INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 8, 2010 licensure renewal inspection. The follow-up inspection was conducted on September 19, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Parkside Recovery was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 interim facility director, the facility failed to ensure and document that counselors completed at least 25 hours of training for the 2010/2011 training year in two of two personnel records.
The findings include:
Two personnel records were reviewed on September 19, 2011. Two employee records represented the counselors who were required to have obtained 25 hours of training for the 2010/2011 training year, #1 and 2. The interim facility director was interviewed on September 19, 2011 and she confirmed the findings.
Employee #1 was hired July 12, 2004 and was required to have obtained 25 training hours for the 2010/2011 training year. Employee record # 1 contained documentation of 14.15 hours of training for the training year 2010/2011.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the November 8, 2010 licensing inspection.
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Plan of Correction
DOH previously approved corrective action plan, 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. |
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 September 19, 2011. The facility did not document any alternate exit used during fire drills for the months of June 2011, July 2011, August 2011 and September 2011. The facility also did not document alternate exits, just put front and back exits, for the months of November 2010, January 2011, February 2011, March 2011, April 2011 and May 2011.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the November 8, 2010 licensing inspection.
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Plan of Correction
Effective October 24, 2011 Security staff persons was trained on propere documentation of alternate exits usage. Security staff and clinical superviosr will be meeting monthly to review building safety procedures and ensure documentation is noted, to avoid any further violation. (On October 24, 2011 was the first fire drill that noted the alternate exit used). |
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.
This was still out of compliance at the time of the follow-up conducted on September 19, 2011.
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Plan of Correction
DOH previously approved corrective action plan, 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. |
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 interim facility 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 two of three client records.
The findings include:
Eight client records were reviewed on September 19, 2011. A psychosocial evaluation was required in three of those client records, #1, 2 and 3.
Client records #1 and 3 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.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the November 8, 2010 licensing inspection.
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Plan of Correction
Intake staff will be re-educated by the clinical supervisor on the process of accepting new admission summaries to include bio-social evaluation, assets, strengths, support system and coping mechanisms; from the referring agency and documenting information received. Clinical staff will be re-trained by clinical supervisor on documenting bio-psychosocial histories to include evaluating client's strengths, assets, support system and coping mechanisms. The clinical supervisor will also train staff to include their clinical impression, prognosis and document the client's attitude towards treatment. Clinical Supervisor will also provide supervision and monitor counselor's ability to request and receive previous treatment records when informed. October 28, 2011 was the beginning of scheduled trainings to re-educate staff on completing bio-psychosocial evaluation within a 30 day period. Scheduled trainings will include the documentation of the client's strengths, assets, support systems, coping mechanisms and including the staff's clinical impression and prognosis of the client's attitude towards treatment. Monthly peer review and chart audits with internal PQI staff will ensure compliance with these steps. |
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 six of eight discharge records.
The findings include:
Eight client records were reviewed on September 19, 2011. The facility did not document follow-up information within 30 days from the date of discharge, as per facility policy, in client records, #1, 3, 4, 5, 6 and 8.
Client #1 was admitted to the program 2/24/11 and discharged on 3/29/11; follow-up was not documented at the time of review on 9/19/11.
Client #3 was admitted to the program 1/24/11 and discharged on 4/7/11; follow-up was documented at the time of discharge 9/19/11.
Client #4 was admitted to the program 3/24/11 and discharged on 4/11/11; follow-up was documented but it could not be determined if it was documented within 30 days of the client's discharge date due to the letter not having a date when it was sent out.
Client #5 was admitted to the program 1/20/10 and discharged on 1/20/11; follow-up was not documented at the time of review on 9/19/11.
Client #6 was admitted to the program 2/24/10 and discharged on 2/8/11; follow-up was not documented at the time of review on 9/19/11.
Client #8 was admitted to the program 3/3/11 and discharged on 3/14/11; follow-up was documented but it could not determined if it was documented within 30 days of the client's discharge date due to fact the letter was not dated.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the November 8, 2010 licensing inspection.
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Plan of Correction
In November 2010 a log book was implemented as a means of documenting outreach and follow-up letters being sent by the medical records clerk within a 30 day period. Effective October 28, 2011 the Program Director/Clinical Supervisor will review the log book weekly with the clinical and medical records staff at the weekly staff meeting to ensure that follow-up letters are being mailed for all discharges over the past 30 days and discharge policy is being addressed. Any letter not completed and sent will be sent before the next weekly meeting and properly documented in the logbook with the date sent. |