INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the December 14, 2011 licensure renewal inspection. The follow-up inspection was conducted on June 5, 2012 to June 6, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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704.9(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 a review of the facility's administrative material and a personnel record, the facility failed to document weekly supervision notes of a clinical supervisor providing direct observation with the counselor assistant.
Also, based on a review of the facility ' s administrative material and a personnel record, the facility failed to provide documentation of supervision notes demonstrating that at least one hour per week of direct observation is being conducted for the counselor assistant under close supervision.
The findings include:
On June 5, 2012 through June 6, 2012, the facility's administrative material and a personnel record requiring documentation of weekly supervision notes of a clinical supervisor giving direct observation to the counselor assistant were reviewed. The facility did not provide documentation of weekly supervision notes of a clinical supervisor providing direct observation with the counselor assistant in one of one personnel record reviewed, specifically, personnel record # 9. Also, on June 5, 2012 through June 6, 2012, the facility did not provide documentation of supervision notes demonstrating that at least one hour per week of direct observation is being conducted for the counselor assistant under close supervision.
Employee # 9 is a counselor assistant, was initially hired June 1, 2010 and was hired for her current position on December 13, 2011. Employee # 9 has a non-qualifying associate ' s degree. The facility was required to provide documentation of weekly supervision notes of a clinical supervisor providing direct observation with employee # 9. However, the facility's administrative material and personnel record # 9 only included documentation of supervision notes of a clinical supervisor providing direct observation with employee # 9 on the following dates: January 20, 2012; February 3, 2012; February 17, 2012; April 20, 2012; May 18, 2012; and June 1, 2012. Also, all of the supervision notes did not include documentation demonstrating that at least one hour per week of direct observation is being conducted for employee # 9 under close supervision.
The findings were confirmed during an interview with the assistant program director on June 6, 2012 at approximately 12:00 P.M.
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Plan of Correction
Plan of Correction:
The Clinical Supervisor of employee #9 was made aware, as of June 6th 2012, that she must provide weekly documented direct observation/supervision of employee #9.
As of June 15, supervision notes of employee #9 are also being submitted electronically to the Program Director as evidence of weekly supervision/observation of employee #9.
Responsible Party:
The Clinical Supervisor is responsible for ensuring that documentation of weekly supervision/observation is conducted with employee #9 and all other Counselor Assistants who do not meet educational/experiential state requirements, who are employed by the Consortium.
Monitoring:
The Clinical Supervisor will document weekly supervision/observation of counselor assistant on a supervision note. This will include documentation that one hour per week of direct observation is being conducted with the counselor assistant under close supervision.
Supervision notes of Counselor Assistants will be maintained in a manual in the Clinical Supervisor's office.
The Clinical Supervisor will send all supervision notes documenting weekly supervision of the Counselor Assistant to the Program Director by the end of each week.
The Program Director, will also review weekly supervision/observation notes submitted with the Clinical Supervisor during bi weekly supervision, to ensure completion.
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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 June 5, 2012 and June 6, 2012, eight personnel records requiring documentation of an individual training plan were reviewed. The facility failed to document an individual training plan for the 2011-2012 training year for existing employees in three of six personnel records reviewed, specifically, personnel records # 1, 7, and 9. The facility also failed to document an individual training plan for each new employee in two of two records reviewed for newly hired employees, specifically, personnel records # 3 and 4.
Employee # 1 is the project director and was hired December 3, 2001. An individual training plan was due the beginning of the facility's current training year by July 2011 or August 2011. However, as of June 6, 2012, the most recent individual training plan in personnel record # 1 was completed on January 8, 2010.
Employee # 3 is a counselor and was hired February 13, 2012. An initial individual training plan was due March 14, 2012. However, personnel record # 3 did not include documentation of an individual training plan as of June 6, 2012.
Employee # 4 is a counselor and was hired April 9, 2012. An initial individual training plan was due May 9, 2012. However, personnel record # 4 did not include documentation of an individual training plan as of June 6, 2012.
Employee # 7 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 June 6, 2012, the most recent individual training plan in personnel record # 7 was completed on June 14, 2010.
Employee # 9 is a counselor assistant and was initially hired July 1, 2010 and was hired for her current position on December 13, 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 June 6, 2012, the most recent individual training plan in personnel record # 9 was completed on July 6, 2010.
The findings were confirmed during an interview with the assistant program director on June 6, 2012 at approximately 12:00 P.M.
This is a repeat citation. The facility was cited on December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
The training year for the Consortium now begins each January through December.
Plan of Correction: Existing Employees #1, #7 and #9 will have training plans completed by 7/21/12, by the respective Supervisor. Additionally new employees #3 and #4 will have an individual training plan completed by 7/21/12.
Responsible Party:
Supervisors are responsible for ensuring that all new hires have an individual training plan completed within the first week of hire.
Supervisors are also responsible for ensuring that all existing employees have an individual training plan completed within one week of the start of the training year, beginning each January.
Monitoring:
The Supervisor will submit a copy of each of their respective employees individual training plan by the end of the first week of each January to the Program Director.
The Supervisor will also submit a copy of each new hires individual training plan by the end of the new hire's first week of employment.
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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.
This was still out of compliance at the time of the follow-up conducted on June 5, 2012 through June 6, 2012.
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Plan of Correction
Plan of Correction: The Project Director will submit all documentation of completed trainings to the HR dept. within one week of each completed training.
Any documentation of additional completed training hours for the 2010-2011 training year will be submitted to the HR Director by 8/6/12.
Responsible Party: The HR Director is responsible for ensuring that the Project Director recieves 12 clock hours of training per training year.
The HR Director will schedule at least one training per month for the Facility Director to ensure that the 12 hours are met each year.
The HR direcotr will also ensure that the a training evaluation and certificate documenting the completed trainings are placed in the Facility Director's personnel record.
Monitoring: On a monthly basis, the HR Director will review the status of annual training hour documentation in the personnel records, to ensure annual hours are being accumulated on a monthly basis.
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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.
This was still out of compliance at the time of the follow-up conducted on June 5, 2012 through June 6, 2012.
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Plan of Correction
Plan of Correction: All employees, including # 8 and #10 will submit all documentation of completed trainings to the HR dept. within one week of each completed training.
Any documentation of additional completed training hours for the 2010-2011 training year for employees #8 and #10 will be submitted to the HR Director by 8/6/12.
Responsible Party: The HR Director is responsible for ensuring that Consortium employees submit verification of training hours to meet state requirements in relation to annual training hours.
Monitoring: On a monthly basis, the HR Director will review the status of annual training hour documentation in the personnel records, to ensure annual hours are being accumulated on a monthly basis.
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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 June 5, 2012 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 June 5, 2012. The following items were identified:
1) At approximately 9:52 A.M., the main hallways on the second floor were observed to have areas of cracking floor tiles and areas on the floor that were stained.
2) At approximately 9:53 A.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 9:54 A.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 9:59 A.M.., the waiting area in section # 238 outside of offices 238 - 239 had areas of cracking and stained floor tiles.
The findings were confirmed during an interview with the security supervisor on June 5, 2012 at approximately 10:00 A.M.
This is a repeat citation. The facility was cited on December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
Plan of Correction:
1) The main hallways on the second floor, which were observed to have areas of cracking floor tiles and areas on the floor that were stained will be reported to the Maintenance and Facilities Department by 7/13/12.
Repairs to the reported areas will be completed by 8/6/12.
2) The carpet in the waiting area in section # 204 outside of medical offices # 202 -207, which was observed to have areas that were stained, will be reported to the Maintenance and Facilities Department by 7/13/12.
Repairs to the reported areas will be completed by 8/6/12.
3) The carpet in the waiting area in section # 240 outside of offices # 240 -244, which was observed to have areas that were stained will be reported to the Maintenance and Facilities Department by 7/13/12.
Repairs to the reported areas will be completed by 8/6/12.
4) The waiting area in section # 238 outside of offices 238 - 239, which was reported to have areas of cracking and stained floor tiles, will be reported to the Maintenance and Facilities Department by 7/13/12.
Repairs to the reported areas will be completed by 8/6/12.
Responsible Party:
The Program Director will make all reports to the Maintenance and Facilities Department for repairs by 7/13/12.
The Maintenance and Facilities Department is responsible for the completion of repairs by 8/6/12.
Monitoring: The Program Director will conduct a monthly walk through of the program grounds to ensure all areas are in compliance.
All findings will be reported to the Maintenance and Facilities Department within 72 hours.
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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 June 5, 2012 the facility failed to maintain counseling areas with furnishings which are in good repair.
The findings include:
A physical plant inspection was conducted on June 5, 2012. The following items were identified:
1) At approximately 10:01 A.M., floor tiles in individual/group counseling room # 236 were observed to have areas of stained floor tiles.
2) At approximately 10:02 A.M., floor tiles in individual/group counseling room # 235 were observed to have areas of stained floor tiles.
3) At approximately 10:04 A.M.., the carpet in group counseling room # 202 was observed to have areas that were stained.
4) At approximately 10:05 A.M., the carpet in group counseling room #249 was observed to have areas that were stained and torn.
5) At approximately 10:15 A.M., the carpet in group counseling room # 243 was observed to have areas that were stained. It was also observed at the same time in group counseling room # 243 that there were areas of the vinyl cove base that were detached from the walls.
6) At approximately 10:16 A.M., the carpet in group counseling room # 242 was observed to have areas that were stained. It was also observed at the same time in group counseling room # 242 that there were areas of the vinyl cove base that were detached from the walls.
7) At approximately 10:16 A.M., the carpet in group counseling room # 121 was observed to have areas that were stained.
8) At approximately 10:18 A.M., the carpet in individual counseling room # 114 was observed to have areas that were stained and torn.
The findings were confirmed during an interview with the security supervisor on June 5, 2012 at approximately 10:20 A.M.
This is a repeat citation. The facility was cited on December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
Plan of Correction:
1) The floor tiles in individual/group counseling room # 236, which were observed to have areas of stained floor tiles will be reported to the Maintenance and Facilities Department by 7/13/12.
Repairs to the reported areas will be completed by 8/6/12.
2) The floor tiles in individual/group counseling room # 235, which were observed to have areas of stained floor tiles will be reported to the Maintenance and Facilities Department by 7/13/12.
Repairs to the reported areas will be completed by 8/6/12.
3) The carpet in group counseling room # 202, which was observed to have areas that were stained will be reported to the Maintenance and Facilities Department by 7/13/12.
Repairs to the reported areas will be completed by 8/6/12.
4) The carpet in group counseling room #249, which was observed to have areas that were stained and torn will be reported to the Maintenance and Facilities Department by 7/13/12.
Repairs to the reported areas will be completed by 8/6/12.
5) The carpet in group counseling room # 243, which was observed to have areas that were stained and the group counseling room # 243 that was also observed to have areas of the vinyl cove base that were detached from the walls will be reported to the Maintenance and Facilities Department by 7/13/12.
Repairs to the reported areas will be completed by 8/6/12.
6) The carpet in group counseling room # 242, which was observed to have areas that were stained and the areas of the vinyl cover base that were detached from the walls will be reported to the Maintenance and Facilities Department by 7/13/12.
Repairs to the reported areas will be completed by 8/6/12.
7) The carpet in group counseling room # 121, which was observed to have areas that were stained will be reported to the Maintenance and Facilities Department by 7/13/12.
Repairs to the reported areas will be completed by 8/6/12.
8) The carpet in individual counseling room # 114, which was observed to have areas that were stained and torn will be reported to the Maintenance and Facilities Department by 7/13/12.
Repairs to the reported areas will be completed by 8/6/12.
Responsible Party:
The Program Director will make all reports to the Maintenance and Facilities Department for repairs by 7/13/12.
The Maintenance and Facilities Department is responsible for the completion of repairs by 8/6/12.
Monitoring: The Program Director will conduct a monthly walk through of the program grounds to ensure all areas are in compliance.
All findings will be reported to the Maintenance and Facilities Department within 72 hours.
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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 June 5, 2012 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 June 5, 2012. The following items were identified:
1) At approximately 10:26 A.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 during an interview with the security supervisor on June 5, 2012 at approximately 10:27 A.M.
This is a repeat citation. The facility was cited on December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
Plan of Correction: The women's public restroom located in the main hallway on the second floor, which was observed to have areas of stained floor tiles in the upper left section of the restroom will be reported to the Maintenance and Facilities Department by 7/13/12.
Repairs to the reported areas will be completed by 8/6/12.
Responsible Party:
The Program Director will make all reports to the Maintenance and Facilities Department for repairs by 7/13/12.
The Maintenance and Facilities Department is responsible for the completion of repairs by 8/6/12.
Monitoring: The Program Director will conduct a monthly walk through of the program grounds to ensure all areas are in compliance.
All findings will be reported to the Maintenance and Facilities Department within 72 hours.
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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 instruct staff in the use of the fire extinguisher upon staff employment.
The findings include:
On June 5, 2012 through June 6, 2012, a total of two personnel records requiring documentation of fire extinguisher training were reviewed. The facility failed to ensure that they instructed staff in the use of fire extinguisher upon staff employment in two of two records reviewed, specifically, personnel records # 3 and 4.
Employee # 3, a counselor, was hired on February 13, 2012. Employee # 3 was due to complete fire extinguisher training upon employment. However, employee # 3 did not complete fire extinguisher training until March 22, 2012.
Employee # 4, a counselor, was hired on April 9, 2012. Employee # 4 was due to complete fire extinguisher training upon employment. However, employee # 4 did not complete fire extinguisher training until April 26, 2012.
The findings were confirmed during an interview with the assistant program director on June 6, 2012 at approximately 12:00 P.M.
This is a repeat citation. The facility was cited on December 14, 2011; August 29, 2011; and October 15, 2010 for noncompliance with this standard.
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Plan of Correction
Plan of Correction: Employees #3 and #4 will have documentation of fire extinguisher training in their personnel records by July 20, 2012.
Responsible Party: The Training and Licensing Director in conjunction with the Human Resource Director are responsible for ensuring that new hires are instructed in the use of the fire extinguisher upon staff employment and documentation of the training is filed in personnel records.
Monitoring: The Human Resource Director will monitor personnel records on a monthly basis to ensure that the documentation of instruction on the use of the fire extinguisher, and filing of the sign-off sheet for receiving fire extinguisher training is in the personnel record.
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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 are trained to perform assigned tasks during emergencies.
The findings include:
On June 5, 2012 through June 6, 2012, two personnel records requiring documentation that all personnel on all shifts had been trained to perform assigned tasks during emergencies were reviewed. The facility did not ensure that all personnel on all shifts completed emergency training upon employment at the facility in two of two personnel records reviewed, specifically, personnel records # 3 and 4.
Employee # 3, a counselor currently working at the facility, was hired on February 13, 2012. Employee # 3 was due to complete emergency training prior to working any shifts at the facility. However, employee # 3 did not complete emergency training until February 28, 2012.
Employee # 4, a counselor currently working at the facility, was hired on April 9, 2012. Employee # 4 was due to complete emergency training prior to working any shifts at the facility. However, employee # 4 did not complete emergency training until April 26, 2012.
The findings were confirmed during an interview with the assistant program director on June 6, 2012 at approximately 12:00 P.M.
This is a repeat citation. The facility was cited on December 14, 2011; August 29, 2011; and October 15, 2010 for noncompliance with this standard.
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Plan of Correction
Plan of Correction: All new hires will receive Disaster Training to be completed within 7 days of hire to ensure staff is trained to perform assigned tasks during emergencies.
Employees #3 and #4 will receive training by July 20, 2012.
Responsible Party: The Training and Licensing Director in conjunction with Human Resource Director will be responsible to ensure staff on all shifts is trained to perform assigned tasks during emergencies.
The Training and Licensing Director will provide Disaster training to all new hires to be completed within 7 days of hire.
Monitoring: The Human Resource Director will monitor personnel records of new hires for the documentation of staff on all shifts being trained to perform assigned tasks during emergencies.
The Training and Licensing Director in conjunction with Human Resource Director will ensure the that existing employees that do not have the emergency training will be trained by June 30, 2012.
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on an interview with the facility director, the facility failed to make available to the public an annual report.
The findings include:
On June 5, 2012 and June 6, 2012, the Licensing Specialist asked to see the facility ' s annual report for the facility ' s July 2010 through June 2011 fiscal year. The facility ' s annual report for the facility ' s July 2010 through June 2011 fiscal year was not presented for review.
The findings were confirmed during an interview with the facility director on June 6, 2012 at approximately 10:30 A.M.
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Plan of Correction
Plan of Correction: The stand alone document of an annual report will be made available to the public no later than December 31 of each year.
The July 2010- June 2011fiscal year annual report will be completed by the Project Director and the Board Liasion by August 5, 2012.
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.
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 is made available to the public. |
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 an interview with the facility director, 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:
On June 5, 2012 and June 6, 2012, the Licensing Specialist asked to see the facility's annual report that included a statement disclosing the names of officers, directors and principal shareholders, where applicable for the facility's July 2010 through June 2011 fiscal year. The facility's annual report that included a statement disclosing the names of officers, directors and principal shareholders, where applicable for the facility's July 2010 through June 2011 fiscal year was not presented for review.
The findings were confirmed during an interview with the facility director on June 6, 2012 at approximately 10:30 A.M.
This is a repeat citation. The facility was cited on December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
Plan of Correction: The stand alone document of an annual report will be made available no later than December 31 of each year.
The annual report including a statement disclosing the names of officers, directors and principal shareholders, will be completed by the Project Director and the Board Liasion for the July 2010 to June 2011 fiscal year no later than August 5, 2012.
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.
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 June 5, 2012, 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 interview with the facility director on June 6, 2012 at approximately 10:30 A.M.
This is a repeat citation. The facility was cited on December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
Plan of Correction: The Program Director will develop a written plan for the coordination of client treatment and rehabilitation services that accurately reflects the program's process for completing psychosocial histories and psychosocial evaluations by 7/19/12.
The plan will be submitted by the Project Director to the board for approval by 8/6/12.
The Project Director will ensure approval by the board by 8/6/12.
Staff will be trained on updated policy within two weeks of approval date.
Responsible Party: The Program Director.
Monitoring: The Project Director will ensure that the written plan is placed in the policy and procedures manual and in effect at the facility.
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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 June 5, 2012 and June 6, 2012, six records were reviewed for informed and voluntary consent. The facility released information without the patients' consent in five of six records reviewed, specifically, patient records # 1, 2, 4, 5, and 6.
Patient record # 1 contained two Eligibility Verification System forms dated April 26, 2012 and one Eligibility Verification System form dated March 19, 2012 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 two Eligibility Verification System forms dated April 24, 2012 in which the facility released information about the patient to a government agency, but the facility did not have a signed consent from the client to release the information until April 25, 2012.
Patient record # 4 contained one Eligibility Verification System form dated April 12, 2012 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 # 5 contained two Eligibility Verification System forms dated April 11, 2012 and one Eligibility Verification System form dated March 5, 2012 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 # 6 contained one Eligibility Verification System form dated April 5, 2012 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.
The findings were confirmed during an interview with the assistant program director on June 6, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on December 14, 2011; October 15, 2010; June 29, 2010; November 18, 2009; November 7, 2008 for noncompliance with this standard.
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Plan of Correction
Plan of Correction: Records #1, 2, 4, 5, and 6 will be updated to include a written consent for the Eligibility Verification System by 7/20/12.
As of 6/15/12, for all patients, the program will obtain a voluntary consent for disclosure of information, specifically to administer Eligibility Verification System checks.
Responsible Party: Intake/Admission Personnel are responsible for ensuring that all voluntary consents are completed prior to providing services, including EVS checks.
Monitoring:
The Intake Supervisor will review all new admission records to ensure that voluntary consents are obtained prior to entering into a treatment service agreement.
Ongoingly, the Counselor of Record is responsible for ensuring that all patients have updated and complete voluntary consents for disclosure of information.
The Clinical Supervisors are responsible for ensuring review of all voluntary consents from each patient for the dislosure of information that are submitted by their respective counselors. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of patient records and an interview with the assistant program director, the facility failed to document a drug or history 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 June 6, 2012, due to conflicting policies relating to the completion of psychosocial histories and the psychosocial evaluation the assistant program director was interviewed to determine which policy the facility was following. The assistant program 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 June 5, 2012 and June 6, 2012, six patient records requiring documentation of a drug or alcohol history were reviewed. The facility did not have documentation of a signature and date from the facility staff indicating a drug or alcohol history from a licensed drug and alcohol treatment provider or the Single County Authority was reviewed by both facility staff and patient in one of six records reviewed, specifically, patient record # 1. The facility also did not document a drug or alcohol history in four of six records reviewed, specifically, patient records # 2, 3, 4, and 6.
Patient # 1 was admitted April 26, 2012. The drug or alcohol history was dated February 18, 2012. However, the drug or alcohol history did not include documentation of a signature from the facility staff indicating the drug or alcohol history was reviewed by both facility staff and patient as of June 6, 2012.
Patient # 2 was admitted April 25, 2012. The drug or alcohol history was due May 25, 2012; however, patient record # 2 did not include documentation of a drug or alcohol history as of June 6, 2012.
Patient # 3 was admitted April 27, 2012. The drug or alcohol history was due May 27; however, patient record # 3 did not include documentation of a drug or alcohol history as of June 6, 2012.
Patient # 4 was admitted April 12, 2012. The drug or alcohol history was due May 12, 2012; however, patient record # 4 did not include documentation of a drug or alcohol history as of June 6, 2012.
Patient # 6 was admitted April 4, 2012. The drug or alcohol history was due May 4, 2012; however, patient record # 6 did not include documentation of a drug or alcohol history as of June 6, 2012.
The findings were confirmed during an interview with the assistant program director on June 6, 2012 at approximately 3:00 P.M.
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Plan of Correction
Plan of Correction: Records 2, 3, 4 and 6 will have a completed drug and alcohol history completed by 7/31/12.
Record #1 will have appropriate signatures from the patient and counselor of record by 7/13/12
The policy for completion of psycho social histories and evaluations will be updated by the Project Director by 7/19/12.
The Project Director will submit the updated policy to the Board by 7/20/12.
The Project Director will ensure that the Board approves the updated policy by 7/31/12.
Staff will be trained in updated policy within 2 weeks of approval date.
Staff will be trained by the Clinical Supervisors in signing off on a review of external drug and alcohol histories by 7/31/12 for both the patient and the staff person.
Responsible Party: Program Director/Intake Staff/Counselor/Clinical Supervisor
Monitoring: The Intake Supervisor will review all new admission records to ensure that drug and alcohol histories are completed upon admission.
The Clinical Supervisors will review all completed drug and alcohol histories to ensure that the client and the staff person have signed off on the document to verify review of the drug and alcohol hisotry.
The Clinical Supervisors will complete random monthly audits of patient records to ensure that drug and alcohol histories are completed, and or signed off on by the patient and staff person, if applicable.
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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 assistant program director, the facility failed to document a personal history and/or review and sign off on a psychosocial history completed within six months prior to admission by the SCA or other D&A treatment facility .
The findings include:
On June 5, 2012, due to conflicting policies relating to the completion of psychosocial histories and the psychosocial evaluation the assistant program director was interviewed to determine which policy the facility was following. The assistant program 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 June 5, 2012 and June 6, 2012, six patient records requiring documentation of a personal history were reviewed. 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 one of six records reviewed, specifically, patient record # 1. The facility also did not document a personal history in four of six records reviewed, specifically, patient records # 2, 3, 4, and 6.
Patient # 1 was admitted April 26, 2012. The personal history was dated February 18, 2012. 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 June 6, 2012.
Patient # 2 was admitted April 25, 2012. The personal history was due May 25, 2012; however, patient record # 2 did not include documentation of a personal history as of June 6, 2012.
Patient # 3 was admitted April 27, 2012. The personal history was due May 27; however, patient record # 3 did not include documentation of a personal history as of June 6, 2012.
Patient # 4 was admitted April 12, 2012. The personal history was due May 12, 2012; however, patient record # 4 did not include documentation of a personal history as of June 6, 2012.
Patient # 6 was admitted April 4, 2012. The personal history was due May 4, 2012; however, patient record # 6 did not include documentation of a personal history as of June 6, 2012.
The findings were confirmed during an interview with the assistant program director on June 6, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
Plan of Correction: Records 2, 3, 4 and 6 will have a complete personal history completed by 7/31/12.
Record #1 will be reviewed and signed off on by patient and staff person completing the review by 7/13/12
The policy for completion of Psycho Social Histories and Evaluations, including, personal histories will be updated by the Project Director by 7/19/12.
The Project Director will submit the udpated policy to the Board by 7/20/12, as well as ensure approval by 7/31/12.
Staff will be trained in updated policy within 2 weeks of approval date.
Staff will be trained in signing off on a review of external personal histories by 7/31/12.
Responsible Party: Program Director/Intake Staff/Counselor/Clinical Supervisor.
Monitoring: The Intake Supervisor will review all new admission records to ensure that personal histories are completed upon admission.
The Clinical Supervisor will ensure that all personal histories recieved from an external licensed provider are reviewed and signed off on by the appropriate counselor of record.
The Clinical Supervisors will also complete random monthly audits of patient records to ensure compliance with this standard.
The Project Director will ensure that the updated policy and procedure remains in effect.
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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 and/or document a physical examination.
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 June 5, 2012 through June 6, 2012, six records requiring documentation of a physical examination were reviewed. The facility did not document a physical examination according to their policy and procedures in two of six records reviewed, specifically, patient records # 2 and 5. The facility also did not document a physical examination in one of six records reviewed, specifically patient record # 4.
Patient # 2 was admitted April 25, 2012. The physical examination was due prior to being admitted on April 25, 2012. However, the physical examination was not completed until May 1, 2012.
Patient # 4 was admitted April 12, 2012. The physical examination was due prior to being admitted on April 12, 2012. However, patient record # 4 did not include documentation of a physical examination as of June 6, 2012.
Patient # 5 was admitted April 9, 2012. The physical examination was due prior to being admitted on April 9, 2012. However, the physical examination was not completed until April 13, 2012.
The findings were confirmed during an interview with the assistant program director on June 6, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
Plan of Correction: The policy for completion of the physical examination will be updated by 7/19/12 by the Project Director.
The Project Director will submit updated policy to the Board by 7/20/12, and ensure approval of the Board by 7/31/12.
Records 2, 4, 5 and 6 will be reviewed for a physical examination by 7/20/12. If still in need, a physical will be completed by 7/31/12.
All staff will be trained in updated policy within 2 weeks of approval date.
Responsible Party: Narcotic Treatment Physicians, Program Director, Nursing Staff.
Monitoring: Intake and admission Supervisor will review all new admission records to ensure that a physical examination is completed in accordance to approved program policy.
The Project Director will ensure that the updated policy remains in effect and that the program remains in compliance with this standard.
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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 patient's assets/strengths, support systems, coping mechanisms, attitude toward treatment, and 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 June 5, 2012 and June 6, 2012, six patient records requiring documentation of psychosocial evaluations were reviewed. The facility did not document a psychosocial evaluation in four of six records reviewed, specifically, patient records # 1, 2, 3, and 4. The facility also did not document a psychosocial evaluation according to their policy procedures in one of six records reviewed, specifically, patient record # 6. In addition, the facility did not document a psychosocial evaluation that included an assessment of the patient's assets/strengths, support systems, coping mechanisms, attitude toward treatment, and counselor conclusions/impressions in one of six records reviewed, specifically, patient record # 6.
Patient # 1 was admitted April 26, 2012. The psychosocial evaluation was due May 26, 2012; however, patient record # 1 did not include documentation of a psychosocial evaluation as of June 6, 2012.
Patient # 2 was admitted April 25, 2012. The psychosocial evaluation was due May 25, 2012; however, patient record # 2 did not include documentation of a psychosocial evaluation as of June 6, 2012.
Patient # 3 was admitted April 27, 2012. The psychosocial evaluation was due May 27, 2012; however, patient record # 3 did not include documentation of a psychosocial evaluation as of June 6, 2012.
Patient # 4 was admitted April 12, 2012. The psychosocial evaluation was due May 12, 2012; however, patient record # 4 did not include documentation of a psychosocial evaluation as of June 6, 2012.
Patient # 6 was admitted April 4, 2012. The psychosocial evaluation was due May 4, 2012; however, the psychosocial evaluation was not completed until May 10, 2012. Also, the psychosocial evaluation did not include an evaluation of the patient's assets/strengths, support systems, coping mechanisms, attitude toward treatment, and counselor conclusions/impressions.
The findings were confirmed during an interview with the assistant program director on June 6, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on December 14, 2011; October 15, 2010; June 29, 2010; November 18, 2009; November 7, 2008 for noncompliance with this standard.
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Plan of Correction
Plan of Correction: Records 1,2,3,4 and 6 will have a completed Psycho Social History and Evaluation completed by 7/31/12, which includes an assessment of the patient's assets/strengths, support systems, coping mechanisms, attitude toward treatment, and counselor conclusions/impressions.
Responsible Party: The Counselor of Record is responsible for completing and/or reviewing (and signing off of the external bio) within 30 days of the admission date of each client.
The Clinical Supervisor is responsible for the review of all submitted bio psycho social evaluations to ensure completeness, and submission within 30 days of the client's admission date.
Monitoring: The Clinical Supervisor will review all new admission records to ensure that bio psycho social evaluations are completed fully and on time. This will be reviewed in bi-weekly supervision.
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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 June 5, 2012 and June 6, 2012, six patient records requiring documentation of individual treatment and rehabilitation plans were reviewed. The facility did not document an individual treatment and rehabilitation plan according to their policy and procedures in five of six records reviewed, specifically, patient records # 1, 2, 4, 5, and 6. The facility also did not document an individual treatment and rehabilitation plan in one of six records reviewed, specifically, patient record # 3.
Patient # 1 was admitted April 26, 2012. The individual treatment and rehabilitation plan was due with the first 30 days of treatment upon the completion of the Psychosocial History and Psychosocial Evaluation. The drug or alcohol history and personal history of the psychosocial history was completed February 18, 2012 and patient record # 2 did not include documentation of a psychosocial evaluation. However, the individual treatment and rehabilitation plan was completed April 26, 2012, prior to the completion of the psychosocial evaluation.
Patient # 2 was admitted April 25, 2012. The individual treatment and rehabilitation plan was due with the first 30 days of treatment by May 25, 2012 upon the completion of the Psychosocial History and Psychosocial Evaluation. Patient record # 2 did not include documentation of a drug or alcohol history and personal history of the psychosocial history as well as did not include documentation of a psychosocial evaluation. However, the individual treatment and rehabilitation plan was not completed until May 30, 2012. Also, the individual treatment and rehabilitation plan was completed prior to the completion of the drug or alcohol history, personal history, and psychosocial evaluation.
Patient # 3 was admitted April 27, 2012. The individual treatment and rehabilitation plan was due May 27, 2012; however, patient record # 3 did not include documentation of an individual treatment and rehabilitation plan as of June 6, 2012.
Patient # 4 was admitted April 12, 2012. The individual treatment and rehabilitation plan was due with the first 30 days of treatment upon the completion of the Psychosocial History and Psychosocial Evaluation. Patient record # 4 did not include documentation of a drug or alcohol history and personal history of the psychosocial history as well as did not include documentation of a psychosocial evaluation. However, the individual treatment and rehabilitation plan was completed April 26, 2012, prior to the completion of the drug or alcohol history, personal history, and psychosocial evaluation.
Patient # 5 was admitted April 9, 2012. The individual treatment and rehabilitation plan was due by May 9, 2012. However, the individual treatment and rehabilitation plan was not completed until May 18, 2012.
Patient # 6 was admitted April 4, 2012. The individual treatment and rehabilitation plan was due with the first 30 days of treatment by May 4, 2012 upon the completion of the Psychosocial History and Psychosocial Evaluation. Patient record # 6 did not include documentation of a drug or alcohol history and personal history of the psychosocial history. However, the individual treatment and rehabilitation plan was not completed until May 10, 2012. Also, the individual treatment and rehabilitation plan was completed prior to the completion of the drug or alcohol history and personal history of the psychosocial history.
The findings were confirmed during an interview with the assistant program director on June 6, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
Plan of Correction: Patient records 1,2,3,4,5, and 6 will be reviewed for updated treatment and Master plans.
All outstanding treatment plans will be submitted by 7/31/12.
Staff will be trained by 7/31/12 on the timeframes for the completion of Master and updated treatment plans.
Responsible Party: The Counselor of record is responsible for completing all Master and updated treatment plans within 30 days of admission for Master Plans, and every 60 days for all updated plans
The Clinical Supervisor is responsible for reviewing status of completed treatment plans by the counselor.
Monitoring: The Clinical Supervisor will review status of treatment plan submission bi weekly in the supervision process.
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