INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 8, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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 December 8, 2010.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure and document that counselors completed at least 25 hours of training for the 2009/2010 training year in two of two personnel records.
The findings include:
Six personnel records were reviewed on November 1, 2010 through November 5, 2010. Two employee records represented the counselors who were required to have obtained 25 hours of training for the 2009/2010 training year.
Employee #4 was hired July 12, 2004 and was required to have obtained 25 training hours for the 2009/2010 training year. Employee record # 4 contained documentation of 15 hours of training for the training year 2009/2010.
Employee #5 was hired July 18, 2005 and was required to have obtained 25 training hours for the 2009/2010 training year. Employee record # 5 contained documentation of 19.5 hours of training for the training year 2009/2010.
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Plan of Correction
Counselors will be instructed that it is their responsibility to complete 25 hours of training per year. The training department will schedule the trainings and clinical supervisors will monitor all trainings to ensure compliance. The training department along with the clinical supervisors will conduct quarterly reviews to assure compliance with DOH requirements. The clinical supervisors will report to the Program Director the results of the quarterly reviews.
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on November 3, 2010 and an interview with the Project Director, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
On November 3, 2010 the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed the project director, facility director, two clinical supervisors and eight counselors for the clinical staff; however, the facility only documented one clinical supervisor and eight counselors, employee #4, 5, 6, 7, 8, 9, 10, 11 and 12 as having clients on a caseload.
The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week 40 and the total number of clients assigned to the following employees on 11/3/10, employees #5, 6, 11 and 12 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients 'treatment by the facility's standard workweek.
The number of hours per week devoted by Employee # 5 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 37.5 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 5 had 34 active clients on November 3, 2010.
Employee # 5 (37.5/40 = 0.9375 FTE 34 clients/7.675 FTE = 37:1 caseload)
The number of hours per week devoted by Employee # 6 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 7 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 6 had 7 active clients on November 3, 2010.
Employee # 6 (7/40 = 0.175 FTE 7 clients/0.175 FTE = 40:1 caseload)
The number of hours per week devoted by Employee # 11 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 37.5 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 11 had 35 active clients on November 3, 2010.
Employee # 11 (37.5/40 = 0.9375 FTE 35 clients/0.9375 FTE = 38:1 caseload)
The number of hours per week devoted by Employee # 12 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 37.5 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 12 had 35 active clients on November 3, 2010.
Employee # 12 (37.5/40 = 0.9375 FTE 35 clients/0.9375 FTE = 38:1 caseload)
During an interview, the project director confirmed that they had exceeded the allowable maximum caseload of 35:1 for each of the counselors, employees # 5, 6, 11 and 12 above.
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Plan of Correction
In filling out the Staffing Requirement Facility Summary Report the standard work week of 40 hours which was inadvertently listed for our clinical staff, refers to our support staff. By Union contract our clinical staff are working a 37.5 hour work week and are paid to reflect a 37.5 hour rate. We failed to indicate that all of our clinical staff are 37.5 hour employees. From this point forward the Project Director will ensure that the Staffing Requirement Facility Summary Report will be filled out correctly while ensuring that the 35:1 client to counselor ratio is always maintained. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill record were reviewed on November 2, 2010. The facility did not document any alternate exit used during fire drills for the months of 3/11/10, 6/10/10, 7/22/10 and 8/17/10.
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Plan of Correction
The security staff has been re-trained in a staff meeting on the proper fire drill procedures including the documentation of alternative exits used. This was presented to staff by the security director in the November security staff meeting. The Security Director will complete monthly reviews to ensure that this does not reoccur. |
709.22(e) 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:
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Observations
Based on the review of the facility's annual report for fiscal year July 1, 2009 through June 30, 2010, the facility failed to ensure that the annual report included a financial statement of income and expenses.
The findings include:
An interview was conducted with the Project Director on November 1, 2010. The Project Director confirmed that the financial statement of income and expenses was not documented on the annual report for July 1, 2009 to June 30, 2010.
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Plan of Correction
The Project Director will introduce the standard to the NHS Parkside Board of Directors and ask them to acknowledge that from this time forward the Department of Treasury Internal Revenue Service Form 990 will be available to the public as a financial statement of income and expenses. This Form 990 will be made available to the public upon request in the same manner as the annual report. The Project Director will ensure all components of the standard are fulfilled.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and an interview with the project director, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms, negative factors and the counselor's conclusions/impressions in eight of twelve client records.
The findings include:
Sixteen client records were reviewed on November 8, 2010. A psychosocial evaluation was required in twelve of those client records.
Client records #1, 2, 3, 4, 5, 6 and 13 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and the counselor conclusions/impressions.
Client record #14 was admitted on 8/31/10 and discharged on 10/21/10 and as of the date of discharge there was no documentation of psychosocial evaluation per the facility's policy and procedure. Per the facility's policy and procedure manual, histories and evaluations are to be completed within 30 days in order to formulate the client's comprehensive treatment plan.
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Plan of Correction
A directive will be given with a follow up training that all counselors will submit the completed psychosocial evaluationto their supervisor for review within 15 business days of the clients admission. The clinical supervisors will be responsible for monitoring this process. This will be done in weekly supervision with the counselor and supervisor to ensure this deficiency does not re occur.
Completion date: Directive immediately. Training by December 20.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in three of six discharge records.
The findings include:
Sixteen client records were reviewed on November 8, 2010. Of the sixteen records reviewed, six required documentation of follow-up information. The facility did not document follow-up information within 30 days from the date of discharge, as per facility policy, in client records, #7, 8 and 13.
Client #7 was admitted to the program 5/28/10 and discharged on 8/6/10; follow-up was not documented at the time of review on 11/8/10.
Client #8 was admitted to the program 10/17/07 and discharged on 7/12/10; follow-up was documented at the time of discharge 7/12/10.
Client #13 was admitted to the program 5/20/10 and discharged on 9/22/10; follow-up was not documented at the time of review on 11/8/10.
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Plan of Correction
The clinical supervisors will be responsible for ensuring that follow up surveys are sent to clients within the required time frame. All supervisors will log into their supervisory notes the date the survey was sent. The program director will review the supervision notes with each clinical supervisor during group supervision to insure the deficiency does not re-occur.
Completion Date: Immediately
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