INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 13, 2011 through December 14, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Consortium 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report (SRFSR) form, the facility failed to ensure that that each counselor met the educational and experiential qualifications for the position of counselor.
The findings include:
On December 12, 2011, the SRFSR form and ten personnel records were reviewed for documentation of the qualifications for the position of counselor. The facility failed to ensure that each counselor met the appropriate educational requirements for the position in one of ten personnel records reviewed, specifically, personnel record # 13.
Based on the Staffing Requirements Facility Summary Report form completed by the facility on December 12, 2011, employee #13 was documented as having completed an Associates of Applied Science in Library Science. A review of the personnel record for employee # 13 and the college transcripts indicated that the educational requirements for the position were not met.
The findings were confirmed during an ongoing dialogue with the division director and human resources director on December 12, 2011 from approximately 1:00 P.M. to 6:00 P.M.
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Plan of Correction
Responsible: The Human Resource Hiring Manager will be responsible to review the staffing requirements to determine if each perspective counselor possess the correct education and experience for the position in question.
Responsible: Employee #13 will be responsible to complete the requires close supervision and observation hours required for the position of counselor assistant. The clinical supervisor will be responsible for the observation, close supervision / monitoring, and documentation of the counselor assistant's status.
The counselor assistant will be responsible to continue education by enrolling, attending, and completing a credited program to earn the appropriate educational requirements needed for the position of counselor, within five (5)years.
Responsible: The program director will be responsible to assure the compliance of the clinical supervisor and counselor assistant during individual supervision with the clinical supervisor. The program director will be responsible to assure that all documentation is forwarded to the employee's records.
Effective 12/23/11 employee #13's status was changed from counselor to counselor assistant. Effective1/9/2012 employee #13 was enrolled in Master's level program for Human Services.
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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of the facility's policies and procedures, the project director failed to 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 overall training plan to address staff training needs.
The findings include:
The facility's policies and procedures were reviewed on December 13, 2011. The policy and procedures presented as the policy and procedures on staff development did not indicate the time frame for completing an overall plan for address staff training needs.
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Plan of Correction
Responsible: 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 completing the overall training plan to address staff training needs. The policy for the staff development program will be revised and presented to the Board of Directors for approval no later that January 10, 2012. The Project Director in conjunction with the Division Director will be responsible to ensure the revised policy remain in place at the facility.
Time Frame: The revised agency policy and procedures for the staff development program indicating who is responsible and the time frames for the completion of the overall training plan to assess staff training needs will be approved no later than January 10, 2012.
Monitoring: The Project director in conjunction with the Program Directors/Managers will monitor completion of the overall training plan to address staff training needs.
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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
Based on a review of personnel records and the facility's Staffing Requirements Facility Summary Report form, the facility failed to document an individual training plan for each employee, appropriate to that employee's skill level, annually with input from both the employee and the supervisor and/or document an individual training plan for each new employee when hired.
The findings include:
On December 12, 2011, thirteen personnel records requiring documentation of an individual training plan were reviewed.
The facility failed to document an individual training plan for the 2010-2011 training year for existing employees in four of ten existing employee personnel records reviewed, specifically, personnel records # 1, 11, 12, and 13.
The facility failed to develop an individual training plan at the beginning of the 2010-2011 training year for existing employees in three of ten existing personnel records reviewed, specifically, personnel records # 3 and 8.
The facility failed to document an individual training plan for each new employee in two of three records reviewed for newly hired employees, specifically, personnel records # 7 and 9.
Employee # 1 is the project director and was hired December 3, 2011. An individual training plan was due the beginning of the facility's current training year by July 2011 or August 2011. However, as of December 13, 2011, the most recent individual training plan in personnel record # 1 was completed on January 8, 2010.
Employee # 3 is a clinical supervisor and was hired February 21, 2010. An individual training plan was due the beginning of the facility's current training year by July 2011 or August 2011. However, the facility did not document an individual training plan for employee # 3 until December 12, 2011.
Employee # 7 is a counselor and was hired December 20, 2010. An initial individual training plan was due January 19, 2011. However, the facility did not document an individual training plan for employee # 7 until February 14, 2011.
Employee # 8 is a counselor and was hired March 12, 2001. An individual training plan was due the beginning of the facility's previous training year by July 2010. However, the facility did not document an individual training plan for employee # 8 until February 14, 2011.
Employee # 9 is a counselor and was hired August 22, 2011. An initial individual training plan was due September 21, 2011. However, the facility did not document an individual training plan for employee # 9 until December 19, 2011.
Employee # 11 is a counselor and was hired May 24, 2010. An individual training plan was due the beginning of the facility's current training year by July 2011 or August 2011. However, as of December 13, 2011, the most recent individual training plan in personnel record # 11 was completed on June 14, 2010.
Employee # 12 is a counselor and was hired June 7, 2010. An individual training plan was due the beginning of the facility's current training year by July 2011 or August 2011. However, as of December 13, 2011, the most recent individual training plan in personnel record # 12 was completed on July 1, 2010.
Employee # 13 is a counselor and was hired July 6, 2010. An individual training plan was due the beginning of the facility's current training year by July 2011 or August 2011. However, as of December 13, 2011, the only individual training plan in personnel record # 13 was completed on July 6, 2010.
The findings were confirmed during an ongoing dialogue with the division director and human resources director on December 12, 2011 from approximately 1:00 P.M. to 7:00 P.M.
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Plan of Correction
Responsible: The Board of Directors or its designee will be responsible to meet annually with the project director and document an individual training plan that is appropriate to that employee's skill level. The clinical supervisor will be responsible to ensure all individual training plans are complelte for all new employees within 30 days of hire.
Time Frame: The individual training plan for employee #1,#11 #12,#13 will be documented in their personnel record no later than January 31st of each year. The Clinical Supervisor will be responsible to assure the training plans are completed and submitted to the Human Resource Mamager.
Monitoring: Human Resources department will monitor employee personnel records for documentation of individual training plans on file no later than January 31st of each year.
Time Frame: The individual training plan for employee #1 will be documented in their personnel record no later than January 31st of each year.
Monitoring: Human Resources department will monitor employee personnel records for documentation of individual training plans on file no later than January 31st of each year.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project director completed 12 clock hours of training for the 2010-2011 training year.
The findings include:
On December 12, 2011, one personnel record requiring documentation of 12 clock hours of training was reviewed. The facility failed to provide documentation of 12 clock hours of training in one of one personnel record reviewed, specifically, personnel record # 1.
Employee # 1, the project director, was hired on December 3, 2001. The facility's training year is from July 1, 2010 to June 30, 2011. Personnel record # 1 did not include documentation of training hours for the July 1, 2010 to June 30, 2011 training year as of December 12, 2011.
The findings were confirmed during an ongoing dialogue with the division director and human resources director on December 12, 2011 from approximately 1:00 P.M. to 6:00 P.M.
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Plan of Correction
Responsible: Employee #1 (Project Director)and Employee #2 ( Facility Director) will be responsible to complete the required 12 clock hours of training during the facility's training year January 1, 2012 to December 31, 2012 and annually thereafter. The Administrative Assistant to the Project Director (Employee #1) and Facility Director (Employee #2) will be responsible to schedule, monitor and ensure the project director attend trainings, webinars, or other related workshops to complete the required 12 training clock hours annually.
Time Frame: Employee #1 and Employee #2 will begin to complete the required 12 clock hours of training as of January 1, 2012 through December 31, 2012.
Monitoring: Human Resource department will monitor the submission of 12 clock hours of training for employee #1 and employee #2 to be documented in the personnel record. The administrative assistant to employee #1 and employee #2 will send all completed training certificates to HR for submission in the personnel record.
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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 ensure that each counselor completed 25 clock hours of required training.
The findings include:
On December 12, 2011, four personnel records requiring documentation of 25 clock hours of training were reviewed. The facility failed to provide documentation of 25 clock hours of training in two of four personnel records reviewed, specifically, personnel records # 8 and 10.
Employee # 8 is a counselor and was hired on March 12, 2001. The facility ' s training year is from July 1, 2010 to June 30, 2011. Employee # 8's personnel record only had documentation of 17 clock hours of training for the July 1, 2010 to June 30, 2011 training year as of December 12, 2011.
Employee # 10 is a counselor and was hired on October 28, 2002. The facility ' s training year is from July 1, 2010 to June 30, 2011. Employee # 10's personnel record only had documentation of 13.5 clock hours of training for the July 1, 2010 to June 30, 2011 training year as of December 12, 2011.
The findings were confirmed during an ongoing dialogue with the division director and human resources director on December 12, 2011 from approximately 1:00 P.M. to 6:00 P.M.
This is a repeat citation. The facility was cited on October 15, 2010; November 18, 2009; and November 7, 2008 for noncompliance with this standard.
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Plan of Correction
Responsible: One of the primary responsibilities of the Licensing / Clinical Training Director is to provide training for Consortium employees.
Responsible:Tha Program Director will be responsible to ensure that all counselor complete at least 25 clock hours of training every year.
The Program Director will collaborate with the Licensing / Clinical Training Director to assure that approximately 25 hours of trainings are provided on site for each training calendar year effective 1/10/12. These trainings are scheduled on the Consortium Training Calendar for two days each month. All DOH Mandatory Training are scheduled for the begining of 2012.
Responsible: The Clinical Supervisor will be responsible to ensure that all counselors attend the on-site required trainings,and make up any missed trainings due to a counselor's absence. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on observations on December 14, 2011 the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients and employees and visitors.
The findings include:
A physical plant inspection was conducted on December 14, 2011. The following items were identified:
1) At approximately 11:15 A.M., the main hallways on the second floor were observed to have areas of cracking floor tiles.
2) At approximately 3:41 P.M., the carpet in the waiting area in section # 204 outside of medical offices # 202 -207 was observed to have areas that were stained.
3) At approximately 3:50 P.M., the carpet in the waiting area in section # 240 outside of offices # 240 -244 was observed to have areas that were stained.
4) At approximately 3:57 P.M., the waiting area in section # 238 outside of offices 238 - 239 had areas of cracking and stained floor tiles.
The findings were confirmed by the Facility Director and the Division Director.
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Plan of Correction
Responsible: The Facilities Supervisor will be responsible to develop a working plan to assess all areas of the building and grounds requiring repair/replacements. Due to the magnitude of the repairs an assessment for the need of an outside contractor, supplies and possible large equipment to complete the work will be needed to replace/repair (1) main hallway on the second floor where cracking floor tiles were observed; (2) repair/replace carpet in the waiting area in section 204 outside medical offices #202-207 where stained carpet was observed; (3) replace/repair stained carpet in waiting area section #240 outside offices #240-244; (4) replace/repair cracking and stained floor tiles in waiting area section #238 outside of offices #238-239. The Facilities Supervisor will be responsible to ensure all repairs/ replacements are completed.
Time Frame: The Facilities Supervisor will meet with the VP of Operations and Interim CFO no later than January 20, 2012 to discus, plan and make decisions on all repairs. Once the decision is made on how to complete all repairs of cracking floor tiles and stained carpets in the most cost effective manner all repairs or replacements will be completed no later than March 30, 2012.
Monitoring: The Facilities Supervisor along with the maintenance staff will monitor daily maintaining the facility building and grounds to keep the facility clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.
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705.23 (2) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on observations on December 14, 2011 the facility failed maintain counseling areas with furnishings which are in good repair.
The findings include:
A physical plant inspection was conducted on December 14, 2011. The following items were identified:
1) At approximately 3:33 P.M., floor tiles in individual/group counseling room # 236 were observed to have areas of stained floor tiles.
2) At approximately 3:36 P.M., floor tiles in individual/group counseling room # 235 were observed to have areas of stained floor tiles.
3) At approximately 3:42 P.M., the carpet in group counseling room # 202 was observed to have areas that were stained.
4) At approximately 3:46 P.M., the carpet in group counseling room #249 was observed to have areas that were stained.
5) At approximately 3:52 P.M., the carpet in group counseling room # 243 was observed to have areas that were stained.
6) At approximately 3:54 P.M., the carpet in group counseling room # 242 was observed to have areas that were stained.
7) At approximately 4:08 P.M., the carpet in group counseling room # 121 was observed to have areas that were stained.
8) At approximately 4:11 P.M., the carpet in individual counseling room # 114 was observed to have areas that were stained.
The findings were confirmed by the Facility Director and the Division Director.
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Plan of Correction
Responsible: The Facilities Supervisor will be responsible to develop a working plan to assess all repairs needed for counseling or activity areas and office space. Due to the magnitude of the repairs an assessment for the need of an outside contractor, supplies and or large equipment will be required to repair/replace (1) floor tiles in the individual/group counseling room #236 where stained floor tiles were observed; (2) repair/ replace stained floor tiles observed in room #235; (3) replace/repair stained carpet in group counseling room #202; (4) replace/repair stained carpet in group counseling room #249; (5) replace/repair stained carpet in group counseling room #242 & #243; (6) replace/repair stained carpet in group counseling rooms #242 and (7) group counseling room #121; (8) replace/repair carpet in individual counseling room #114 where stained areas were observed. The Facilities Supervisor will be responsible to insure all stained floor tiles and stained carpets or replaced or repaired.
Time Frame: The Facilities Supervisor will meet with the VP of Operations and Interim CFO no later than February 27, 2012 to discus, plan and make decisions on all repairs. Once the decision is made on how to complete all repairs of cracking floor tiles and stained carpets in the most cost effective manner all repairs or replacements will be completed no later than March 30, 2012.
Monitoring: The Facilities Supervisor along with the maintenance staff will monitor daily maintaining the facility building and grounds to keep the facility clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.
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705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on observations on December 14, 2011, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom.
The findings include:
A physical plant inspection was conducted on December 14, 2011. It was observed during the inspection at approximately 4:03 P.M. that the facility failed to provide paper towels or a mechanical dryer in women's handicap restroom on the first floor.
The findings were confirmed during an ongoing dialogue with the division director on December 14, 2011 at approximately 4:03 P.M.
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Plan of Correction
Responsible: The facility's maintenance staff will be responsible to provide individual paper towels or a mechanical dryer in each bathroom in particular the women's handicap restroom on the first floor.
Time Frame: The maintenance staff will provide paper towels or an mechanical dryer in the women's handicap restroom no later than January 7, 2012.
Monitoring: The facilities director will monitor supplies needed to ensure the maintenance staff will provide paper towels or a mechanical dryer in each bathroom.
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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on observations on December 14, 2011 the facility failed to Maintain each bathroom in a functional, clean and sanitary manner at all times.
The findings include:
A physical plant inspection was conducted on December 14, 2011. The following items were identified:
1) At approximately 11:18 A.M., the men's public restroom located in the main hallway on the second floor was observed to have missing and cracking floor tiles in one of the restroom stalls.
2) At approximately 11:24 A.M. and again at 3:26 P.M., the women's public restroom located in the main hallway on the second floor was observed to have areas of stained floor tiles in the upper left section of the restroom.
The findings were confirmed by the Facility Director and the Division Director.
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Plan of Correction
The Facilities Supervisor will be responsible to ensure the maintenance staff maintains each bathroom in a functional, clean and sanitary manner at all times. The Facilities Supervisor will be responsible to develop a working plan to assess the repairs needed to replace missing and cracking floor tiles in the men's restroom located on the second floor (2) replace/repair stained floor tiles observed in the women's restroom in the main hallway on the second floor.
Time Frame: The Facilities Supervisor will meet with the VP of Operations and Interim CFO no later than February 27, 2012 to discus, plan and make decisions on all repairs. Once the decision is made on how to complete all missing , cracking or stained floor tiles in the men's and women's restrooms in the main hallway on the second floor in most cost efficient manner all replacements./repairs will be completed no later than March 30, 2012.
Monitoring: The Facilities Supervisor along with the maintenance staff will monitor daily the men's and women's restrooms on second floor in main hallway to be kept and maintained functional, clean and sanitary at all times.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observations on December 14, 2011, the facility failed to ensure that heaters that are not permanently mounted or installed were not permitted in the facility.
The findings include:
A physical plant inspection was conducted on December 14, 2011. It was observed during the inspection at approximately 11:10 A.M., that there was a portable space heater in room # 237.
The findings were confirmed during an interview with a facility director from another program of the project on December 14, 2011 at approximately 11:10 A.M.
This is a repeat citation. The facility was cited on June 29, 2010 for noncompliance with this standard.
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Plan of Correction
Responsible: The Program Director's/Managers/Supervisors will be responsible to ensure that heaters that are to permanently mounted or installed are not allowed in the facility. The Program directors will be responsible to remove from the facility the space heater observed in room #237.
Time Frame: The space heater observed in room #237 was removed from the facility on 12/14/11.
Monitoring: The Managers/Supervisors will monitor staff offices to ensure space heaters are not in the facility or counseling or activity areas and office spaces.
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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 ensure that all staff were instructed in the use of the fire extinguisher upon staff employment
The findings include:
On December 12, 2011, four personnel records requiring documentation of fire extinguisher training were reviewed. The facility failed to ensure that staff were instructed in the use of the fire extinguishers upon staff employment in one of four personnel records reviewed, specifically, employee # 7
Employee # 7 is a counselor and was hired on December 20, 2010. Employee # 7 was due to complete fire extinguisher training by December 20, 2010; however, employee # 7 did not complete fire extinguisher training until November 17, 2011.
The findings were confirmed during an ongoing dialogue with the division director and human resources director on December 12, 2011.
This is a repeat citation. The facility was cited on August 29, 2011 and October 15, 2010 for
noncompliance with this standard.
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Plan of Correction
Responsible: The Humam Resources Manager will assure that all new employees receive the emergency training during New Hire Orientation and forward the documentation to the employee's file. The Clinical Supervisor will confirm completion of the required training with the Human Resources Manager.
Fire extinguisher training will be done within 7 days of hire.
Responsible: The Program Director will schedule all required trainings to occur on site and assign all affected and other employees to the required training no later than 2/28/12. A copy of the training evaluation and certificate will be filed on site and the original will be forwarded to the Human Resources Manger for submission to the employee's file.
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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 were trained upon employment to perform assigned tasks during emergencies.
The findings include:
On December 12, 2011, four personnel records requiring documentation that all personnel on all shifts had been training to performed assigned tasks during emergencies were reviewed. The facility failed to ensure that employees completed emergency training upon employment in two of four personnel records reviewed, specifically, employees # 7 and 9.
Employee # 7 is a counselor and was hired on December 20, 2010. Employee # 7 was due to complete emergency training by December 20, 2010; however, employee # 7 did not complete emergency training until November 17, 2011.
Employee # 9 is a counselor and was hired on August 22, 2011. Employee # 9 was due to complete emergency training by August 22, 2011; however, employee # 9's personnel record did not include documentation of emergency training as of December 12, 2011.
The findings were confirmed during an ongoing dialogue with the division director and human resources director on December 12, 2011.
This is a repeat citation. The facility was cited on August 29, 2011 and October 15, 2010 for
noncompliance with this standard.
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Plan of Correction
Responsible: The Humam Resources Manager will assure that all new employees receive the emergency training within 7 days of hire and forward the documentation to the employee's file. The Clinical Supervisor will confirm completion of the required training with the Human Resources Manager.
Responsible: The Program Director will schedule all required trainings to occur on site and assign all affected and other employees to the required training no later than 2/28/12. A copy of the training evaluation and certificate will be filed on site and the original will be forwarded to the Human Resources Manger for submission to the employee's file.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record that included documentation of problems encountered and whether the fire alarm or smoke detector was operative.
The findings include:
Fire drill records were reviewed on December 13, 2011. The records were reviewed from the period covering November 2010 to November 2011. The facility did not have documentation for whether there were problems encountered and whether the fire alarm or smoke detector was operative in nine of twelve months reviewed, specifically, November 24, 2010; December 28, 2010; January 11, 2011; February 28, 2011; March 15, 2011; April 29, 2011; May 31, 2011; June 2, 2011; and July 26, 2011.
The findings were confirmed during an ongoing dialogue with the division director on December 13, 2011 from approximately 10:00 A.M. to 10:15 A.M.
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Plan of Correction
Responsible: The Program Director will maintain, on site, a binder with copies of each Fire Drill Log prepared by the security staff. The program Director will assure that all required elements are completed on the fire drill log. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill records, the facility failed to provide documentation that they set off a fire alarm or smoke detector during each fire drill.
The findings include:
Fire drill records were reviewed on December 13, 2011. The records were reviewed from the period covering November 2010 to November 2011. The facility did not have documentation for whether or not they set off a fire alarm or smoke detector during each fire drill in nine of twelve months reviewed, specifically, November 24, 2010; December 28, 2010; January 11, 2011; February 28, 2011; March 15, 2011; April 29, 2011; May 31, 2011; June 2, 2011; and July 26, 2011.
The findings were confirmed during an ongoing dialogue with the division director on December 13, 2011 from approximately 10:00 A.M. to 10:15 A.M.
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Plan of Correction
Responsible: The Program Director will maintain, on site, a binder with copies of each Fire Drill Log prepared by the security staff. The program director will assure that all the required elements, including whether the facility set off a fire alarm or smoke detector during each drill, are completed on the fire drill log. effective 1/31/2012 |
709.22(e)(3) 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:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of the administrative material and review of the document presented at the time of the administrative review as the annual report, the facility failed to make available to the public an annual report that included a statement disclosing the names of officers, directors and principal shareholders, where applicable.
The findings include:
The administrative material was reviewed on December 12, 2011. The document presented at the time of review as the annual report for the facility's July 2009 through June 2010 fiscal year was incomplete and did not include a statement disclosing the names of officers, directors and principal shareholders, where applicable that coincided with the date of the annual report. There was a list of board members attached to the report; however, it was dated December of 2010 and the annual report was dated June of 2010.
The findings were confirmed during an ongoing dialogue with the division director on December 12, 2011 from approximately 1:00 P.M. to 3:30 P.M.
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Plan of Correction
Responsible: The Project Director in conjunction with the Board Liaison will be responsible to ensure and make available to the public a stand alone document identifiable as an annual report that includes a statement disclosing the names of officers, directors and principal shareholders, where applicable.
Time Frame: The stand alone document of an annual report will be made available no later than December 31 of each year.
Monitoring: The Project Director will begin monthly communication with the Board Liaison to provide a stand alone document of an annual report. By third month after end of fiscal year and each month thereafter a reminder call will be made to Board Liaison to ensure information on current names of officers, directors and principal shareholders are available for the annual report no later than 6 months after end of fiscal year.
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709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to develop a written plan for the coordination of client treatment and rehabilitation services that accurately reflects their process for completing psychosocial histories and psychosocial evaluations.
The findings include:
On December 13, 2011, the facility's policy and procedures manual was reviewed. The facility had three conflicting policies regarding the completion of psychosocial histories and two conflicting policies regarding psychosocial evaluations.
The facility's policy titled: "Treatment/Rehabilitation Management," stated:
"The Counselor/Primary Clinician completes the Psychosocial History and Psychosocial Evaluation within thirty (30) days following admission."
The facility had a second policy titled: "Treatment/Rehabilitation Management," that stated:
"A Personal History shall be completed within 7 days from admission."
The facility's policy and procedure manual contained a third policy titled: "Client Records." This third policy stated:
"Psycho-social History due before 30th day."
The findings were confirmed during an ongoing dialogue with the division director on December 12, 2011 from approximately 1:00 P.M. to 7:00 P.M.
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Plan of Correction
Responsible: The Division Director will be responsible to review and revise the conflicting policies regarding psychosocial histories and psychosocial evaluations. The Division Director will be responsible to develop one written plan for the coordination of client treatment and rehabilitation services. The governing body shall adopt the written plan at the next Board of Directors meeting following the revision of the written policy.
Time Frame: The revised policy for procedures for the management of treatment/rehabilitation services for clients will be presented to the Board subcommittee, Performance Oversight & Finance Committee no later than February 21, 2012 who will submit to the governing body for adoption no later than April 12, 2012.
Monitoring: The program director will monitor the implementation of the revised policy to accurately reflect the facility's process for completing psychosocial histories and psychosocial evaluations.
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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
Based on a review of personnel records and the facility's policy and procedure manual, the facility failed to document work performance evaluations at least annually and/or in accordance with facility policy.
The findings include:
The facility's policy titled: "Performance Appraisal," states:
"It is The Consortium's policy to provide a performance appraisal process that measures employee performance and aids employees in their development. This is an ongoing process between employees and their supervisors; however, employees formally evaluated upon completion of their initial 90-days of employment and annually, thereafter, in their anniversary month."
On December 12, 2011, twelve personnel records requiring documentation of a work performance evaluation were reviewed. The facility did not document a work performance evaluation according to their policy and procedures in two of twelve personnel records reviewed, specifically, personnel records # 1 and 3. Also, the facility did not document a work performance evaluation in two of twelve personnel records reviewed, specifically, personnel records # 7 and 9.
Employee # 1 is the project director and was hired on December 3, 2001. Employee # 1 was due an annual work performance evaluation by January 8, 2011; however as of December 12, 2011, the most recent signed annual work performance evaluation in personnel record # 1 was completed on January 8, 2010. Although the facility presented an additional performance evaluation for 2010 and another performance evaluation for 2011, neither evaluation had a signature or date indicating that employee # 1 received the performance evaluations.
Employee # 3 is a clinical supervisor and was hired for her current position October 30, 2006. Employee # 3 was due an annual work performance evaluation by October 6, 2011. However, an annual work performance evaluation was not completed for employee # 3 until December 12, 2011.
Employee # 7 is a counselor and was hired December 20, 2010. Employee # 7 was due an initial 90 day work performance evaluation by March 20, 2011. However, personnel record # 7 did not include documentation of work performance evaluation as of December 12, 2011.
Employee # 9 is a counselor and was hired August 22, 2011. Employee # 9 was due an initial 90 day work performance evaluation by November 20, 2011. However, personnel record # 9 did not include documentation of work performance evaluation as of December 12, 2011.
The findings were confirmed during an ongoing dialogue with the division director and human resources director on December 12, 2011 from approximately 1:00 P.M. to 6:00 P.M.
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Plan of Correction
Responsible: The Governing Body (Board of Directors) will be responsible to provide an annual work performance appraisal for employee #1, the Project Director and ensure it is reviewed and signed by employee #1. The Board reviews the work performance of the project director and completes the review on an annual basis.
The Supervisor will be responsible for completing the work performance evaluation of new employee #3, #7, #9.
Time Frame: The annual work performance appraisal for employee #1 will be completed no later than January 31, 2012. The annual work performance appraisal for employee #3 will be completed no later than January 31, 2012.
Monitoring: The Human Resource Director will monitor personnel records for completion of annual work performance appraisals and ensure the work performance appraisals are on file in personnel records no later than January 31st of each year. HR will send reminders to the Chair of the Board of Directors, Program Directors/Managers and Clinical Supervisors at least two months before January 31st of each year. By January 13th of each year HR will send a second reminder that work performance appraisals are due for submission no later than January 31st of each year. At that time program directors/,managers and/or supervisors will receive a list of all staff work performance appraisals not received to ensure documentation of annual work performance appraisals are received on each staff member no later than January 31st of each year.
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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 a review of patient records, the facility failed to obtain an informed and voluntary consent from the patient for the disclosure of information.
The findings include:
On December 13, 2011, eight records were reviewed for informed and voluntary consent. The facility released information without the patients' consent in three of eight records reviewed, specifically, patient records # 1, 2, and 8.
Patient record # 1 contained one Eligibility Verification System form dated 11/2/11 in which the facility released information about the patient to a government agency, but the facility did not document a signed consent from the patient to release the information.
Patient record # 2 contained one Eligibility Verification System form dated October 28, 2011 in which the facility released information about the patient to a government agency, but the facility did not document a signed consent from the patient to release the information
Patient record # 8 contained a lab report dated October 17, 2011 in which the facility released information about the patient to an agency, but the facility did not document a signed consent from the patient to release the information until October 20, 2011.
The findings were acknowledged during an ongoing dialogue with the facility director on December 14, 2011 from approximately 10:00 A.M. to 10:20 A.M.
This is a repeat citation. The facility was cited on October 15, 2010; June 29, 2010; November 18, 2009; November 7, 2008 for noncompliance with this standard.
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Plan of Correction
Responsible: The Program Director will ensure that Confidentiality regulations are reviewed during team meetings on or before 2/7/12. The clinical supervisor will assure that this information is documented on the meeting agenda and that all attending staff sign the attendance sheet.
Responsible: The staff will assure that releases are executed according to regulatory requirements. The clinical supervisors will review releases during chart audits.
Responsible: medical record clerks will review releases prior to filing and inform the clinical suoervisors of any incomplete elements. |
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 a review of patient records and an interview with the division director, the facility failed to document a personal history in accordance with their policy and procedures and/or review and sign off on psychosocial histories completed within six months prior to admission by the SCA or other D&A treatment facility .
The findings include:
On December 12, 2011, due to conflicting policies relating to the completion of psychosocial histories and the psychosocial evaluation the division director was interviewed to determine which policy the facility was following. The director stated that it was the policy that stated that the History and Evaluation were to be completed within thirty (30) days following admission.
The facility's policy titled: "Treatment/Rehabilitation Management," states:
"The Counselor/Primary Clinician completes the Psychosocial History and Psychosocial Evaluation within thirty (30) days following admission.
Personal History (Demographic & Screening Information)
Information from the client must be obtain concerning pertinent personal data including: family, legal, employment/vocational, educational, military, recreational, sexual and other information where appropriate."
On December 13, 2011, eight patient records requiring documentation of a personal history were reviewed. The facility did not document a personal history according to their policy and procedures in three of eight records reviewed, specifically, patient records # 5, 6, and 8.
The facility also did not document a personal history in four of eight records reviewed, specifically, patient records # 2, 3, 4, and 7.
The facility did not have documentation of a signature and date from the facility staff indicating a personal history from a licensed drug and alcohol treatment provider or the Single County Authority was reviewed by both facility staff and patient in two of eight records reviewed, specifically, patient records # 5 and 6.
Patient # 2 was admitted November 11, 2011. The personal history was due December 11, 2011; however, patient record # 2 did not include documentation of a personal history as of December 13, 2011.
Patient # 3 was admitted November 10, 2011. The personal history was due December 10, 2011; however, patient record # 3 did not include documentation of a personal history as of December 13, 2011.
Patient # 4 was admitted November 3, 2011. The personal history was due December 3, 2011; however, patient record # 4 did not include documentation of a personal history as of December 13, 2011.
Patient # 5 was admitted October 21, 2011. The personal history was dated September 20, 2011. However, the personal history did not include documentation of a signature from the facility staff indicating the personal history was reviewed by both facility staff and patient as of December 13, 2011. Also, the personal history did not include a complete family history.
Patient # 6 was admitted November 1, 2011. The personal history was dated October 13, 2011. However, the personal history did not include documentation of a signature from the facility staff indicating the personal history was reviewed by both facility staff and patient as of December 13, 2011. Also, the personal history did not include a complete family history.
Patient # 7 was admitted October 31, 2011. The personal history was due November 30, 2011; however, patient record # 7 did not include documentation of a personal history as of December 13, 2011.
Patient # 8 was admitted October 25, 2011. The personal history was completed November 4, 2011. However, the personal history did not include a complete family history, legal history, and educational history.
The findings were acknowledged during an ongoing dialogue with the facility director on December 14, 2011 from approximately 10:00 A.M. to 10:20 A.M.
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Plan of Correction
Responsible: The Division Director will be responsible to review and revise the conflicting policies regarding psychosocial histories and psychosocial evaluations. The Division Director will be responsible to develop one written plan for the coordination of client treatment and rehabilitation services. The governing body shall adopt the written plan at the next Board of Directors meeting following the revision of the written policy.
Time Frame: The revised policy for procedures for the management of treatment/rehabilitation services for clients will be presented to the Board subcommittee, Performance Oversight & Finance Committee no later than February 21, 2012 who will submit to the governing body for adoption no later than April 12, 2012.
Monitoring: The program director will monitor the implementation of the revised policy to accurately reflect the facility's process for completing psychosocial histories and psychosocial evaluations.
The Clinical Supervisor will ensure that a personal history is completed for patients # 2,3,4,& 7 no later than 4/12/12.
The Clinical Supervisor will ensure that a personal history is documented on time in accordance with the facility's policy and procedures.
The Clinical Supervisor will be responsible to ensure that a personal history from another licensed drug and alcohol treatment provider is reviewed and signed by facility staff and patient according to the regulations.
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709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of patient records, the facility failed to document a physical examination in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "OTP 715.9, 709.24, 709.91," states:
"Prior to being admitted to the program a client must be able to corroborate a one-year history of narcotic dependency. In addition, the program physician conducts a physical examination of each client, which includes the following:"
On December 13, 2011 eight records requiring documentation of a physical examination were reviewed. The facility did not document a physical examination according to their policy and procedures in one of eight records reviewed, specifically, patient record # 3. The facility also did not document a physical examination in one of eight records reviewed, specifically patient record # 4.
Patient # 3 was admitted November 10, 2011. The physical examination was due prior to being admitted on November 10, 2011. However, the physical examination was not completed until November 15, 2011.
Patient # 4 was admitted November 3, 2011. The physical examination was due prior to being admitted on November 3, 2011. However, patient record # 4 did not include documentation of a physical examination as of December 13, 2011.
The findings were acknowledged during an ongoing dialogue with the facility director on December 14, 2011 from approximately 10:00 A.M. to 10:20 A.M.
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Plan of Correction
Responsible: The Nurse Manager will ensure that physical examinations are scheduled, completed, documented, and file in the patient's file in accordance with the facility's policy and procedures.Effective 2/1/12
The physical eval for patient record #4 is completed and filed in the chart.
Responsible: The clinical supervisor will ensure that all required elements are present in the patient's file during monthly chart audits.2/1/12
Responsible: The therapists will review for the required documents and all required elements during monthly chart audits. 2/1/12
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of patient records, the facility failed to document a psychosocial evaluation or document a psychosocial evaluation in accordance with their policy and procedures. In addition, the facility failed to document a psychosocial evaluation that included an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and/or counselor conclusions/impressions.
The findings include:
The facility's policy titled: "Treatment/Rehabilitation Management" states:
"The Counselor/Primary Clinician completes the Psychosocial History and Psychosocial Evaluation within thirty (30) days following admission."
On December 13, 2011, eight patient records requiring documentation of psychosocial evaluations were reviewed. The facility did not document a psychosocial evaluation in five of eight records reviewed, specifically, client records # 1, 2, 3, 5, and 7. The facility also did not document a psychosocial evaluation according to their policy and procedures in one of eight records reviewed, specifically, record # 4.
In addition, the facility did not document a psychosocial evaluation that included an assessment of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and/or counselor conclusions/impressions in two of eight records reviewed, specifically, records # 4 and 8.
Patient # 1 was admitted November 4, 2011. The psychosocial evaluation was due December 4, 2011; however, patient record # 1 did not include documentation of a psychosocial evaluation as of December 13, 2011.
Patient # 2 was admitted November 11, 2011. The psychosocial evaluation was due December 11, 2011; however, patient record # 2 did not include documentation of a psychosocial evaluation as of December 13, 2011.
Patient # 3 was admitted November 10, 2011. The psychosocial evaluation was due December 10, 2011; however, patient record # 3 did not include documentation of a psychosocial evaluation as of December 13, 2011.
Patient # 4 was admitted November 3, 2011. The psychosocial evaluation was due December 3, 2011; however, the psychosocial evaluation was not completed until December 8, 2011. Also, the psychosocial evaluation did not include an evaluation of the patient's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
Patient # 5 was admitted October 21, 2011. The psychosocial evaluation was due November 20, 2011; however, patient record # 5 did not include documentation of a psychosocial evaluation as of December 13, 2011.
Patient # 7 was admitted October 31, 2011. The psychosocial evaluation was due November 30, 2011; however, patient record # 7 did not include documentation of a psychosocial evaluation as of December 13, 2011.
Patient # 8 was admitted October 25, 2011. The psychosocial evaluation was completed on November 4, 2011, but did not include an evaluation of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, and counselor conclusions/impressions.
The findings were acknowledged during an ongoing dialogue with the facility director on December 14, 2011 from approximately 10:00 A.M. to 10:20 A.M.
This is a repeat citation. The facility was cited on October 15, 2010; June 29, 2010; November 18, 2009; November 7, 2008; and December 19, 2007 for noncompliance with this standard.
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Plan of Correction
Responsible: The Division Director will be responsible to review and revise the conflicting policies regarding psychosocial history and psychosocial evaluations. The Division Director will be responsible to develop one written plan for the coordination of client treatment and rehabilitation services. The governing body shall adopt the written plan at the next Board of Directors meeting following the revision of the written policy.
Time Frame: The revised policy for procedures for the management of treatment/rehabilitation services for clients will be presented to the Board subcommittee, Performance Oversight & Finance Committee no later than February 21, 2012 who will submit to the governing body for adoption no later than April 12, 1012.
Monitoring: The program director will monitor the implementation of the revised policy to accurately reflect the facility's process for completing psychosocial history and psychosocial evaluations.
Responsible: The clinical supervisor will utilize the chart audit tracker to ensure that psychosocial history and evaluations are completed timely according to the policy which states (within 30 days of admission)The clinical supervisors will review status of psychosocial history and evals during one on one supervision with the therapists. 2/1/2012
Responsible: The therapist will utilize the chart audit tracker to ensure that psychosocials history and evaluations are completed timely according to the policy which states (within 30 days of admission)2/1/2012
Responsible: The Program Director will review status of the psychosocials and evals during one on one supervision with the clinical supervisors. 2/1/2012
Responsible: The Clinical Supervisor will ensure that the psychosocial evaluations for patients # 1,2,3,5, & 7 will be completed by 4/12/12.
Responsible: The Clinical Supervisor will ensure that psychosocial evaluations include an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and counselor conclusion/impressions.
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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
Based on a review of patient records, the facility failed to document an individual treatment and rehabilitation plan or document an individual treatment and rehabilitation plan in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Treatment and Rehabilitation Services", states:
"The Master Treatment Plan is developed by staff in close collaboration with the person in recovery within the first 30 days of treatment upon the completion of the Psychosocial History and Psychosocial Evaluation".
On December 13, 2011, eight patient records requiring documentation of individual treatment and rehabilitation plans were reviewed. The facility did not document an individual treatment and rehabilitation plan in four of eight records reviewed, specifically, patient records # 2, 3, 4, and 7. The facility also did not document an individual treatment and rehabilitation plan according to their policy and procedures in one of eight records reviewed, specifically, -patient record # 6.
Patient # 2 was admitted November 11, 2011. The individual treatment and rehabilitation plan was due December 11, 2011; however, patient record # 2 did not include documentation of an individual treatment and rehabilitation plan as of December 13, 2011.
Patient # 3 was admitted November 10, 2011. The individual treatment and rehabilitation plan was due December 10, 2011; however, patient record # 3 did not include documentation of an individual treatment and rehabilitation plan as of December 13, 2011.
Patient # 4 was admitted November 3, 2011. The individual treatment and rehabilitation plan was due December 3, 2011; however, patient record # 4 did not include documentation of an individual treatment and rehabilitation plan as of December 13, 2011.
Patient # 6 was admitted November 1, 2011. The individual treatment and rehabilitation plan was due December 1, 2011; however, the individual treatment and rehabilitation was not completed until December 2, 2011.
Patient # 7 was admitted October 31, 2011. The individual treatment and rehabilitation plan was due November 29, 2011; however, patient record # 7 did not include documentation of an individual treatment and rehabilitation plan as of December 13, 2011.
The findings were acknowledged during an ongoing dialogue with the facility director on December 14, 2011 from approximately 10:00 A.M. to 10:20 A.M.
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Plan of Correction
Responsible: The clinical supervisor will ensure that all Master Plans are completed timely via one on one supervision with the therapists and review of the chart audit tracking tool. 2/1/2012
Responsible: The Clinical Supervisor will ensure that the treatment
and rehabilitation plans will be completed for patients # 2, 3, 4, and 7. 4/12/12
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709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of patient records, the facility failed to document the long-term goals for treatment as formulated by both staff and patient in the individual treatment and rehabilitation plan.
The findings include:
On December 13, 2011, four patient records requiring documentation of short-term and long-term goals for treatment as formulated by both staff and patient in the individual treatment and rehabilitation plan were reviewed. The facility did not document the long-term goals for treatment in four of four records reviewed, specifically, client records # 1, 5, 6, and 8.
Patient # 1 was admitted November 4, 2011. The individual treatment and rehabilitation plan was completed on November 18, 2011, but it did not include documentation of the long-term goals for treatment as of December 13, 2011.
Patient # 5 was admitted October 21, 2011. The individual treatment and rehabilitation plan was completed on November 18, 2011, but it did not include documentation of the long-term goals for treatment as of December 13, 2011.
Patient # 6 was admitted November 1, 2011. The individual treatment and rehabilitation plan was completed on December 2, 2011, but it did not include documentation of the long-term goals for treatment as of December 13, 2011.
Patient # 8 was admitted October 25, 2011. The individual treatment and rehabilitation plan was completed on November 4, 2011, but it did not include documentation of the long-term goals for treatment as of December 13, 2011.
The findings were acknowledged during an ongoing dialogue with the facility director on December 14, 2011 from approximately 10:00 A.M. to 10:20 A.M.
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Plan of Correction
Responsible:The clinical supervisor will ensure that therapists complete and submit all treatment plans timely and containing all required elements accoding to regulartory and agency policy. 2/1/2012 |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and/or frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan.
The findings include:
On December 13, 2011, four patient records requiring documentation of the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the type and/or frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan in three of four records reviewed, specifically, patient records # 1, 5, and 6
Patient # 1 was admitted November 4, 2011. The individual treatment and rehabilitation plan was completed on November 18, 2011, but did not include documentation of the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan as of December 13, 2011.
Patient # 5 was admitted October 21, 2011. The individual treatment and rehabilitation plan was completed on November 18, 2011, but did not include documentation of the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan as of December 13, 2011.
Patient # 6 was admitted November 1, 2011. The individual treatment and rehabilitation plan was completed on December 2, 2011, but did not include documentation of the frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan for group sessions as of December 13, 2011.
The findings were acknowledged during an ongoing dialogue with the facility director on December 14, 2011 from approximately 10:00 A.M. to 10:20 A.M.
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Plan of Correction
Responsible: The clinical supervisor will ensure that all treatment plans submitted contain all the required elements and that therapist complete and submit them timely. 2/1/2012 |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of patient records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan.
The findings include:
On December 13, 2011, four patient records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in one of four records reviewed, specifically, patient record # 8.
Patient # 8 was admitted October 25, 2011. The individual treatment and rehabilitation plan was completed on November 4, 2011, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 13, 2011.
The findings were acknowledged during an ongoing dialogue with the facility director on December 14, 2011 from approximately 10:00 A.M. to 10:20 A.M.
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Plan of Correction
Responsible: The clinical supervisor will ensure that the therapist complets all required elements of the treatment plan. 2/1/12
Responsible: The Clinical Supervisor will ensure that counselors document the proposed type of support services in the individual treatment and rehabilitation plan for all patients. 2/1/12
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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 patient records, the facility failed to document a treatment and rehabilitation plan update in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Treatment and Rehabilitation Services", states:
"The Master Treatment Plan is developed by staff in close collaboration with the person in recovery within the first 30 days of treatment upon the completion of the Psychosocial History and Psychosocial Evaluation. Every 60 days (OP) and 30 days (IOP), Treatment Plans are reviewed and updated to track progress and identify goals that need to be dropped, amended or added since the last Treatment Plan."
On December 13, 2011, one patient record requiring documentation of a treatment and rehabilitation plans was reviewed. The facility did not document a treatment and rehabilitation plan update according to their policy and procedures in one of one record reviewed, specifically, patient record # 8.
Patient # 8 was admitted October 25, 2011. The individual treatment and rehabilitation plan was completed on November 4, 2011 and the treatment plan update was completed on December 1, 2011. However, the treatment plan update did not included documentation of the patient's progress relative to the treatment goals and objectives.
The findings were acknowledged during an ongoing dialogue with the facility director on December 14, 2011 from approximately 10:00 A.M. to 10:20 A.M.
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Plan of Correction
Responsible: The clinical supervisor will ensure that therapists complete and submit all treatment plan updates timely. This will be monitored during suoervision.3/1/12
Responsible: The clinical supervisor will ensure that the treatment plan updates are documented in accordance with the facility's policy and procedures.3/1/12
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of patient records, the facility failed to document follow-up information and/or in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Aftercare and Follow-Up Policy", states:
"A follow-up letter will be prepared at time of case closing and readied for mailing thirty days from the date of formal termination ... Included with the letter will be a Follow-Up questionnaire, which the client will be asked to complete and return to the program. This return questionnaire and any additional contacts will be filed/noted in the clinical records."
On December 13, 2011, four patient records requiring documentation of follow-up information were reviewed. The facility did not document follow-up information according to their policy and procedures in one of four records reviewed, specifically patient record # 9. The facility also failed to document follow-up information in three of four records reviewed, specifically, patient records # 10, 11, and 12.
Patient # 9 was admitted June 28, 2011 and was discharged September 9, 2011. The follow-up information was due October 9, 2011; however, the follow-up information was not completed until October 10, 2011.
Patient # 10 was admitted July 25, 2011 and was discharged September 9, 2011. The follow-up information was due October 9, 2011. However, patient record # 10 did not include documentation of follow-up information as of December 13, 2011.
Patient # 11 was admitted December 20, 2004 and was discharged September 20, 2011. The follow-up information was due October 20, 2011. However, patient record # 11 did not include documentation of follow-up information as of December 13, 2011.
Patient # 12 was admitted December 16, 2010 and was discharged September 8, 2011. The follow-up information was due October 8, 2011. However, patient record # 12 did not include documentation of follow-up information as of December 13, 2011.
The findings were acknowledged during an ongoing dialogue with the facility director on December 14, 2011 from approximately 10:00 A.M. to 10:20 A.M.
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Plan of Correction
Responsible: The clinical supervisor will, prior to signing off on the discharge packet, ensure that all follow - up is completed and documented according to the agency policy and regulartory requirements. 2/1/2012
Responsible: The Clinical Supervisor will ensure that follow up information is completed for patients # 10, 11 & 12 by 3/1/12. |