INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 17, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc., Erie Outpatient 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.
|
Plan of Correction
|
704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Reports, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Reports for the project's 14 facilities were reviewed on October 15, 2013. The project employed the equivalent of 105.275 full-time counselors, which would require the project to have at least 13 full-time clinical supervisors. The project failed to employ a full-time clinical supervisor for every eight full-time counselors as the project only employed 7 full-time clinical supervisors as of October 15, 2013.
|
Plan of Correction
The Vice President of Clinical Services will ensure that the ratio of Clinical Supervisors for the project is within the defined regulation of 1 fulltime clinical supervisor for every 8 fulltime counselors or counselor assistants. The Project will re-evaluate its current system and restructure the project to include the appropriate number of clinical supervisors. Human Resources coordinators will identify the number of clinical supervisors, counselors, and counselor assistants within the system on a quarterly basis. Vice President of Clinical Services will be responsible to review staffing hours quarterly to ensure that ratio is maintained. Program Directors will notify the Vice President of Clinical Services should any changes in the ratio per site occur during the quarter. Restructuring of the Clinical Supervisor ratio will begin December 1, 2013. Clinical Supervisor ratio will be in 100% compliance by January 1, 2014.
|
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.
|
Observations
Based on a review of personnel and training records, the facility failed to ensure that staff persons and/or volunteers received 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 as per the regulatory requirements in one of three personnel records reviewed.
The findings include:
Ten personnel records were reviewed on October 17, 2013. Three personnel records required documentation verifying the completion of the mandatory HIV/AIDS and TB/STD training. Personnel record # 10 lacked documentation that the trainings were completed as per the regulatory requirements.
Employee # 10 was hired on August 8, 2010 as a support staff person. Employee # 10 was required to obtain 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training by August 8, 2012. The facility failed to ensure that employ # 10 received the HIV/AIDS and TB/STD training as of the date of the inspection.
The Facility Director was interviewed on October 17, 2013 and confirmed the findings.
|
Plan of Correction
Staff Members who are currently in noncompliance of training requirements will be registered to attend needed training. All needed trainings will be completed by February 1, 2014. Program Director will monitor staff trainings during monthly staff meetings to ensure all employees are completing required training in timely fashion. |
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.
|
Observations
Based on a review of employee records, the facility failed to document the completion of 12 clock hours of annual training required for project directors in one of one employee records.
The findings include:
The facility training year runs from July 1 through June 30.
Fourteen employee records were reviewed on October 7, 2013. One employee record pertained to the project director and required the documentation of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in employee record # 1.
Employee # 1 has been the project director since July 1, 1999. The facility failed to document 12 clock hours of annual training for employee # 1 for the July 2012 - June 2013 training year as the record only contained documentation of 10.5 hours of training.
This is repeat citation from the October 18, 2012 licensing inspection.
|
Plan of Correction
Project Manager will complete 12 hours of training annually. Project Manager will ensure needed documentation of completed trainings is presented to Human Resources to be recorded in Personnel File. Human Resource Coordinators will monitor employee files quarterly to ensure 100% 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.
|
Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training in one of two personnel records.
The findings include:
The facility training year is from January 1 to December 31.
Ten personnel records were reviewed on October 17, 2013. Six personnel records pertained to counselors. Two personnel records required documentation of the completion of 25 clock hours of annual training for the 2012 training year. The facility failed to ensure that 25 clock hours of annual training were completed and documented in personnel record # 4.
Employee # 4 was hired on November 1, 2010. The facility failed to document 25 clock hours of annual training in record # 4 as only 10 clock hours of annual training were documented for the 2012 training year.
The Facility Director was interviewed on October 17, 2013 and confirmed the findings.
|
Plan of Correction
Counselors will complete required 25 hours of training per year. Clinical Supervisors and Program Directors will be responsible for tracking counselors' training hours as part of clinical supervision monthly. HR coordinators will audit completed training hours quarterly and supply Program Directors with results to ensure training hours are being met. |
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.
|
Observations
Based on a review of client records, the facility failed to provide individual counseling, at least twice weekly, in three of the five client records.
The findings include:
Five client records were reviewed on October 17, 2013. The facility failed to ensure that individual counseling was conducted at least twice weekly in client records # 2, 3, and 4.
Client # 2 was admitted on June 18, 2013. The facility failed to provide at least two individual counseling sessions for the weeks of July 1, July 8, July 15, July 22, July 29, August 19, September 2, September 30 and October 7, 2013.
Client # 3 was admitted on July 15, 2013. The facility failed to provide at least two individual counseling sessions for the weeks of July 22, September 19, September 30 and October 7, 2013.
Client # 4 was admitted on July 10, 2013. The facility failed to provide at least two individual counseling sessions for the weeks of July 19, July 29, August 5, August 12, August 19, September 2, September 16 and September 30, 2013.
The findings were reviewed with the facility director and were not disputed.
|
Plan of Correction
Counselors will ensure services are offered and completed as prescribed. Completion of individual sessions twice weekly in the Acute Partial and Partial levels of care will be monitored through a monthly open chart monitor beginning December 1, 2013. Program Director will complete chart monitors and review in monthly supervision. |