INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18-21, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Wyoming Valley Alcohol and Drug Services, 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 and a plan of correction is due on April 18, 2008.
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Plan of Correction
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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 the review of employee records and training files during the on site licensing inspection held March 18-21, 2008, the facility failed to properly document the required supervision for employee # 7. The employee record contained documentation of close supervision for a six month period beginning in February 2007. The employee was required to have three months of direct observation and an additional nine months of close supervision, based on the employees educational credentials. The employee still needed the required period of direct observation and an additional three months of close supervision at the time of the inspection despite being employed for a one year period as a counselor assistant.
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Plan of Correction
Employee identified as #7 shall undergo a 3-month period of direct supervision and additional 3 months of close supervision. This direct supervision will be conducted by the Treatment Supervisor and the close supervision shall be conducted by the Adult Partial Coordinator. This has already begun as of April 1, 2008. Full compliance with the standards will be completed on October 1, 2008. The Deputy Director will monitor this area. |
704.12(b) & (c) & (d) LICENSURE Counselor Asst/Exceptions
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(b) Counselor assistants. Counselor assistants may be included in determining FTE ratios when the counselor assistant is eligible for a caseload.
(c) Exemption for transitional living. Specific client/staff ratios are not required for transitional living facilities.
(d) Exceptions. A project director may submit to the Department a written petition requesting an exception to the client/staff and client/counselor ratios in this section. The petition shall describe how the characteristics of the program and its client mix support the request for the exception and shall be approved by the governing body. Granting the petition shall be at the discretion of the Department. Long-term residential facilities and halfway houses which include a client's participation in schooling or employment as part of a treatment day are examples when requests for exceptions will be considered.
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Observations
Based on the review of employee and administrative records during the on site licensing inspection held March 18 - 21, 2008, the facility failed to properly document the required period of supervision for one of two counselor assistants ( #7). This employee could not be counted in the FTE ratio as a result.
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Plan of Correction
Employee identified as #7 shall complete the required amount of supervision (3 months direct and 3 months close) as per the standards by October 1, 2008. This supervision shall be conducted by the Treatment Supervisor and the Adult Partial Coordinator. Following completion of this standard, the employee will then be counted in the FTE ratio in the future. The Deputy Director will monitor the completion of this supervision. |
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
Based on the review of the client records during the onsite licensing inspection held March 18-22, 2008, the facility failed to document complete personal histories in each record. Family relationships were not described in records # 1, 2, 3, 4 and 8. Personal histories were missing sexual orientation and the client's relationship history in client records # 1, 2, 3, 4 and 8. The client record sample consisted of 6 records.
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Plan of Correction
Based upon these findings with this standard, our intake form was changed to include more specific questions in the area of sexual orientation and the client's relationship history. A full (3 hours) morning training with the clinical staff on the above issues as well as accurate descriptions of family relationships was conducted on April 11, 2008, by the Treatment Supervisor and Intake Coordinator. As a result, we are now in full compliance with this standard as our personal histories will reflect more scope and depth of the client's background. The Intake Coordinator will monitor continued compliance of this standard. |
709.83(a)(9) 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:
(9) Progress notes.
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Observations
Based on the review of the client records during the onsite licensing inspection held March 18-22, 2008, the facility failed to document group notes which complied with the Licensing Alert requirements specified in the Group Counseling licensing alert of 11/29/1994. This document stipulates that when group notes are written to summarize services for the week that the same counselor must conduct all sessions and that there is one common theme for the group such as women's issues. incest survivors, anger management, etc. Group notes reviewed in records # 1, 2, 3, 4 and 8 were written in a weekly summary format and included several different topics, not all of which were consistent with the requirement of a common theme. The records sample consisted of six records.
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Plan of Correction
A meeting is scheduled on April 30, 2008, with all group counselors addressing this compliance issue. We will discuss the need to adhere to a theme for each week that one group note is written discussing the topics covered to summarize services. This meeting will be conducted by the Deputy Director and Partial Program Coordinator. The Partial Program Coordinator will have the responsibility of continuing to monitor this area. Therefore, the agency will be in full compliance with this standard by May 1, 2008. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of client records during the onsite licensing inspection held March 18-, 21, 2008 the facility failed to consistently document consents to release information which clearly identified what would be released as required at 28 Pa. Code subsection 709.28(c). Documentation in client records # 3, 7, 9 and 11 did not identify specific information to be released in the event of an emergency. A PCPC continued stay document identified the prescription drug and dose used and the client's legal status to funding entities in client record # 10. Documentation in client record # 3 identified the drug of choice used on the PCPC form which is sent to funding entities. The client sample consisted of 12 records.
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Plan of Correction
In a staff meeting conducted on April 25, 2008, the area of confidentiality and release of information forms was discussed in detail. Staff were all provided with copies of 255.5 and we also discussed the need to write down what exactly would be released in case of emergency on a client. We also talked about the need to limit information written on PCPC forms--not disclosing the drug of choice or dose used and not disclosing a client's legal status. The meeting was conducted by the Deputy Director and will be monitored by the Deputy Director, as well as the Intake Coordinator and the Partial Coordinator for continued compliance in this area. Therefore, the agency will be in full compliance with this standard by May 1, 2008. |
709.30(1) LICENSURE Client Rights
709.30. Client rights.
(1) A person receiving care or treatment under section 7 of the act (71 P. S. 1690.107), shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on the review of the facility manual and administrative materials at the onsite licensing inspection held March 18-21, 2008, the facility failed to document a policy which addressed the client's right to retain all civil rights during treatment.
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Plan of Correction
The CEO of the agency is formulating a policy which clearly states the client's right to retain all civil rights during treatment. This policy will be placed in the facility's manuals by May 15, 2008. At that time, the facility will be in full compliance with this standard. The CEO will insure the completion of this policy. |
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
Based on the review of the client records during the onsite licensing inspection held March 18-22, 2008, the facility failed to document complete personal histories in each client record. Family relationships were not described in client records # 5, 6, 7, 9, 10 and 11. The personal histories were missing sexual orientation and the client's relationship history in client records #5, 6, 7, 10 and 11. The record sample consisted of 8 records.
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Plan of Correction
This standard has been addressed through a training (3 hours), which was held on April 11, 2008, by the Treatment Supervisor and Intake Coordinator. Based upon these findings with this standard, our intake form was changed to include more specific questions in the area of sexual orientation and the client's relationship history. The 3-hour training with the clinical staff was on the above issues, as well as accurate descriptions of family relationships. As a result, we are now in full compliance with this standard as our personal histories will reflect more scope and depth of the client's background. The Intake Coordinator will monintor continued compliance of this standard. |