INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Alternatives Group 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 and a plan of correction is due on October 16, 2009.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the agency policy and procedure manual, the facility failed to document a procedure for 28 Pa. Code subsection 704.11(a)(1) "An assessment of staff training needs"; 28 Pa. Code subsection 704.11(a)(2) "An overall plan for addressing these needs"; 28 Pa. Code subsection 704.11(a)(3) "A mechanism to collect feedback on completed training."; and 28 Pa. Code subsection 704.11(a)(4) "An annual evaluation of the overall training plan." There were no procedures to address who, by job title, is responsible for completing the documentation and when, within the year, the documentation will be completed.The findings include:The agency training policy and procedure manual was reviewed on September 14 and 15, 2009. The procedure did not document who, by job title, is responsible for the completion of the assessment of staff training needs; development of an overall plan for addressing the staff training needs; development of a mechanism to collect feedback on completed training; and an annual evaluation of the overall training plan. The procedure did not document timeframes for completion of 28 Pa. Code subsection 704.11(a)(1) "An assessment of staff training needs"; 28 Pa. Code subsection 704.11(a)(2) "An overall plan for addressing these needs"; 28 Pa. Code subsection 704.11(a)(3) "A mechanism to collect feedback on completed training."; and 28 Pa. Code subsection 704.11(a)(4) "An annual evaluation of the overall training plan." The facility training year was identified as November 1 through October 31 of each year.
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Plan of Correction
The project director will write a policy for the agency manual which will be approved by the board as it is currently composed, which addresses the methodology for completing an annual assessment plan and evaluation of the training plan. The policy will also identify the mechanism for feedback on training. The policy will identify timeframes and specific steps for (1) overall plan to address training needs for that year, (2)mechanisms to collect feedback on completed trainig for each individual (3) annual evaluation of the program. The clinical director will be responsible for carrying out the plan. |
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on the review of the facility training files and personnel files, the facility failed to document an assessment of staff training needs for the November 1, 2008 to October 31, 2009 training year. .The findings include:The facility training documents and personnel files were reviewed on September 14, 2009 and an interview with the project director was conducted on September 14, 2009 at 12:30 p.m. The project director confirmed that the facility failed to document an assessment of staff training needs for the November 1, 2008 to October 31, 2009 training year.
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Plan of Correction
An assessment of staff training needs will be documented by the director for training by 11/30/09. This assessment will include a list of obligatory trainings which certain staff members lack and a timeframe for completing those trainings. In addition an annual evaluation of training needs for the agency as a whole will be completed by 09/30 of each year.All documentaton will be kept in a file cabinet in the records room. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on the review of the facility training documents and personnel records, the facility failed to document an overall training plan for the November 1, 2008 to October 31, 2009 training year. The findings include:A review of the facility training documents and personnel records was conducted on September 14, 2009, and an interview with the project director was conducted on September 14, 2009 at 12:30 P.M. The project director confirmed that the facility failed to document an overall training plan for the November 1, 2008 to October 31, 2009 training year.
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Plan of Correction
An overall training plan for 11/1/09 to 10/31/10 will be filled by the director for training by 11/30/09. They will assess the needs of the agency (for example need for CPR training of staff members) and list these needs in the document, will created deadlines for such training and will list resources for these trainings (Red Cross, Alpha Fire Fighters, etc).Each employee will receive a copy of the plan and an evaluation of progress will be made quarterly when agency goals are reviewed at a business meeting in January, April, July and September. |
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
Based on the review of facility training documents and personnel records, the facility failed to document a mechanism to collect feedback on completed training in three out of five personnel and training records for the November 1, 2008 through October 31, 2009 training year.The findings include:A review of the facility training documents and personnel records was conducted on September 14, 2009, and an interview was conducted with the project director at 12:30 P.M. on September 14, 2009. Three out of five personnel and training records required documentation of feedback forms. The project director confirmed that the facility failed to document a mechanism to collect feedback on completed training in three of five personnel and training records. Training feedback forms were not documented in personnel and training records # 1 ,3 and 4.
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Plan of Correction
The Training Form provides a way to give feedback for any given training experience. This is a case where the agency procedure was not followed. Clients #1,3,and 4 were individually approached and told about the deficiency and reminded about the proper procedure by the director. The specific deficiency and proper procedure will be discussed at the agency's clinical meeting held on 11/18/09. All staff members are required to be present at these clinical meetings. In the future the director for training will review training forms quarterly (January, April, July and September) to make certain that feeback is included for each training an employee attends. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on the review of the facility training documents and personnel records, the facility failed to document an annual evaluation of the overall training plan for the November 1, 2007 to October 31, 2008 training year.The findings include:A review of the facility training documents and personnel records and an interview with the facility director was conducted on September 14, 2009. The facility director confirmed that the facility failed to document an evaluation of the overall training plan for the November 1, 2007 to October 31, 2008 training year.
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Plan of Correction
By 11/30/09 the project director and the director for training will develop a document which will evaluate the agency's overall training plan for the past training year (11/1/08 to 10/31/09).
A policy will be written by 11/30/09 indicating the procedure, timeframe and responsible party for conducting an evaluation of the overall training plan for any given year. The board members will approve a plan by 11/30/09 and it will go into the policy and procedures manual. |
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
Based on the review of facility training documents and personnel records and an interview with the project director, the facility failed to document that the required 6 hours of HIV/ AIDS training was completed within one year of the date of hire for a clinical staff employee in one of five personnel records representing clinical staff.The findings include: An interview with the project director and the review of staff training records and personnel records on September 14, 2009 revealed that employee # 4, a clinical staff person, was hired on 7/1/2007. The facility failed to document that employee #4 had received the required 6 hours of HIV/AIDS training within the first year of employment. This is a repeat citation from the previous licensing inspection as the facility was found in non compliance for this same staff person on August 7, 2008. This issue was to have been corrected by November 15, 2008.
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Plan of Correction
Employee #4 has had the required training. She cannot find the certificate of completion which she thought her previous employer was holding. The situation was discussed on 9/15/09 and the project director asked her within 120 days to find the certificate or retake the training. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of facility documentation and an interview with the project director, it was determined that the facility failed to provide a sufficient number of staff persons, so that at least one person with current CPR certification and first aid training is onsite during the project's hours of operation.The findings include:According to an interview with the project director on September 14, 2009 at 12:40 P.M., and a review of training documentation for CPR certification and First Aid Training, it was noted that the facility failed to have sufficient staff, certified in CPR and first aid training, on duty during the project's hours of operation. Employees # 1, 2, 3, and 4 did not have current CPR certification and first aid training . Employee # 5 was hired on 9/1/2009 but is a part time employee and is only scheduled to work three hours per week at the facility. Employee #6 also had current CPR certification; however, this employee spends the majority of his time at the prison and away from the facility, only spending about 3 hours a week on site. The facility could only provide CPR and First Aid coverage for 6 hours of the 40 operating hours a week as of September 14, 2009.
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Plan of Correction
The director addressed this issue with staff on 9/16/09. At that meeting staff members were told that everyone needed either to be certified or recertified. At the 11/18/09 staff meeting individuals will be told that everyone must have CPR/ First Aid certification by 2/15/10 and that at least 3 individuals must have certification by 12/20/10. The project director who comes to work daily and whose hours are typically 9am to 6pm will call and attend the next CPR class given by either the fire department or the Red Cross. |
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 documentation reviewed in facility training and personnel records and an interview with the project director, it was determined that employee #1, the project and facility director, did not have the minimum number of training hours for the November 1, 2007 through October 31, 2008 training year. The findings include:According to the review of the facilities training documentation and an interview with the project/facility director on September 14, 2009 at 12:40 P. M., it was determined that employee #1, the project/facility director, did not meet the required training hours. Employee # 1 was hired on 9/1/1994. This employee was required to have a minimum of 12 hours of training for the November 1, 2007 through October 31, 2008 training year. Employee #1 had 6 hours of training documented for the November 1, 2007 through October 31, 2008 training year. The facility failed to document the minimum training hours in one of one record where required for the project and facility director positions..
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Plan of Correction
Employee #1 will complete 12 hours of training during this new training year. The director of training agreed on 9/16/09 to review her training forms qusrterly and remind employee #1 or this requirement. |
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 documentation reviewed in facility training and personnel records, it was determined that in two out of four training and personnel records for counselors, the facility failed to document at least 25 hours of training for the November 1, 2007 through October 31, 2008 training year.The findings include:The training and personnel records of four counselors were reviewed on September 14, 2009. Employee #3 was hired on 9/1/1994 and was employed as a counselor. The training and personnel record for employee #3 included documentation of 22 hours of training for the November 1, 2007 through October 31, 2008 training year. Employee # 4 was hired 4/1/2007 and was employed as a counselor. The training and personnel record for employee #4 included documentation of 22.5 hours of training for the November 1, 2007 through October 31, 2008 training year.
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Plan of Correction
The director spoke to employees #3 and 4 privately on 9/16/09 about the deficiency in their training hours. This will be further discussed at the staff meeting on 11/18/09. The training hour requirements will be reviewed and employees will be reminded that the requirement is 25 hours. Training and training hours will be reviewed quarterly (January, April, July and September) and number of hours will be discussed with each employee by the director for training. |
709.22(b) LICENSURE Governing Body
709.22. Governing body.
(b) If a project is publicly funded, not more than one staff member of the project may sit on the governing body at a designated time.
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Observations
Based on an interview with the project director, the facility failed to limit employee participation on the board of directors to one staff member of the project.The findings include:During an interview with the project director on September 14, 2009 at 9:45 A. M. it was disclosed to the licensing specialists that four partners, all clinical employees of the corporation, are current board members. The project director confirmed that all four partners are employees and do sit on the board of directors. This is a repeat citation from the August 6 - 7, 2008 licensing inspection.
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Plan of Correction
The articles of incorporation for Counseling Alternatives Group, Inc state that all four original partners of the partnership of Counseling Alternatives Group are board members with equal shares and interest in the corporation. Under the incorporation laws of the state of Pennsylvania this arrangement is within the law. To change this would go against the by laws and the incorporation structure of organization. The agency will apply for an exeption by 12/15/09. In the event that an exception is not granted the current board will restructure itself within 7 days of the denial of exception by asking our lawyer to amend the articles of incorporation and reflect the changes to the composition of the board. Within 14 days the board will consist of one current board member and the other three will be replaced by two individuals who have a knowledge of the agency, a knowledge of business principles and who the original parners feel will provide practical guidance to the agency.The picking of candidates will take place at a business meeting tp be held within 5 days of the denial of exception.
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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
Based on an interview with the project director, it was determined that the facility failed to document an annual audit of financial activities completed by an independent public accountant for the fiscal year ended December 31, 2008.The findings include: During an interview with the project director on September 14, 2009 at 9:50 A.M. it was disclosed that the facility did not complete an annual audit of financial activities for the January 1, 2008 through December 31, 2008 fiscal year. The facility did not produce a copy of annual audit. The facility is an "S" type, small business corporation and was not reviewed for compliance with this standard during the licensing inspection of August 6-7, 2008.
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Plan of Correction
Compliance with this regulations was not checked for in 2008 and before due to the size of this organization. An audit would place an unreasonable financial burden on our agency. The senior inspector gave the project director a request for an exemption which will be filed by 11/30/09.
In case the exemption is denied the agency will ask a local accountant who does audits for small businesses to do the annual audit. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel files and personnel policies and procedures regarding performance evaluations, the facility failed to document annual performance evaluations in four out of five personnel records reviewed.The findings include:Five personnel records were reviewed on September 14, 2009. Four out of five personnel records reviewed required annual performance evaluations. The facility failed to document annual performance evaluations in personnel records # 1, 2, 3, and 4. Facility policy and procedure states that annual performance evaluations would be conducted based on the employees date of hire. Employees # 1, 2, and 3 were hired on 9/1/1994. The facility failed to document performance evaluations that were due on 9/1/2009. Employee #4 was hired on 7/1/2007. The facility failed to document the performance evaluation that was due on 7/1/2009.
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Plan of Correction
The project director will meet with employees all employees before December 15, 2009 and do an annual performance evaluation. The evaluation will be based on an employee evaluation form that has been used in the past and which records the evaluation of the project director of that employee's work habits, knowledge of the field, general work attributes and areas of professional improvement. The employee also fills out a similar form about themselves and the two forms are compared and discussed.A recommendation is made to the employee and the form is signed.
In the case of the project director feedback on the quality of work (administrative and professional) is obtained from each of the other employees and the director creates an annual goal plan for improvement.
The evaluations will be kept in the employees' personnel files in a locked file cabinet in the administrative assistant's office. |
709.26(d)(5)(ii) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
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Observations
Based on a review of personnel files and the facility's policies and procedures regarding annual performance evaluations, the facility failed to document that individuals were informed, by written copy, of their annual evaluation in four out of five personnel records reviewed.The findings include:Five personnel records were reviewed on September 14, 2009. Four out of five personnel records reviewed required documentation that the employees were informed in writing of their annual performance evaluations. The facility failed to document that the employees were informed of their annual performance evaluations in personnel records # 1, 2, 3, and 4. Facility policy and procedure indicate that the annual written performance evaluations will be based on the employee's date of hire. Employees # 1, 2, and 3 were hired on 9/1/1994. The facility failed to demonstrate that the employees were informed by written copy of their annual performance evaluations that were due on 9/1/2009. Employee #4 was hired on 7/1/2007. The facility failed to demonstrate that the employee was informed by written copy of his/her annual performance evaluation that was due on 7/1/2009.
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Plan of Correction
The project director will send a written message to each employee one week before the date of the evaluation stating that the evaluation process described previously will take place. One week after the evaluation a written statement stating the results of the evaluation and any agreements made during the evaluation process will be sent to each employee via office mail. A copy of this document will be placed in the employee's personnel folder which is kept in a locked file cabinet in the administrative assistant's office. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a procedure for informing the employees of their rights.The findings include:Personnel records and the employee bulletin board was reviewed on September 14, 2009. The facility did not have a policy and procedure in place that described how employees would be informed of their rights and there was no documentation that described the project's efforts toward informing staff of their rights.
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Plan of Correction
The project director will write a policy which states how employees are to be informed of their rights Those rights will be stated in the policy manual as well.
Each individual staff member will receive a copy of their rights via office mail and a copy will be placed in their personnel folders which are kept in a locked file in the administrative assistant's office.
A copy of the rights will be displayed in the employee mail room. |
709.26(e)(1) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(1) The employe's right to inspect his own records.
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Observations
Based on the review of personnel records and the employee bulletin board, the facility failed to demonstrate the project's efforts to inform staff of their right to inspect their own records.The findings include:Five personnel files were reviewed on September 14, 2009. There was no documentation in place in personnel records # 4 and 5 that indicated they have been advised of their right to inspect their own record. There was no posting on the employee bulletin board that demonstrated staff were informed of their right to inspect their own records.
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Plan of Correction
The project director will send a memo to all staff members informing them that they have the right to inspect their own records: evaluative, personal and financial.
The project director will write a policy describing the process by which an employee can request to inspect their own evaluative, personal and fiscal records and it will be placed in the employee policy and procedure manual.
A copy of the memo stating that employees have the right to inspect their own fiscal, evaluative and personal records will be placed in the employees' personnel folders which are kept in a locked file cabinet in the office of the administrative assistance.
A copy of the memo will be posted in the staff mail room. |
709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based on the review of personnel records and the employee bulletin board, the facility failed to demonstrate the project's efforts toward informing staff of their right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from their personnel records.The findings include:Five personnel records were reviewed on September 14, 2009. There was no documentation in place in personnel records # 4 and 5 that indicated they had been advised of their right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records. As of September 15, 2009, no information was posted at the facility to advise staff of their right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Plan of Correction
The project director will write a memo concerning employees' rights to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from their records. This right will be stated and the procedure that needs to be followed for this action will be outlined. This memo will be sent to each employee via office mail.
A copy of this memo will be placed in each staff member's personnel folder which is kept in a locked file cabinet in the administrative aassistant's office.
A copy of the memo will be displayed in the staff mail room.
This information will be included in the staff policy and procedure manual.
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709.26(e)(3) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(3) The employe's right to submit rebuttal data or memoranda to his own records.
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Observations
Based on the review of personnel records and the employee bulletin board, the facility failed to demonstrate the project's efforts to inform staff of their right to submit rebuttal data or memoranda to their own record.The findings include:Five personnel files were reviewed on September 14, 2009. There was no documentation in place in personnel records # 4 and 5 that indicated the employees had been advised of their right to submit rebuttal data or memoranda to their own record. As of September 15, 2009, there was nothing on the staff bulletin board advising staff of their right to submit rebuttal data or memoranda to their own personnel record.
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Plan of Correction
The project director will write a memo to inform staff of their right to submit rebuttal data or memoranda to their record and the procedure to be followed for doing so. A copy of this memo will be sent to each staff member via placement in the staff member's mail box.
A copy of this memo will be placed in each staff member's personnel folder. Personnel folders are kept in a locked file cabinet in the administrative assiatant's office.
A copy of the memo will be placed for viewing in the staff mail room.
A policy will be written concerning the right of each staff member's right to submit rebuttal data or memoranda to their own record and the procedure for doing so. |
709.26(f)(3) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
(3) The requisite skills, knowledge and experience.
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Observations
Based on the review of personnel records, the facility failed to document the requisite skills, knowledge, and experience on the job descriptions in five of five personnel records reviewed. The findings include:Five personnel files were reviewed on September 14, 2009. The job descriptions did not include documentation of the requisite skills, knowledge and experience required for the position in five of five records reviewed. The job description in personnel record # 1, Project Director, did not include documentation of the requisite skills, knowledge and experience required for the project director position. The job description in personnel record 2, Clinical Supervisor, did not include documentation of the requisite skills, knowledge and experience required for the clinical supervisor position.The job descriptions in personnel records # 3, 4, and 5, counselors, did not include documentation of the requisite skills, knowledge and experience required for the counselor position.
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Plan of Correction
The project director will rewrite the job descriptions of Project Director, Clinical Supervisor, and Counselor to include the requisite skills, knowledge and experience required for the positions of Project Director, Clinical Supervisor and Counselor, respectively.
The Project Director, Clinical Supervisor and Counselors will be notified of these additions and will receive a copy of the new job description relevant to their position via a memo which will be placed in each individual's mailbox. their mail boxes.
A copy of the new descriptions will be placed in each indiviual's personnel record which is kept in a locked file cabinet in the administrative administrator's office. |
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 upon the review of client records, the facility failed to document that an informed and voluntary consents to release information were obtained in four of fourteen client records. The findings include:Fourteen client records were reviewed on September 14 and 15, 2009. Four of fourteen client records reviewed did not have written, informed and voluntary consents signed by the client for the disclosure of information contained in the client record. There was no written consent to release information to a third party payer in client record #2 for the treatment episode that began on 1/15/2008. Client records #6, 12 and 14 did not include documentation of consents to release information forms for releases of information to third party payers.
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Plan of Correction
At the next clinical staff meeting the project director and the clinical supervisor once again will review the policy that states that an informed release of information needs to be signed for any party with whom information about a client is shared including third party payers.
The clinical director and the project director will conduct spot checks twice a month pulling 2 folders for each conselor to check that informed releases of information for third party payers have been signed. Counselors will receive written feedback on what is found. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on the review of client records, the facility failed to document that the client was offered a copy of each consent to release information form in five of fourteen client records.The findings include:Fourteen client records were reviewed on September 14 and 15, 2009. In five out of fourteen client records reviewed, there was no documentation that clients were offered a copy of each consent to release information. The facility included a check off on the consent to release information forms to document whether the client accepted or refused a copy of the consent to release information form they had just signed. This check off was left blank on the consent to release information forms documented in client records # 3, 9,11,12, and 13.
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Plan of Correction
At the next clinical staff meeting the project diector and the clinical director will once again review the regulation that states that there needs to be documentation that clients are offered a copy of every consent to
release of information.
A spot check will be done by the project director and the clinical director twice a month by pulling two folders from each counselor, at random, and checking for this documentation.
Written feedback will be given to each counselor on what was found. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of the facility's policy and procedure manual and a review of client records, the facility failed to document preliminary treatment and rehabilitation plans in three out of eleven client records reviewed. The findings include:On September 14 and 15, 2009, during the review of client records, the facility failed to document preliminary treatment and rehabilitation plans in three out of eleven client records reviewed. The policy and procedure regarding preliminary treatment plans was then reviewed on September 14, 2009. The policy for completion of the preliminary treatment plan stated that it will be based on the first interview and documented at the end of the psychosocial evaluations. A preliminary treatment plan was not documented in client records # 5, 10, and 14. Client record # 5 was admitted on 4/14/2009. A psychosocial evaluation was completed on 4/14/2009; however, the facility failed to document a preliminary treatment plan in the client record. Client record # 10 was admitted on 3/31/2009. A psychosocial evaluation was completed in the client record; however, the facility failed to document a preliminary treatment plan in the client record. Client record #14 was admitted on 12/10/2008. The facility failed to document a preliminary treatment plan in this client record as of September 15, 2009.
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Plan of Correction
At the next clinical staff meeting the clinical supervisor and the project director will again review with staff the requirement that preliminary treatment and rehabilitation plans need to be documented at the end of the psychosocial evaluations.
The clinical supervisor and the project director twice a month will pull random folders from each counselor's case load and look for the preliminary evaluations. Written feedback will be given to each counselor as to the findings and corrections will need to be made within 7 days if required. Followup for compliance will be done by the clinical director or the project director. |
709.93(a)(3) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
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Observations
Based on a review of client of records, the facility failed to document complete and current records of services in six out of ten client records reviewed.The findings include:On September 14 and 15, 2009 ten client records were reviewed. In client records # 2, 3, 6. and 7, there were no documentation of records of services provided. In client records # 1 and 4 the records of services were not current. Client # 2 was admitted on 1/15/08 and was last seen on 9/8/09. There was no documentation of a record of services.Client # 3 was admitted on 2/18/09 and was last seen on 9/10/09. There was no documentation of a record of services.Client # 6 was admitted on 4/2/09 and was last seen on 8/26/09. There was no documentation of a record of services.Client # 7 was admitted on 5/10/07 and was last seen on 9/4/09. There was no documentation of a record of services.Client # 1 was admitted on 4/24/09. The record of services listed only the date of admission and did not list the session for 9/3/09 for which a progress note had been recorded.Client # 4 was admitted on 7/28/08. The last documented service for client # 4 on the record of services was 8/31/09. The record of services did not list the session for 9/14/09 for which a progress note had been recorded.
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Plan of Correction
At the next clinical staff meeting the clinical director and the project director will review the requirement that the record of service be filled out for each client.
The project director and the clinical director twice a month will randomly pick out two folders from each counselor's case load and check if the record of service forms are filled and are up to date. Each counselor will receive written feedback on the findings and will be given 7 days to fix any problem. The clinical director and the project director will then review the folders for compliance. |
709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on a review of ten client records, the facility failed to document progress notes which included a plan in five out of ten client records reviewed.The findings include:On September 14 and 15, 2009 a review of ten client records revealed that in five out of ten client records reviewed, the plan portion of the progress note was not specific to the individual client's treatment plan.In client record #3 progress notes did not include a plan that was consistent with the treatment plan on the following dates: 2/18/2009, 2/25/2009, 3/4/2009, 3/17/2009, 3/27/2009, 4/1/2009, 4/7/2009, 4/15/2009, 4/22/2009, 4/29/2009, 6/2/2009, 6/11/2009, and 6/17/2009. In client record # 5 the progress notes did not include a plan that was consistent with the treatment plan on the following dates: 7/14/2009, 7/21/2009, 8/25/2009, 9/1/2009, and 9/8/2009. In client record # 7 the progress notes did not include a plan that was consistent with the treatment plan. In client record # 9 the progress notes did not include a plan that was consistent with the treatment planIn client record # 10 the progress notes did not include a plan that was consistent with the treatment plan
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Plan of Correction
At the next clinical staff meeting the clinical director will discuss the need to try to follow a client's treatment plan in individual sessions to provide a smooth flow of services and progress to the client.
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709.93(a)(7) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(7) Client-related correspondence.
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Observations
Based on the review of client records, the facility failed to maintain copies of all client related correspondence within the client record. The regulation at 4 Pa. Code subsection 255.5 (a)(10) states that the "Project shall keep and maintain a written record of all information which is disclosed under this section." The client identifying information released to third party payers and criminal justice entities, as identified at 4 Pa. Code Subsection 255.5, was not documented in seven of fourteen client records.The findings include:The facility failed to document correspondence to funding entities in seven out of 14 client records reviewed on September 14 and 15, 2009. The facility failed to document correspondence to funding entities in client records # 6, 7, 8, 9,10, 12, and 14 .
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Plan of Correction
In the next clinical staff meeting the clinical director and the project director will again review the requirement that all correspondence (information)written or verbal given to funding agents, third party payers, criminal justice entities, and other parties be documented and kept in the client's file.
The clinical director and the project director twice a month will randomly pick two folders from each counselor's case load and spot check for the presence of documentation pertinent to this situation. Written feedback will be given to each counselor about what was found. If there are any deficiencies the counselor has 7 days to fix the problem and report the changes. |