INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 20, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A Better Today, Inc. 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(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 personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position in one of one personnel record.
The findings include:
One personnel record which required documentation of monthly meetings between the clinical supervisor and their supervisor were reviewed during the Administrative review November 4-6, 2013. The facility failed to document monthly supervision meetings which included their duties and performance in personnel record # 3.
Employee # 3 was hired at the project on 10/9/09 and was promoted to the position of clinical supervisor on 1/2/13. Monthly supervision meetings took place for the first six months in the position of clinical supervisor, however, the meeting documentation did not include a review of Employee # 3's duties and performance.
The Project Director confirmed the findings.
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Plan of Correction
Based on the findings the supervision form used by A Better Today has been redesigned to better outline the duties and performance of the employee being supervised. Employee #3 has completed her supervision, but this form will be used for all current and future supervision. The new form has a designated area to cover all areas needed, and has been put into use as of 12/02/2013. The Clinical director redesigned the form and began putting it to use. He will be responsible for assuring it is properly completed in the future in order so that this error does not occur. |
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 records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one records reviewed.
The findings include:
One personnel record which required documentation of the completion of 25 clock hours of annual training was reviewed on November 7-8, 2013 during the administrative review. The facility failed to document 25 clock hours of annual training in personnel record # 5.
Employee # 5 was hired as a counselor on 9/27/10. The facility training year was from January 2012 through December 2012. This employee record contained documentation for only 6 clock hours of annual training.
The Clinical Director confirmed the findings.
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Plan of Correction
Based on the findings A Better Today will begin to monitor staff attended trainings on a monthly basis to assure all training requirements are met in a timely manner.
This task will be completed by the Clinical Supervisor. The training hours of each employee will be calculated on a monthly basis so the agency is aware of what trainings are still needed by the end of the calendar year.
This practice will begin immediately to assure that training hours are meet for the 2013 calendar year. |
709.82(d) 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:
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling at least twice weekly and group counseling at least twice weekly, in one of one records reviewed in the partial hospitalization activity.
The findings include:
One client record which required documentation of individual counseling at least twice weekly and group counseling at least twice weekly was reviewed November 20, 2013. The facility failed to document both individual counseling and group counseling at least twice weekly in record # 1.
Client # 1 was admitted on 10/22/13 and was still an active partial hospitalization client at the time of the inspection. The facility documented only one individual counseling session for the weeks of 10/20/13 and 10/27/13. Additionally, the facility documented only one group counseling session the week of 10/27/13.
The Clinical Director confirmed the findings.
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Plan of Correction
Based on the findings and client who is found to need a level of care which included individual sessions will be scheduled for these sessions as they currently are, however if the sessions are missed the counselor will contact the client to reschedule, if the client does not make their two individuals sessions per week their non-compliance will be reviewed and it will be decided if they need to be referred to a higher level of care or discharged on a case by case basis.
In the future the counselor will monitor the client's attendance and will consult with the treatment team when sessions are missed to determine the best course of action. Training will be provided to all counselors regarding this new procedure by 01/02/2014. This procedure will be continuously monitored by the clinical director to assure that clients are receiving all needed services and this does not happen again in the future.
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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 the review of Administrative documentation, the facility failed to make available to the public an annual report which included a financial statement of income and expenses.
The findings include:
An administrative review, which included a review of the facility's 2012 annual report, was conducted from November 4-6, 2013. The facility's 2012 annual report was made available to the public on July 5, 2013, via an ad that was placed in a local newspaper.
The annual report included a page with a bar graph with "bars" representing the 5 facilities contained in the project: Scranton, Tunkhannock, Stroudsburg, Hazelton (sic) and Bradford. However, there were no numerical values assigned to any of the bars or to the graph itself. In addition, the report did not contain any reference to expenses for any of the facilities contained in the project. Therefore, the annual report did not include a statement or disclosure of income and expenses as required.
The findings were confirmed by the Project Director during the Administrative review.
This is a repeat deficiency. The facility was previously cited for this deficiency on 11/30/11 and 12/5/12.
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Plan of Correction
Based on the finding the annual report for 2013 will be recreated to include numerical values along with the graphs to meet licensing requirements. In addition to the graphs with numerical values an actual income and expense statement will be provided with the annual report. This will be completed by the Clinical Supervisor and overseen by the Executive Director to assure that all licensure requirements are meet and included in the annual report. This will be completed by 01/31/2014 so it can be advertised in the local paper for public review.
In the future the Clinical Supervisor will prepare the annual report every year and it will be reviewed by the Executive Director to assure it meets licensure standards.
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based upon observation of the Licensing Specialist and a review of the client sign-in sheet, the facility failed to protect the confidentiality of client identities.
The findings include:
While at the facility on 11/20/13 the Licensing Specialist requested to see the client sign-in sheets. The sign-in sheet was presented to the Licensing Specialist upon request. The sign-in sheet had the first initial and last name of the client, however, the clients would sign in using their full name. In addition, any client that would sign in after the initial client, would have had access to all of the other client names. Therefore, the facility failed to protect the identity of its clients.
The findings were confirmed by the Clinical Director
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Plan of Correction
Based on these findings A Better Today will begin to have the group counselor individually allow each client to sign in while covering the other signatures on the page. This practice will prevent violating the client's confidentiality while allowing the agency to accurately track client attendance for billing purposes.
All counselors have been notified of this new practice and have been instructed to begin immediately. The Clinical Supervisor will monitor the effectiveness and compliance so client confidentiality is not violated again in the future. |
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 a review of client records, the facility failed to document a complete client record which included progress notes for each significant client contact in eight of fourteen records reviewed and failed to document an individualized aftercare plan which included personal goals and objectives in seven of seven records reviewed.
The findings include:
Fourteen client records which required documentation of progress notes for each significant client contact were reviewed November 20, 2013. The facility failed to document progress notes for each significant client contact in client records # 4, 5, 6, 7, 8, 9, 12, and 13. Four client records which required documentation of an individualized aftercare plan which included personal goals and objectives were reviewed November 20, 2013. The facility failed to document an individualized aftercare plan which included personal goals and objectives in client records # 4, 5, 6, 7, 12, 13, and 14
Client # 4 was admitted on 5/2/13 and discharged on 9/5/13. Treatment plan updates, which are considered significant client contact, were completed and signed by the client on 6/8/13 and 8/8/13. This client record did not include documentation of a progress note for the significant client contact that occurred on 6/8/13 and 8/8/13. Additionally, this client record contained an aftercare plan that was signed and dated by the client on 9/5/13. However, the aftercare plan was not individualized as it was a standardized form that did not address client # 4's personal goals and objectives.
Client # 5 was admitted on 5/20/13 and discharged on 10/14/13. Treatment plan updates, which are considered significant client contact, were completed and signed by the client on 7/20/13 and 9/20/13. This client record did not include documentation of a progress note for the significant client contact that occurred on 7/20/13 and 9/20/13. Additionally, this client record contained an aftercare plan that was signed and dated by the client on 10/14/13. However, the aftercare plan was not individualized as it was a standardized form that did not address client # 5's personal goals and objectives.
Client # 6 was admitted on 2/21/13 and discharged on 7/24/13. Treatment plan updates, which are considered significant client contact, were completed and signed by the client on 4/19/13 and 6/19/13. This client record did not include documentation of a progress note for the significant client contact that occurred on 4/19/13 and 6/19/13. Additionally, this client record contained an aftercare plan that was signed and dated by the client on 7/24/13. However, the aftercare plan was not individualized as it was a standardized form that did not address client # 6's personal goals and objectives.
Client # 7 was admitted on 5/30/13 and discharged on 8/5/13. A treatment plan update, which is considered significant client contact, was completed and signed by the client on 8/2/13. This client record did not include documentation of a progress note for the significant client contact that occurred on 8/2/13. Additionally, this client record contained an aftercare plan that was signed and dated by the client on 8/5/13. However, the aftercare plan was not individualized as it was a standardized form that did not address client # 7's personal goals and objectives.
Client # 8 was admitted on 8/27/13 and was still an active client at the time of the inspection. A treatment plan update, which is considered significant client contact, was completed and signed by the client on 10/27/13. This client record did not include documentation of a progress note for the significant client contact that occurred on 10/27/13.
Client # 9 was admitted on 7/26/13 and was still an active client at the time of the inspection. A treatment plan update, which is considered significant client contact, was completed and signed by the client on 9/26/13. This client record did not include documentation of a progress note for the significant client contact that occurred on 9/26/13.
Client # 12 was admitted on 5/6/13 and discharged on 9/6/13. A treatment plan update, which is considered significant client contact, was completed and signed by the client on 7/5/13. This client record did not include documentation of a progress note for the significant client contact that occurred on 7/5/13. Additionally, this client record contained an aftercare plan that was signed and dated by the client on 9/613. However, the aftercare plan was not individualized as it was a standardized form that did not address client # 12's personal goals and objectives.
Client # 13 was admitted on 7/31/13 and discharged on 10/25/13. Treatment plan updates, which are considered significant client contact, were completed and signed by the client on 9/30/13 and 10/2/13. This client record did not include documentation of a progress note for the significant client contact that occurred on 9/30/13 and 10/2/13. Additionally, this client record contained an aftercare plan that was signed and dated by the client on 10/25/13. However, the aftercare plan was not individualized as it was a standardized form that did not address client # 13's personal goals and objectives.
Client # 14 was admitted on 6/25/13 and discharged on 7/15/13. This client record contained an aftercare plan that was signed and dated by the client on 7/15/13. However, the aftercare plan was not individualized as it was a standardized form that did not address client # 14's personal goals and objectives.
The Clinical Director confirmed the findings.
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Plan of Correction
Based on the findings A Better Today has begun to recreate many of our clinical documents, including the after care plan. These documents will be put into use as of 01/02/2014 after all staff are properly trained in their use. The new after care plan will have space to include individualized goals, and a follow up form will be included in all charts to show that contact was made with each client to check on their progress after leaving our program. The forms were redesigned by our Clinical Director and the trainings on their use will also be provided by our Clinical Director. All active charts, including those which were reviewed, will be updated to include progress notes of significant client contact. In the future the quality assurance team will review charts on an ongoing basis to assure all forms are being used correctly and that aftercare plans are individualized and all significant client contact is being documented in either an individual note or on the blue progress note. This will be overseen by the Clinical Director. |