director and/or Senior Counselor. |
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
Based on a review of personnel training records, the facility failed to ensure the completion of 25 clock hours of annual training as required for counselors in one of two training records.
The findings included:
Twelve personnel records were reviewed on October 29, 2013. Two personnel records pertained to counselors who required the completion of 25 clock hours of annual training. The facility failed to ensure 25 clock hours of annual training for employee # 4.
Employee # 4 was hired on June 7, 2010, as a counselor. The facility training year occurred from January 1, 2012, to December 31, 2012. Training record # 4 contained documentation of 13 hours for the 2012 training year.
The findings were reviewed and confirmed by the facility director and lead counselor.
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Plan of Correction
The facility failed to comply with
regulation 704.11 (f)(2) requiring
employee #4 to receive 25 hours training for the 2012 training year. Employee #4 received 13 hours for the 2012 training year.
It will be the responsibility of the
Facility Director and/or Clinical Supervisor to ensure that employee #4 and all staff receive the required training hours annually.
A copy of the training certificate
will be placed in employee #4 and all staff persons' personnel record.
Miner's Medical will include the training completion date on the facility
Training Tracking form to be
reviewed monthly by the Facility
Director and/or Clinical Supervisor.
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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 facility's Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that caseloads not exceed 35 active patients per counselor.
The findings included:
The Staffing Requirements Facility Summary Report (SRFSR), completed by the facility on October 28, 2013, was reviewed on October 29, 2013. The form listed four counselors with more than 35 patients on their caseload.
Counselor # 1, facility director, had a caseload of 35 patients with only 5 clinical hours available.
Counselor # 4, lead counselor, had a caseload of 36 patients.
Counselor # 5, senior counselor, had a caseload of 37 patients.
Counselor # 9 had a caseload of 40 patients.
Counselor # 10 had a caseload of 37 patients.
The findings were reviewed and confirmed with the facility director.
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Plan of Correction
The facility failed to comply with regulation 704.12(a)(6)requiring the facility to maintain counselor caseloads to no more than 35 to 1.
In order to maintain the client/counselor 35:1 ratio, the Facility Director along with the Senior Counselor will track census and staff composition daily. Miner's Medical will not accept clients over the census in order to remain in compliance with this regulation.
Facility Director hired 2 additional Full-time Counselors to remain in compliance with this regulation. |
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 the facility's annual report, the facility failed to include all of the required content in the annual report.
The findings included:
On October 29, 2013, the facility's annual report was reviewed.
The 2012 annual report was provided and reviewed during the inspection; however, the facility failed to include a financial statement of income and expenses within the annual report.
The facility director was informed and confirmed that documentation did not include a financial statement.
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Plan of Correction
The facility failed to comply with regulation 709.22(e)requiring the facility to include a financial statement of income and expenses within the 2012 annual report. It will be the responsibility of the COO to ensure income and expenses are included in the annual report in order to maintain compliance with this regulation ongoing.
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709.28(c) 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 include, but not be limited to:
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Observations
Based on the review of patient records, the facility failed adhere to the limits imposed by 4 Pa. Code 255.5 (b) in two of five records reviewed.
The findings included:
Eight patient records were reviewed during the onsite inspection. Five records were reviewed for consent to release information. The facility failed adhere to the limits imposed by 4 Pa. Code 255.5 (b) in records, # 2 and 4.
4 Pa. Code 255.5 (b) states:
(b) Restrictions. Information released to judges, probation or parole officers,
insurance company health or hospital plan or governmental officials, under subsection
(a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability
of continuing the client with the assigned project and shall be restricted to
the following:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
A review of patient record # 2 revealed a consent to release information to a legal entity that included dose, urine results, and information for guest medication. The information listed within the consent exceeded that permitted by Pa Code 255.5 (b).
A review of patient record # 4 revealed correspondence to a government entity dated September 18, 2013, that noted the medication received by the patient. The information provided in the correspondence exceeded that permitted by Pa Code 255.5 (b). The documentation required to permit the disclosure was received on October 12, 2013.
The findings were reviewed and confirmed with the facility director.
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Plan of Correction
The facility failed to comply with regulation 709.28 (c). The Facility Director conducted a staff training on 10.31.2013 on 4 Pa code 255.5 to ensure that the staff has a clear understanding of what can and cannot be disclosed. Ongoing chart audits will be held by the Facility Director and/or Clinical Supervisor monthly to ensure competency and efficiency. |
709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to document a complete client record that included discharge summaries in three of eight records reviewed
The findings included:
Eight patient records were reviewed during the onsite review. Three records were reviewed for discharge summaries and the required content.
Patient # 6 was admitted on May 10, 2011, and discharged on September 6, 2013. The discharge summary did not include the reasons for treatment and services offered.
Patient # 7 was admitted on May 22, 2013, and discharged on October 10, 2013. The discharge summary did not include services offered and the patient's status upon discharge.
Patient # 8 was admitted on June 17, 2013, and discharged on August 2, 2013. The discharge summary did not include services offered and the patient's status upon discharge.
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Plan of Correction
The facility failed to comply with regulation #709.93(a)regarding the discharge summary providing the following information: the patient's reasons for treatment, services offered,and the patient's status upon discharge.
On 10.31.2013, the Facility Director provided a staff training session in the area of writing a comprehensive discharge summary that includes, but is not limited to, all Department and Facility required information. Training included proper documentation of Discharge Summaries and included: Client's Reason for Treatment, Services Offered, and Client's Status upon Discharge. Ongoing monitoring and supervision will be provided by the Facility Director and Senior Counselor.
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