INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 1, 2007 through May 4, 2007 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 June 4, 2007.
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
The core curriculum training has not been obtained for two employees, #3 and 18.
|
Plan of Correction
1. The facility has had challenges in locating the five-day required training for new Clinical Supervisors. However, the facility will research with the Bureau of Drug and Alcohol Programs to determine the next available offering of the curriculum.
2. The facility will ensure that employees 3 and 18 will complete the curriculum the next time it is offered in Southeastern Pennsylvania.
3. The Project Director will monitor for compliance and report to the Executive Committee upon completion. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Counselor assistant #23 was missing 7 of the 9 months of close supervision required.
|
Plan of Correction
1. During the recent licensing visit, the status of employee #23 was clarified. The facility had previously provided supervision to the employee based on his completion of a master's degree. However, the facily now understands that because his degrees do not meet state standards that he will be counted as having a high school diploma.
2. As a result, the program's Facility Director, will provide documented close supervision over the next seven months.
3. The status of the close supervision will be reported monthly to the Executive Committee over the next seven months for oversight and monitoring. |
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.
|
Observations
The assessments of staff training needs were not documented in 25 of 27 employee records reviewed, # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25.
|
Plan of Correction
The Project Director will ensure compliance with this standard by ensuring that, annually, the individual assessment of training needs -- which form the basis for the facility's annual training plan -- is included in individual employees' personnel files. |
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.
|
Observations
Feedback forms were not completed on all training attended in 16 of 27 employee records reviewed, # 1, 3, 6, 7, 12, 13, 15, 16, 17, 18, 19, 20, 22, 23, 24, and 25.
|
Plan of Correction
1. The Human Resources Department, the Faiclity Director and the Clinical Supervisor have been re-trained by the Project Director in the requirement that training feedback forms accompany any certificates for internal and external trainings. The information was relayed on May 28, 2007.
2. To ensure compliance with the requirement, the Facility Director and the Clinical Supervisors will review staff personnel records on a quarterly basis for the next three quarters to ensure compliance.
3. Results of the quarterly review of personnel files will be reported to the Executive Committee for oversight and monitoring.
4. Remedial education will be provided immediately to any staff member who does not complete the training feedback form following participation in both internal and external trainings. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
The individual training plans did not include potential resources for training in 17 of 27 employee records reviewed, #7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 18, 19, 24, 25, 26, and 27.
|
Plan of Correction
1. The 2007-2008 training plans will be revised to ensure that they include potential resources for all trainings listed.
2. This will be completed by the Facility Director and the Clinical Supervisors who each supervise the Primary Therapists.
3. Completion of the curent project will be reported to the Executive Committee in August 2007.
4. The Project Director will revise the Policy and Procedure governing training plans to include a requirement of resources for potential trainings. This will be completed by June 30, 2007. |
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
HIV/AIDS training was missing in 13 of 24 employee records reviewed, #2, 8, 9, 10, 12, 18, 19, 20, 21, 22, 23, 24, and 25. TB/STD training was missing in 14 of 24 employee records reviewed, #2, 7, 8, 9, 10, 12, 18, 19, 20, 21, 23, 24, 25, and 27.
|
Plan of Correction
1. The Human Resources Department conducted an audit in May 2007 to identify any staff member in need of the mandatory HIV/AIDS and TB/STD trainings.
2. The mandatory trainings were conducted May 18 and May 23, with about 25 employees in attendance.
3. The mandatory trainings will be offered quarterly over the next six months to ensure that all staff have completed the mandatory trainings. |
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
Six counselors did not receive the required number of training hours for the 2005 - 2006 training year, #7, 8, 10, 12, 19, and 21.
|
Plan of Correction
1. Moving forward, the facility will ensure that Primary Therapists and Social Workers complete the required number of training hours.
2. The facility is currently considering an employee benefit to help defray the cost of some outside trainings as a means of ensuring compliance with the training hour requiements.
3. Quarterly over the next 12 months, during the 2007-2008 training year, the Facility Director and the Clinical Supervisors will review personnel files to determine whether staff are on target for completion of the required training hours.
4. Results of those reviews will be provided quarterly to the Executive Committee for oversight and monitoring. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
|
Observations
Employee #23 earned only 7 of the required 30 hours of training for the 2005 - 2006 training year.
|
Plan of Correction
1. The employee has been informed that due to his status as a Counselor Assistant that he is required to complete 30 hours of training annually.
2. His immediate supervisor, the Facility Director, will ensure that the employee completes 30 hours of trainings during the 2007-2008 training year. |
709.123(b)(2) LICENSURE Tx Plan Update
709.123. Treatment and rehabilitation.
(b) Treatment and rehabilitation services.
(2) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
|
Observations
Treatment plan updates did not provide an assessment of the client's progress in relationship to the previously stated goals in two of two client records reviewed, #10 and 23.
|
Plan of Correction
1. One of the Clinical Supervisors has revised the Treatment Plan Template to ensure that on each update that a review of progress on previous goals is completed.
2. Clinical Staff will be retrained by the Clinical Supervisor in the correct completion of Updated Treatment Plans to include a review of progress attained on previous treatment goals.
3. Chart Audits on both open and closed charts are conducted monthly. The chart audits will include a review of the progress section of the Updated Treatment Plan.
4. Chart audit results will be reported monthly to the Executive Committee for the next three months for oversight and monitoring. |
709.123(c)(5) LICENSURE Follow-up information
709.123. Treatment and rehabilitation.
(c) Client records. 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) Follow-up information.
|
Observations
Follow up information was not documented in three of three client records reviewed, # 9, 10 and 14.
|
Plan of Correction
1. The Facility Director and the Clinical Supervisors in weekly supervision will re-train therapists in the requirement that follow-up be conducted for each patient within seven days of discharge.
2. The facility has modified its procedure and will attempt to obtain follow-up information on patients who leave the facility AMA or AWOL.
3. Closed-chart audits will be used to determine the facility's level of compliance with this requirement. Chart audit results will be reported monthly to the Executive Committee for oversight and monitoring for the next three months. |
705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
|
Observations
Dresser drawers were missing knobs and/or the drawers were broken in ten bedrooms inspected, # 102, 104, 105, 106, 107, 109, 110, 111, 115, and 511.
|
Plan of Correction
1. The Project Director, the Facility Director and the chairman of the Environment of Care Committee will inspect all patient rooms to ensure that all dressers are in good condition and include knobs.
2. Work orders for the Maintenance Department will be generated as a result of the inspections.
3. Repairs will be completed by the Maintenance Department or new furniture will be purchased to ensure all dressers are in good condition.
4. Following completion of the work orders, the Project Director, the Facility Director and the chairman of the Environment of Care Committee will re-inspect all patient rooms to ensure completion of the work. They will report their findings to the Environment of Care Committee at the August meeting. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
A fire drill was not conducted during sleeping hours in the last 6 months.
|
Plan of Correction
1. The Environment of Care Committee during its monthly meeting in May voted to ensure that at least one fire drill during each quarter will occur during patient sleeping hours.
2. Patient sleeping hours have been defined as from 11 p.m. to 6:30 a.m. daily.
3. The Environment of Care Committee will ensure that the Supervisor of Security and the Engineering Department Manager schedule at least one fire drill during sleeping hours each quarter.
3. Results of fire drills are reported monthly to the Environment of Care Committee for oversight and monitoring. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
|
Observations
The annual report for the 2005 - 2006 fiscal year did not include a statement disclosing the names of offices, directors, and principal shareholders.
|
Plan of Correction
1. The Project Director will ensure that the annual report for 2005-2006 is revised to include the names of officers, directors and principal shareholders.
2. The Administrative Assistant has been educated in ensuring the name of officers, directors and principal shareholders are contained in future reports. |
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.
|
Observations
The annual performance evaluation was missing or late in 15 of 27 employee records reviewed, # 9, 10, 12, 13, 15, 16, 17, 18, 20, 22, 23, 25, 26, and 27.
|
Plan of Correction
1. The Human Resources Department will audit all personnel files to determine which annual evaluations are currently due. The list will be provided to the Project Director and Director of Nursing, who will ensure annual evaluations are completed.
2. Quarterly, the Facility Director and the Clinical Supervisors will audit the personnel files to determine which employee evaluations are upcoming. Within one week, the evaluations will be completed.
3. Quarterly, the Facility Director and the Clinical Supervisors will report the status of employee evaluations to the Executive Committee for oversight and monitoring. |
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:
|
Observations
The facility failed to demonstrate that employees were informed of their rights since the employee handbook did not include employee rights under Chapter 709.26 (e) (2) & (e) (3).
|
Plan of Correction
1. The Human Resources Department will revise the employee handbook to ensure that it enumerates employee rights under Chapter 709.26(e)(2) & (e)(3).
2. Each employee will be asked to sign a statement that they have received a revised copy of the employee handbook.
3. New employees during the two-day New Hires Orientation also be provided copies of the handbook and will be asked to sign an attestation that they have received their employee rights. |
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.
|
Observations
The policy states that "the employee should submit to the Manager of Human Resources rebuttal data detailing reasons for the correction or removal of information in the personnel file." The policy does not state that the employee may submit rebuttal data or memoranda to his/her own record as a separate action.
|
Plan of Correction
1. The policy has been revised to include the mechanism by which an employee may submit rebuttal data or memoranda detailing reasons for the correction or removal of information in the personnel file.
2. The Human Resources Department has been instructed in the policy revision. |
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:
|
Observations
Information was released to DPW without a consent to release information form signed in one client record reviewed, #17 and exceeded that allowed by 4 Pa. Code 255.5 to CBH in one record, #5.
The specific information to be released was not documented in two of seventeen client records reviewed, #8 and 27.
Consent to release information forms to the client's emergency contact did not identify the specific person to whom the information would be released to or had the statement "none listed" but were signed by the client in three of seventeen records reviewed, #18, 19 and 20.
|
Plan of Correction
1. Staff in both the Chemical Dependency and Acute Psychiatric Programs have been re-trained by the Facility Director, Clinical Supervisors and Director of Social Services in ensuring that consent forms are executed prior to the release of information to governmental agencies, such as DPW.
2. Staff have been re-trained by the Facility Director, Clinical Supervisors and Director of Social Services to limit information to managed-care organizations in accordance with 4PA. Code 255.5. In addition, staff will be re-trained in what information is permitted to be recorded in the Pennsylvania Client Placement Criteria forms that are provided to managed-care organizations.
3. Staff will be re-trained by the Facility Director, Clinical Directors and Director of Social Services to be specific in identifying information that will be released.
4. The Director of Admissions will re-train Admissions staff in appropriately filling out emergency contact consents. In the cases in which prospective patients refuse to sign a consent for an emergency contact, the Admissions Coordinator will remove the form from the patient record, as per recommendation of on-site reviewer.
5. Consent forms are part of the routine open- and closed-chart audits that are reported monthly to the Executive Committee for oversight and monitoring. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
|
Observations
The facility failed to demonstrate clients were informed of their rights as identified in Chapter 709.30 (a) (3)(i)-(iv).
|
Plan of Correction
1. The Patient Handbook will be distributed to all new incoming patients by the Admissions Department. The Patient Handbook contains the Client Rights in both English and Spanish.
2. All incoming patients will be asked to sign a statement that they have received a copy of their rights.
3. The Patient Rights will be revised to include information:
A)that the project director may temporarily remove portions of the record prior to client inspection if he/she determines that information may be detrimental to the client. Reasons for removing sections of the record will be kept on file.
B)that the patient will have the right to appeal a decision limiting access to his/her records to the Project Director.
C) that the patient will have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his/her record.
D) that the patient will have the right to submit rebuttal data or memoranda to his/her own record. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
|
Observations
The form that is utilized by the program to verify that the client was made aware of their opportunity to request reconsideration of the termination of their treatment was not completed or signed by the client in one of one client records, # 12.
|
Plan of Correction
1. The Clinical Operations Supervisor will revise the form used for non-routine discharges so that the form is user-friendly and ensures the patient is notified of his/her right to appeal a termination.
2. The Clinical Operations Supervisor will provide a training to all Primary Therapists during the weekly staff meetings in ensuring that patients being discharged involuntarily sign that they understand their right to appeal the decision. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
|
Observations
The psychosocial evaluations were summaries of the client's personal history and did not address the client's composite picture, problems/needs, support systems, and attitude towards treatment in three of three client records reviewed, # 4, 5 and 7.
|
Plan of Correction
1. The facility sponsored a two-hour training in Cognitive Case Conceptualization, given by a professor from Philadelphia College of Osteopathic Medicine, on April 19, 2007. The training was attended by Primary Therapists who retire the psychosocial evaluations and summaries.
2. Monthly for the next four months, the Facility Director and the Clinical Supervisors will conduct audits of 10 percent of all new admissions each month to determine level of remediation for specific counselors.
3. Results of the audits will be provided monthly for three months to the Executive Committee for oversight and monitoring.
|
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
The psychosocial evaluations are summaries of the client's personal history and do not address the client's support systems, coping mechanisms, and attitude towards treatment in eight of ten client records reviewed, #6, 8, 11, 16, 19, 22, 24, and 27.
|
Plan of Correction
1. The facility sponsored a two-hour training in Cognitive Case Conceptualization, given by a professor from Philadelphia College of Osteopathic Medicine, on April 19, 2007. The training was attended by Primary Therapists who retire the psychosocial evaluations and summaries. 2. Monthly for the next four months, the Facility Director and the Clinical Supervisors will conduct audits of 10 percent of all new admissions each month to determine level of remediation for specific counselors. 3. REmediation will be provided, as necessary, to ensure summaries include client's support systems, coping mechanisms and attitudes toward treatment. 4. Results of the audits will be provided monthly for three months to the Executive Committee for oversight and monitoring. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Treatment plan updates did not provide an assessment of the client's progress in relationship to previously stated goals in seven of fourteen records reviewed, #10, 13, 17, 18, 19, 23, and 24. Additionally, the treatment plan updates were either late or missing in three of fourteen records reviewed, # 6, 8, and 27.
|
Plan of Correction
1. One of the Clinical Supervisors has revised the Treatment Plan Template to ensure that on each update that a review of progress on previous goals is completed. 2. Clinical Staff will be retrained by the Clinical Supervisors in the correct completion of Updated Treatment Plans to include a review of progress attained on previous treatment goals. 3. Chart Audits on both open and closed charts are conducted monthly. The chart audits will include a review of the progress section of the Updated Treatment Plan. 4. Chart audit results will be reported monthly to the Executive Committee for the next three months for oversight and monitoring. |