INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 31- February 1, 2012 licensure renewal inspection. The follow-up inspection was conducted on July 31-August 2, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Soar Corporation Chester 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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704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on documentation filed in personnel records, the facility failed to ensure that at least one-half of all training was provided by trainers not directly employed by the project in two of three personnel records.
The findings include:
Ten personnel records were reviewed on January 31, 2012. Three personnel records were reviewed for required training hours. Two of three employees failed to document that at least one-half of their training hours were provided by trainers not directly employed by the project, specifically personnel records # 3 and 4.
Employee # 3 was required to have 12 hours of training for the 2011 training year and facility documentation indicated the employee received 14.5 hours of training. A review of the employee's training record revealed that only 2.5 hours of the 14.5 hours of training were provided by a trainer not directly employed by the project.
Employee # 4 was required to have 25 hours of training for the 2011 training year. A review of the employee's training record revealed that the employee had obtained only 13 hours of the required 25 hours with only 3 hours of the training provided by a trainer not directly employed by the project.
This finding was discussed with the project director and was not disputed.
This was still out of compliance at the time of the follow-up conducted on July 31- August 2, 2012.
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Plan of Correction
Program Director and H.R. Director will develop a tracking grid for all personal within the next 30 days. Tracking grid will be updated by the H.r. Director after a staff member presents a copy of the completed training certificate. Staff will be updated every 60 days by H.R. and the Program Director of their personal standing for training hours, update will be completed by e-mail. H.R. Director and Program Director will complete a review of required trainings for staff within the next 2 weeks. These types of reviews will be completed every 3 months by the Program Director and H.R. Director. Program Director and Supervisors will discuss hours needed for training and identified training needs with the staff in monthly supervison session . Counselor will register for outside training based off of trainings recommended. Program director and H.R. Director will obtain proof of attending at least 2 outside trainings by cerficates of completion fromt he training Current Staff will attend at least 2 external trainings in the next 90 days to ensure meeting hours for this year. Program director to monitor the registration for training and the attendance to training. |
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 staff training documentation maintained in the personnel record, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel records reviewed.
The findings included:
Ten personnel records were reviewed on January 31, 2012. Four personnel records were counselors and four were required to complete 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel records # 4.
Employee # 4 was hired on November 23, 2008. The facility training year is from January through December. The training year for January 2011 to December 2011 was reviewed and, according to the documentation provided, employee # 4 completed 13 clock hours of annual training in 2011.
This was still out of compliance at the time of the follow-up conducted on July 31- August 2, 2012.
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Plan of Correction
Correction---Program Director and H.R. Director will develop a tracking grid for all personal within the next 30 days. Tracking grid will be updated by the H.r. Director after a staff member presents a copy of the completed training certificate. Staff will be updated every 60 days by H.R. and the Program Director of their personal standing for training hours, update will be completed by e-mail. H.R. Director and Program Director will complete a review of required trainings for staff within the next 2 weeks. These types of reviews will be completed every 3 months by the Program Director and H.R. Director. Program Director and Supervisors will discuss hours needed for training and identified training needs with the staff monthly supervison session. Counselor will be required to attend at least 2 outside trainings in the next 90 days to ensure meeting hours for this years. Program director to monitor the registration for training and the attendance to training. Program director to set a year long internal training schedule, with a least one internal training a month. schedule will be set within the next 30 days. All staff will attend at least one internal training in a month. Program director to monitor staff to ensure attendance |
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 the review of patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in five of twelve patient records reviewed. The facility exceeded 4 Pa. Code, Subsection 255.5(b) in one of twelve records reviewed.
The findings included:
Twenty-four patient records were reviewed July 31- August 2, 2012. Twelve records were reviewed regarding release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in six patient records reviewed, # 3, 12, 17, 22, and 23. Patient record # 2 exceeded 4 Pa. Code, Subsection 255.5(b).
A review of patient record # 2 revealed a consent to release for Children and Youth was signed on May 28, 2012 that exceeded 4 Pa. Code, Subsection 255.5(b). The release allowed for the release of ,"what I am doing at Soar and all files." The release did not indicate what the purpose for the release.
A review of patient record #3 revealed information was released to a funding source on May 23, 2012. The patient did not sign a release prior to releasing information to the funding entity. The consent to release was signed on May 28, 2012.
A review of patient record #12 revealed information was released to a funding source on May 23, 2012. The patient did not sign a release prior to releasing information to the funding entity.
A review of patient record #17 revealed information was released to a funding source on May 23, 2012. The patient did not sign a release prior to releasing information to the funding entity. The consent to release was signed on May 28, 2012.
A review of patient record #22 revealed information was released to a funding source on May 23, 2012. The patient did not sign a release prior to releasing information to the funding entity. The consent to release was signed on May 29, 2012.
A review of patient record #23 revealed information was released to a funding source on May 23, 2012. The patient did not sign a release prior to releasing information to the funding entity.
This is a repeat citation from the January 31-February 1, 2012 licensing inspection.
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Plan of Correction
Program Director to develop a new intake package which includes all of the new ROI's and forms within 30 days. Intake Coordinator and staff start to use this new intake package within 30 days. All Roi's for funding sources will be signed on admission with intake worker. Yearly updates of annual ROI's will be completed annually by the primary counselor in the month of January. Program Director and Admin assist to complete monthly chart audits to ensure ROI's are updated. Program Director to complete a formal training on the 255.5 regulations for confidentiality within the next 30 days. Program director to create Specific ROI's for Human service providers such as DHS stating information allowed to be released. Counselor's will use these new ROI's, and implementation of these ROI's will be within 30 days. |
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, the facility failed to document a drug and alcohol history that included lengths and patterns of use in one of four records reviewed.
The findings included:
Twenty-four patient records were reviewed on July 31-August 2, 2012. Four patient records were reviewed for documentation of a drug and alcohol history that included lengths and patterns of use. One patient record # 11 failed to document a drug and alcohol history that included lengths and patterns of use.
This is a repeat citation from the January 31-February 1, 2012 licensing inspection.
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Plan of Correction
Program Director will complete a inservce training with all intake and counseling staff in regards to proper completion of the personal history. Training will focus collecting information on progression patterns and history of use. This training will be completed within 30 days. Initial personal history including history of use and progression of use will now be collected during the initial intake process by the intake worker. Program director has started reviewing completed intakes on the same day it is done to ensure personal history is completed at admission, that all signatures are in place and completed as part of the intake process. Program director to review all biopsychosocial assessments on completion by counselor and intake worker. Program director will check clinicial content and check the time frames for completion to ensure the information is correct. Any Incomplete / inaccurate paperwork will be returned to the counselor for correction by the program director the same day of the review. the counselor will have 5 days to correct and return to the Program director. |
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, the facility failed to provide a personal history that was completed within the time frames indicated by facility policy in four of five patient records.
The findings include:
Twenty-four patient records were reviewed on July 31- August 2, 2012. Five patient records were reviewed for compliance with the facility policy. The facility policy indicated the personal history is to be completed within 30 days of admission. The facility failed to sign and date the personal histories in patient records # 1, 2, 11 and 24. There was no way to determine if the histories were documented within the required time frame.
This is a repeat citation from the January 31- February 1, 2012 licensing inspection.
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Plan of Correction
The clinical biopsychosocial form will be modified by the Program Director to include more detail on the personal history and will include the signature lines within 30 days. The Counseling staff will receive a formal training on the biopsychosocial social, focusing on gathering clinical information time frames for completion. Formal training will be completed by the Program Director within 30 days. Program Director and Admin Assistant will audit new intakes within 30 days of admission to locate any issues with missing signatures. If issue identified, counselor assigned will address, and program director will monitor to ensure correction completed |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of patient records it was determined that the facility failed to document the patient's progress as it related to the goals identified in the treatment and rehabilitation plan in one of ten patient records. Additionally, three of ten records failed have the treatment plan updates, as required.
The findings were:
Twenty-four patient records were reviewed on July 31- August 2, 2012. Ten patient records were reviewed for treatment plan updates that included progress as it related to the goals identified in the treatment and rehabilitation plan. Per the facility's policy and procedures, treatment plan updates are required every sixty days. The facility failed to document in the treatment plan update the patient's progress as it related to the the goals identified in the individualized treatment and rehabilitation plan in patient records # 5. New goals were identified in the treatment plan update without documentation of the progress of previous goals identified in the treatment plan. Additionally, records # 8, 9, and 15 failed to have treatment plan updates documented every sixty days.
Patient # 5 was admitted on August 8, 2011. The record contained a treatment and rehabilitation plan update was documented on May 10, 2012 and July 11, 2012. Both treatment plan updates failed to include progress as it related to the current goals identified on the treatment and rehabilitation plan.
Patient # 8 was admitted November 13, 2008. The record contained a treatment plan update documented on April 13, 2012. According to the regulation and the facility's policy, the next treatment plan was due by June 13, 2012. As of the date of the inspection the facility had failed to document additional treatment plan updates as required.
Patient # 9 was admitted on August 26, 2010. The record contained a treatment plan update documented on March 13, 2012. According to the regulation and the facility's policy, the next treatment plan was due May 13, 2012. As of the date of the inspection the facility had failed to document additional treatment plan updates as required.
Patient # 15 was admitted December 18, 2010. The record contained a treatment plan update documented on January 13, 2012. According to the regulation and the facility's policy, the next treatment plan was due by March 13, 2012. As of the date of the inspection the facility had failed to document additional treatment plan updates as required.
This is a repeat citation from the January 31-February 1, 2012 licensing inspection.
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Plan of Correction
Clinical tracking grid will be established within 30 days by the program director in order to track due dates for treatment plans by caseload. New treatment plan form will be introduced within 60 days by the Program Director to the counselors. Counselors will receive formal training on the form and start to use it within 30 days. New treatment plan form will address issues with progress within individual goals by the format it will be in |