INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 6, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Ridgeview Adolescent Behavioral Health Center at Pittsburgh 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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704.7(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
The facility failed to ensure that each counselor met the qualifications for the position in one of five personnel records reviewed on December 6, 2016.
Eight personnel records were reviewed. Five personnel records were required to have documentation of the qualifications for the position of counselor. Personnel record # 6 had a Bachelor's degree and only 7 months of the required 1 year of experience documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, any potential counselor candidates will be reviewed with Chief Clinical Compliance Officer, Regional Clinical Supervisor, and or Human Resources. This process will ensure that the candidates are properly vetted and have the correct requirements to hold a position as a counselor. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
The facility failed to provide an exhaust fan or window in two bathrooms as observed during the December 6, 2016 licensing inspection.
The second floor boys and girls bathrooms did not have operable fans or windows.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pyramid Western Region Construction Maintenance Manager will ensure that current inoperable fans are evaluated by Ridgeview Maintenance or professional service personnel if required and either repaired to working order or replaced with new units if necessary.
Repaired or replaced units will be inspected by Ridgeview Maintenance monthly to ensure they are in proper working order. |
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.
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Observations
The facility failed to obtain informed and voluntary consent forms for the disclosure of information contained in the client record in seven of ten client records reviewed on December 6, 2016.
Ten client records were reviewed. Ten records required an informed and voluntary consent to release client information. The facility failed to obtain an informed and voluntary consent to release information in client records # 1, 2, 3, 4, 8, 9 and 10.
The consent to release information form states that revocation must be in writing. 42 CFR Part 2, Subpart C, subsection 2.31 (a) Required elements, specifies that the following information must be included on the written consent: "(8) A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it." Therefore, as per 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) the consent to release client information form can be revoked by the client at any time and there is no restriction on the manner in which they may revoke it. The facility failed to adhere to the requirements outlined in the federal confidentiality regulations by requiring the clients to revoke consent forms in writing.
In addition, consents to release information to criminal justice authorities were observed to include a statement that the consent could not be revoked. There were no court orders mandating treatment documented for these clients and therefore, the consents could be revoked verbally or in writing at any time.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
VP of Clinical Services revised consents on November 28, 2016 to ensure that all consents contain appropriate elements of a valid consent, inlcudng acknowledgement that a copy was offered to the client as well as the ability to revoke consents verbally or in writing. Criminal Justice consent was revised to eliminate statement that consent cannot be revoked. All staff members who deal directly with consents will receive additional training on revisions and completion of consents. Training will be concluded by February 2017. Completion of training will be verified by post test completion and monitored by Human resources Coordinators. |
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 record.
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Observations
The facility failed to document that a copy of signed consents were offered to the client in seven of ten client records reviewed on December 6, 2016.
Ten client records were reviewed. Seven client records, # 1, 2, 3, 4, 8, 9 and 10 included at least one signed consent in which the client was not offered a copy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
VP of Clinical Services revised consents on November 28, 2016 to ensure that all consents contain appropriate elements of a valid consent, inlcudng acknowledgement that a copy was offered to the client as well as the ability to revoke consents verbally or in writing. Criminal Justice consent was revised to eliminate statement that consent cannot be revoked. All staff members who deal directly with consents will receive additional training on revisions and completion of consents. Training will be concluded by February 2017. Completion of training will be verified by post test completion and monitored by Human resources Coordinators. |
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
The facility failed to document that treatment and rehabilitation plans were reviewed and updated at least every 60 days in one of three records reviewed on December 6, 2016.
Ten records were reviewed. Three records were reviewed as outpatient client records, and required plan updates. Client # 6 update was due to be completed by September 26, 2016. The update was completed on October 25, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will address treatment plan updates during weekly supervision as well as weekly treatment team. Clinical Supervisor will be responsible to complete a monthly chart monitoring process for all current clients in order to review and ensure all treatment plan updates are completed with the client in the time frame specified by the licensing process. This process will continue to ensure that all current and future client treatment plan updates are completed in a timely manner. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
The facility failed to provide a physician's signature on treatment plans in one of two client records reviewed on December 6, 2016.
Ten client records were reviewed. Three records were reviewed as outpatient client records. Two records required a physician's signature on the treatment plan. There was no physician's signature on the treatment plan in client records # 6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will work with the outpatient counselor to ensure that any materials required to be signed by the facility physician will be completed in a timely manner and available for the the physician to review and sign in the time frame specified by the licensing process. |