INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 10 through 12, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on November 20, 2006.
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Plan of Correction
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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
The policy for recruitment and hiring does not address hiring staff appropriate to the population to be served or state that efforts will be made to hire staff persons representative of that population.
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Plan of Correction
This particular deficiency is being reviewed by this Executive Director, Division Vice President, Division H.R. Director and Quality Improvement committee. Our current BGB policy, sister facility policy and Corporate policy indicate that we will hire the most qualified person for the job : without regard to race, color, religious creed, sex etc... We will be reviewing the regulations and making ammendments to the H.R. policy after recommendations from all of the above. Process will be complete by 12/31/06.
This Executive Director will annually review the policy and procedure manuals to assure proper compliance with all appropriate licensing and regulatory agencies. |
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
Employee #5 did not meet the qualifications for the position of counselor.
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Plan of Correction
Employee #5 has signed a Counselor Assistant Job Description and will be counted as such on staff roster until he meets requirements as a Counselor under 704.7.
Proper clinical and Human Resource staff will be trained by 11/30/06 to assure familiarity with the staffing regulations to avoid in the future. H.R. file audits will occur with each staff members annual review. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Feedback was not completed for training attended outside the facility.
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Plan of Correction
Memo distributed to all staff 11/6/06 indicating that all training certificates must be accompanied by an In-serve evaluation form. The form was also attached for each employee.
Human Resource Representative will monitor this compliance as she is the point person that all staff turns training certificates into. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Employee #4 had completed only 6 hours total of both HIV/AIDS and TB/STD training. Employees # 14, 15, 16 and 17 did not receive 6 hours of HIV/AIDS training and 4 hours of TB/STD training as required.
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Plan of Correction
Employee # 4 is scheduled for 4 hours of STD training 1/12/07.
Employee # 15 has had all required trainings - certificates will be faxed to DOH office
Employee # 16 has completed 4 hours of STD/TB - certificate will be faxed to DOH office -
Same employee scheduled for HIV training 12/12/06
Employee # 17 has completed 4 hours of STD/TB - certificate will be faxed to DOH office -
Same employee scheduled for HIV training on 12/12/06.
Patient # 14 scheduled for HIV training 12/12/06 and is scheduled for 4 hours of STD/TB training on 1/12/07.
Proper clinical and Human Resource staff will be trained by 11/30/06 to assure familiarity with the staffing and training regulations to avoid in the future. Training file audits will occur 3 x per year by Clinical Director and H.R. representative to assure that all staff have mandatory trainings and are making progress on their annual training hours so that requirements are met within mandatory time frames. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Employee #4 did not receive the required 12 hours of training for the 2005 training year.
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Plan of Correction
Employee # 4 was placed on an EIP (Employee Improvement Plan) for not completing required 12 hours of training. A new system of tracking training hours will be implemented by 1/1/07 to assure that all annual training hours are being completed. Each department manager will have oversight and responsibility for thier department, however, Human Resource Representative will have main roster to track compliance. |
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
Employee #12 did not receive the required 25 hours of training for the 2005 training year.
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Plan of Correction
Employee # 12 was placed on an EIP (Employee Improvement Plan) for not completing required 25 hours of training. A new system of tracking training hours will be implemented by 1/1/07 to assure that all annual training hours are being completed. Each department manager will have oversight and responsibility for thier department, however, Human Resource Representative will have main roster to track compliance.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The water temperature (hot) in the motel unit measured only 78 degrees Fahrenheit. The water temperature in the main building measured 138 degrees Fahrenheit.
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Plan of Correction
Meeting scheduled with Cloud Mechanical 11/16/06 to investigate cause of problem. Once the problem is identified, Maintenance Supervisor will assure it is corrected in a timely manner. The time frame is dependent on the result of the visit 11/16/06. Ongoing monthly checks will occur by maintenance supervisor to assure water temp on the campus remains consistent with Physical Plant Requirements. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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
Documentation of the number of persons in the facility at the time of the fire drill was missing or incomplete for seven of twelve fire drills conducted.
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Plan of Correction
Safety Officer responsible for proper documentation of the number of persons in the facility at the time of a fire drill.
As of date of the plan, this has been corrected and will be properly documented moving forward. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Exit routes used were not documented for twelve of twelve fire drills.
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Plan of Correction
Current Fire Drill form indicates "Alternative Route used" - Yes or No. While this indicates that an alternate route was used, it is not clear "what" route was used. 11/15/06 - Form ammended to state "Which exit route was used." so that specific routes are documented.
Safety officer responsible for correct documentation of the fire dril form.
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709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
The medical histories did not include a complete family medical history in two of two client records reviewed, #22 and 23.
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Plan of Correction
As of 10/27/06 - Current H & P form revised to include a grid specific to family history illnesses. This form was already presented to DOH as part of the action plan for NTP licensing visit. Will resend if necessary. |
709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. 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
Drug and alcohol histories did not address the client's perception of their use and lengths and patterns of use in two of two client records reviewed, #22 and 23.
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Plan of Correction
Page one of the psychosocial asks:
"What are the problems resulting from your drug use? (Duration of problems and list emotional, spiritual, behavioral and legal consequences.)" It is our position that this question does address the client's "perception" of how their use has effected their life.
As of 11/15/06 - Adjusted Drug and Alcohol History on Nursing Assessment to include lengths and patterns. This form was previously sent to the DOH as part of the POA's for NTP licensing visit. Will send again if necessary. ________________________ |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories were incomplete in two of two client records reviewed, #22 and 23. Specifically, the family history, employment history and recreational history.
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Plan of Correction
The clinical Director will hold an in-service with the Biopsychosocial team to improve their process for obtaining more comprehensive personal histories. Random weekly chart audits will be done to assure ongoing compliance. Follow up supervision and/or in-services will be held as needed.
Already completed: target 11/10/06 |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations did not provide an assessment by the counselor or a composite picture of the individual in relationship to the data collected, but was instead observations and repetition of the historical data collected in two of two client records reviewed, #22 and 23.
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Plan of Correction
The Clinical Director will hold a mandatory by In-service for all counselors by 11/17/06 on the topic of Chart Documentation and Clinical Record time frames to assure that the information being gathered during the assessment process is being used and documented for evaluative purposes, not restatement purposes. Random weekly chart audits will be done to assure ongoing compliance. Follow up supervision and/or in-services will be held as needed. |
709.82(a)(1) LICENSURE Treatment and rehabilitation services
709.82. 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
Treatment plan goals were not based on the individual client's needs identified in the evaluation in two of two client records reviewed, #22 and 23.
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Plan of Correction
The Clinical Director will hold a mandatory In-service by 11/17/06 for all counselors on the topic of Chart Documentation and Clinical Record time frames. This will include individualization of treatment plan goals based on client needs. Random weekly chart audits will be done to assure ongoing compliance. Follow up supervision and/or in-services will be held as needed. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Individual counseling was not provided twice weekly in two of two client records reviewed, #22 and 23.
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Plan of Correction
Clinical Director will hold mandatory in-service training by 11/17/06 to all Clinical Staff. This will include reiterating the partial regulation of 2 individuals per week being done and properly documented.
Random weekly chart audits will be done by the Clinical Director to assure this is in compliance. |
709.83(a)(12) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(12) Verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan.
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Observations
Work done by the client at the project was not documented as an integral part of the treatment and rehabilitation plan in two of two client records reviewed, #22 and 23.
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Plan of Correction
Clinical Director will hold mandatory in-service training by 11/17/06 to all Clinical Staff. THis will include training with regards to treatment planning specific to those clients who partake in work groups during their stay (lunch room clean up, snack distribution etc..) and how these duties are an integral part of their skill development during their treatmetn stay. Random weekly chart audits will be done by the Clinical Director to assure this is in compliance. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
The project director did not prepare and update the written manual. Project policies and procedures contained conflicting information due to new policies and procedures being developed without the removal of the old policies and procedures.
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Plan of Correction
Employee # 2 received approval from Governing Board on 11/15/06 to have the authority to review, prepare and update written policy manuals as Employee # 2 does report directly to the Governing Body for Bowling Green.
Copy of Governing Body minutes/approval will be faxed to DOH - |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
An annual audit has not been completed.
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Plan of Correction
2004 Annual audit completed and submitted to Bowling Green 11/13/06.
2005 Annual audit is underway - visit to occur to Bowling Green 12/06.
Copy of 2004 audit completion letter will be faxed to DOH.
The timing and process of our annual audit is dictated by our Corporate Entity CRC, Health. We have submitted all recommended information and paperwork in a timely fashion so not to prolong the process. We will continue to advocate and communicate the importance of this process being done in a timely manner. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Closed client records were stored in an unsecured area on the second and third floors of the barn.
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Plan of Correction
Locks have been ordered adn will be installed by Maintenance Supervisor or designated staff by 11/15/06.
Facilty walk throughs are done on a monthly basis by Maintenance Supervisor or designee. Will give copy of Confidentiality Regulations as well as Physical Plant standards to assure that proper high risk elements are being attended to. |
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
The consent to release information form for pharmaceutical services contained language indicating a blanket consent for the pharmacy to contact any funding source for payment. This is not a valid and informed consent since the client would not know where this information would be sent.
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Plan of Correction
The PharAmerica consent has been revised and sent to PharAmerica 10/27/06 to place on their letterhead. Verbiage is congruent with 255.5 Confidentiality Regulations.
Any consent forms utilized at BGB will be reviewed by designated staff: (internal and/or external) to assure that proper confidentiality verbiage is indicated and is valid under the state and federal confidentiality laws. This will be completed by 11/30/06. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
The medical history did not include a complete family medical history in ten of fourteen client records reviewed, #1, 2, 4, 8, 9, 10, 11, 12, 13 and 21.
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Plan of Correction
As of 10/27/06 - Current H & P form revised to include a grid specific to family history illnesses. This form was already presented to DOH as part of the action plan for NTP licensing visit. Will resend if necessary. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. 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
Drug and alcohol histories did not address the client's perception of their use and lengths and patterns of use in six of twelve records reviewed, # 2, 5, 7, 14, 15 and 17.
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Plan of Correction
Page one of the psychosocial asks:
"What are the problems resulting from your drug use? (Duration of problems and list emotional, spiritual, behavioral and legal consequences.)" It is our position that this question does address the client's "perception" of how their use has effected their life.
As of 11/15/06 - Adjusted Drug and Alcohol History on Nursing Assessment to include lengths and patterns. This form was previously sent to the DOH as part of the POA's for NTP licensing visit. Will send again if necessary.
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709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories were incomplete in nine of eighteen records reviewed, # 1, 2, 4, 5, 7, 8, 9, 14 and 16. Specifically, history forms contained yes or no answers with no further elaboration.
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Plan of Correction
The clinical Director will hold an in-service with the Biopsychosocial team to improve their process for obtaining more comprehensive personal histories. Random weekly chart audits will be done to assure ongoing compliance. Follow up supervision and/or in-services will be held as needed.
Already completed: target 11/10/06
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations did not include an assessment of the client were not based on the historical data obtained in fourteen of eighteen records reviewed, #1, 3, 4, 5, 6, 7, 8, 9, 10, 12, 15, 16, 17 and 21.
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Plan of Correction
The Clinical Director will hold a mandatory by In-service for all counselors by 11/17/06 on the topic of Chart Documentation and Clinical Record time frames to assure that the information being gathered during the assessment process is being used and documented for evaluative purposes, not restatement purposes. Random weekly chart audits will be done to assure ongoing compliance. Follow up supervision and/or in-services will be held as needed. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
709.52. 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
Treatment plan goals and objectives were not based on the client's needs identified in the evaluations in eight of fourteen records reviewed, #1, 3, 10, 11, 12, 13, 17 and 21. Some goals were phrased as questions and included standardized action steps.
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Plan of Correction
The Clinical Director will hold a mandatory In-service by 11/17/06 for all counselors on the topic of Chart Documentation and Clinical Record time frames. This will include individualization of treatment plan goals based on client needs. Random weekly chart audits will be done to assure ongoing compliance. Follow up supervision and/or in-services will be held as needed. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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:
(8) Case consultation notes.
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Observations
Case consultations were missing in six of thirteen client records reviewed, #3, 6, 9, 12, 13 and 15.
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Plan of Correction
The Clinical Director will hold a mandatory In-service for all counselors on the topic of Chart Documentation and Clinical Record time frames. This will include review and training on Case Consult procedures. Random weekly chart audits will be done to assure ongoing compliance. Follow up supervision and/or in-services will be held as needed. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Work done by clients at the project was not documented on the treatment plan.
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Plan of Correction
Clinical Director will hold mandatory in-service training by 11/17/06 to all Clinical Staff. THis will include training with regards to treatment planning specific to those clients who partake in work groups during their stay (lunch room clean up, snack distribution etc..) and how these duties are an integral part of their skill development during their treatment stay. Random weekly chart audits will be done by the Clinical Director to assure this is in compliance. |
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
Personal history information was incomplete in one of two records reviewed, # 25. Specifically, the history form contained yes or no answers without further elaboration.
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Plan of Correction
The clinical Director will hold an in-service with the Biopsychosocial team to improve their process for obtaining more comprehensive personal histories. Random weekly chart audits will be done to assure ongoing compliance. Follow up supervision and/or in-services will be held as needed.
Already completed: target 11/10/06
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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
Psychosocial evaluations did not provide an assessment of the client and were not based on the historical data collected in two of two client records reviewed, #24 and 25.
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Plan of Correction
The Clinical Director will hold a mandatory by In-service for all counselors by 11/17/06 on the topic of Chart Documentation and Clinical Record time frames to assure that the information being gathered during the assessment process is being used and documented for evaluative purposes, not restatement purposes. Random weekly chart audits will be done to assure ongoing compliance. Follow up supervision and/or in-services will be held as needed. |