INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 9-11, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Familylinks, Inc. 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 February 12, 2008.
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Plan of Correction
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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on a review of agency policy at the onsite inspection held January 9-11, 2008 the facility failed to present a a statement approved by the governing body that verified the intent of the project to comply with the regulation. This was a repeat citation.
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Plan of Correction
Sr. Program Manager will develop a written compliance plan approved by governing body to insure that all staff persons affected by this chapter meets the appropriate educational, experiential qualification and receive training as stipulated by the chapter.
The compliance plan will be reviewed three times a year by the Sr. Program Manager. The plan shall document the qualifications and training of all staff. The plan will be presented to licensing representative at next visit.
Completion Date: March 30, 2008.
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704.5(b) LICENSURE Clinical Supervisor
704.5. Qualifications for the positions of project director and facility director.
(b) If the facility does not have a clinical supervisor on staff, clinical responsibilities shall be addressed in one of the following ways:
(1) A facility director who has direct responsibility for clinical services shall meet the qualifications in at least one of the paragraphs of 704.7 (b) (relating to qualifications for the position of counselor).
(2) If the facility director does not meet counselor qualifications and the facility employs less than eight counselors, a lead counselor or part-time clinical supervisor shall be appointed.
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Observations
Based on a review of personnel policies at the onsite inspection held January 9-11, 2008 the facility failed to address the issue of hiring staff persons appropriate to the population served in the recruitment policy statement.
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Plan of Correction
Sr. Program Manager and Facility Director has hired a Lead Counselor on 1/29/08. The Clinical Supervisor meets the BDAP Licensing staffing requirements for lead Counselor. Sr. Program Manager and Human Resources Director will insure that the staff persons hired are appropriate to the population served in the recruitment policy statement. Sr. Program Manager will also develop new job descriptions for Lead Counselor, Counselor and facility Director to which will include BDAP Licensing staffing requirements and will submit to the governing body for approval. |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of personnel and training records at the onsite inspection held January 9-11, 2008 the facility failed to demonstrate that the counselor assistant was supervised by a full time counselor or clinical supervisor.
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Plan of Correction
Beginning March 1, 2008, the Facility Director will ensure that all assigned full-time counselors complete weekly supervision of counselor assistants. |
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 personnel and training policies at the onsite inspection held January 9-11, 2008 the facility failed include timeframes for completion of various components of the agency training plan in the written policy and procedure.
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Plan of Correction
Sr. Program Manager will develop a complete comprehensive staff development program that will include time frames for the assessment, plan and evaluation. A narrative summarizing group needs will conducted at the middle and end of fiscal year. The policy will be submitted to the govern body for approval.
Completion Date: April 1, 2008
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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 a review of personnel and training records at the onsite inspection held January 9-11, 2008 the facility failed to document a compilation of the data or demonstrate that the data was collected.
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Plan of Correction
Training Needs Assessment
Sr. Program Manager will develop a comprehensive staff development that will include an assessment of training needs. Sr. Program Manager will submit a trainings needs assessment questionnaire to all staff persons and collect the data at the end of the fiscal year. Once the data is collect the Sr. Program Manager will develop a narrative summarizing the overall needs, progress of the plan and how the overall needs will be addressed.
Completion Date: April 1, 2008.
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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 a review of personnel and training records at the onsite inspection held January 9-11, 2008 the facility failed to consistently document training feedback forms. Training feedback forms were not consistently documented in accordance with agency policy (to be documented for each training attended) in employee records # 1 and 4 in the sample of 4 employee records at this site.
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Plan of Correction
Beginning March 1, 2008, the Facility Director will ensure that all AOD-OP employees complete training feedback forms by reviewing training files monthly. The Facility Director will review the facility training policy in staff meetings once monthly. |
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 a review of personnel and training records at the onsite inspection held January 9-11, 2008 the facility failed to provide for an annual evaluation that was complete. The documentation consisted of a summary of training held on a semi annual basis, but failed to
determine the extent to which the plan addressed the identified needs, including a determination of the extent to which implementing the plan eliminated or satisfied the identified needs.
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Plan of Correction
Training Needs Assessment
Sr. Program Manager will develop a comprehensive staff development that will include an assessment of training needs. Sr. Program Manager will submit a trainings needs assessment questionnaire to all staff persons and collect the data at the end of the fiscal year. Once the data is collect, the Sr. Program Manager will develop a annual
narrative summarizing the overall needs, progress of the plan and how the overall needs will be addressed.
Completion Date: April 1, 2008.
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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 and training records at the onsite inspection held January 9-11, 2008 the facility failed to document the required 25 annual training hours for two of the five counselors who work at this site, specifically employee records # 5 and 6.
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Plan of Correction
Beginning March 1, 2008, The Facility Director will review all AOD-OP training files monthly to ensure that all staff is current with the required hours of training for their specific positions. The Facility Director will discuss training hours during biweekly supervisions. The Facility Director will make Familylinks training calendar available during staff meetings once monthly to ensure staff receives the appropriate number of training hours. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a review of the physical plant at the onsite inspection held January 9-11, 2008 the facility failed to ensure privacy of the counseling areas. Counseling sessions could be heard through the walls in at least one of the counseling areas in the facility. The counseling area at issue is adjacent to the conference area used by clients and staff from other agencies for meetings. This area is also used by clients with children as a lounge at times. Client confidentiality in the adjacent office is compromised.
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Plan of Correction
The Facility Director obtained white noise machines for all offices on January 31, 2008 to ensure privacy of counseling areas. |
705.25 (4) LICENSURE Food service.
705.25. Food service.
A nonresidential facility may provide meals to clients through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers. A nonresidential facility which operates an onsite food preparation area or a central food preparation area shall:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on a review of the physical plant at the onsite inspection held January 9-11, 2008 the facility failed to ensure that appliances used to store and prepare meals were clean when not in use. Food particles and food splatter were noted in the oven used to warm meals served to the clients and in the refrigerators used to store food served to clients when meal preparation was not occurring.
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Plan of Correction
Beginning March 1, 2008, the Facility Director will ensure the oven and refrigerator ware cleaned daily by assigned staff. The Facility Director will complete spot inspections once weekly. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records at the onsite inspection held January 9-11, 2008 the facility failed to document fire drills for May and June, 2007.
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Plan of Correction
Beginning March 1, 2008, the Facility Director will ensure the assigned staff member completes monthly fire drills by reviewing the fire drill log by the end of each month. The Facility Director will conduct in-service trainings on a quarterly basis to educate all staff on the procedures for monthly fire drills |
709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records at the onsite inspection held January 9-11, 2008 the facility failed to document a drug and alcohol history that included current and previous alcohol and/or drugs used by the client , lengths and patterns related to the progressions of use, prior treatment experiences and/or the client's perception of use. Incomplete histories were noted in two of two applicable client records (client records #2 and 3). This is a repeat citation.
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Plan of Correction
Beginning March 1, 2008, the Facility Director will conduct trainings on detailed documentation of Drug and Alcohol histories in AOD staff meetings once monthly. The Facility Director will review 10 charts monthly to ensure compliance. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records at the onsite inspection held January 9-11, 2008 the facility failed to document complete personal histories. A review of two client records, specifically #2 and 3, revealed that employment/vocation, recreation and sexual histories within the personal history had unanswered questions. This is a repeat citation.
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Plan of Correction
Beginning March 1, 2008, the Facility Director will conduct in-service trainings on a monthly basis to review complete documentation of personal histories within the required periods and will review 10 charts monthly to ensure compliance. |
709.82(a)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records at the onsite inspection held January 9-11, 2008 the facility failed to provide for individualized treatment plans. The short and long-term goals were not individualized in 1 of 2 client records reviewed, specifically client record #2. This is a repeat citation.
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Plan of Correction
Beginning March 1, 2008, the Facility Director will ensure through weekly supervisions and Quality Assurance Reviews that treatment plan goals are individualized. In-service trainings will occur during AOD staff meetings monthly to ensure compliance with facility policy. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records at the onsite inspection held January 9-11, 2008 the facility failed to provide for complete treatment plan updates. In one of one applicable client records for this level of care, the treatment plan update failed to address the client's progress on the stated goals of the treatment plan.
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Plan of Correction
Beginning March 1, 2008, the Facility Director will conduct monthly in-service trainings to review facility policy of completing treatment plan updates that identify client progress within the required time frames. |
709.84(d) LICENSURE Project management services
709.84. Project management services.
(d) The project shall develop a written client aftercare policy.
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Observations
Based on a review of agency policy at the onsite inspection held January 9-11, 2008 the facility failed to provide for a complete policy and procedure for aftercare plans. The policy did not address staff members responsible for the plan or the time frame for completion of the plan.
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Plan of Correction
Beginning March 12, 2008, Facility Director will revise the aftercare policy to state the person responsible for completion of the aftercare plan is the primary therapist with input from the client. The aftercare plan will be completed 7 days prior to scheduled discharge date. If the client leaves before the scheduled discharge date the aftercare plan will be completed the day of the clients discharge. Facility Director will redesign the aftercare form to identify the person responsible for completion of the plan and the time frames required for completion of the plan. This revised form wil be reviewed and discussed at the monthly AOD managers meeting in February. This form will begin to be used by March 1, 2008. |
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 a review of administrative materials presented at the inspection of January 9-11, 2008, the facility failed to produce documentation of an audit for the last fiscal year.
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Plan of Correction
Sr. Program Manager will coordinate with Finance Director to insure that an annual audit is completed yearly by an independent public accountant. The documentation of the annual audit will presented to licensing representative at the next visit.
Completion Date: April 1, 2008
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709.28 (c)(1) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on client record reviews during the onsite licensing inspection of January 9-10, 2008, the facility failed to comply with Pennsylvania Code. Documentation of releases of information to government entities included in the client records demonstrates that the facility exceeded the restrictions on the release of information imposed at 4 Pa. Code subsection 255.5(b) in client records # 1, 2 and 8, or three of six client records reviewed for this purpose.
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Plan of Correction
Beginning March 1, 2008, the Facility Director will review the limits of Pennsylvania Confidentiality Code 255.5 in bi-weekly AOD staff meetings. The Facility Director will review 10 charts monthly to ensure compliance. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records at the onsite inspection held January 9-11, 2008 the facility failed to provide for complete drug and alcohol histories. Drug and alcohol histories in client records # 1, 7 and 8 were incomplete, missing the amount and type of drugs used, and the frequency of use. Client records # 4 and 5 did not include complete information on the lengths and patterns of substance use. The total outpatient record sample consisted of 6 client records.
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Plan of Correction
Beginning March 1, 2008, the Facility Director will conduct trainings on accurate documentation of Drug and Alcohol histories. The Facility Director will ensure through weekly supervisions that the Drug and Alcohol histories are completed within the required time frames. The Facility Director will review 10 charts monthly to ensure compliance. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records at the onsite inspection held January 9-11, 2008 the facility failed to fully address the client's personal history. The personnel histories in client records # 1,4,5 and 8, representing four of four client records reviewed for this purpose, were in complete in the areas of family history, educational history, vocational history and legal history.
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Plan of Correction
Beginning March 1, 2008, the Facility Director will ensure through weekly supervisions that personal histories are completed by the required time frames and will review 10 charts monthly to ensure compliance. |
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 at the onsite inspection held January 9-11, 2008 the facility failed to provide for complete psychosocial evaluations. The psychosocial evaluations in client records # 4, 5 and 8 did not fully assess support systems, coping mechanisms and the composite picture. This accounted for 3 of 4 applicable client records in the sample.
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Plan of Correction
Beginning March 1, 2008, the Facility Director will ensure through weekly supervision that psychosocial evaluations are completed and specific within the required time frames. The Facility Director will review 10 charts monthly to ensure compliance. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records at the onsite inspection held January 9-11, 2008 the facility failed to consistently provide for individualized and measurable short and long term goals. Treatment plan goals written in records # 1, 4, 5 and 8 lacked measurability criteria or any relationship to the identified D&A issues noted in counselor comments elsewhere in the client records. This accounted for four of four applicable records in the sample.
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Plan of Correction
Beginning March 1, 2008, the Facility Director will conduct monthly in-service trainings with AOD staff to review completion of treatment plan goals that are measurable and specific to D/A issues. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records at the onsite inspection held January 9-11, 2008 the facility failed to provide for a complete treatment plan. The proposed type of support services was missing from the treatment plans in 3 of 4 client records in the sample ( # 4, 5 and 8).
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Plan of Correction
Beginning March 1, 2008, the Facility Director will ensure through weekly supervisions that proposed type of support services and indicated on treatment plans. The Facility Director will review 10 charts monthly to ensure compliance. |
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
Based on a review of client records at the onsite inspection held January 9-11, 2008 the facility failed to address progress on the stated goals of the treatment plan update. This was observed in two of two applicable client records (# 1 and 8).
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Plan of Correction
Beginning March 1, 2008, the Facility Director will ensure through weekly supervisions that client progress of stated goals is indicated on treatment plans. |
709.94(d) LICENSURE Project management services
709.94. Project management services.
(d) The project shall develop a written client aftercare policy.
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Observations
Based on a review of the agency manual at the onsite inspection held January 9-11, 2008 the facility failed to provide for a complete aftercare policy and procedure. The after care policy must address the following components : the staff members responsible for the aftercare plan, when and how it is to be developed and the format to be used. The policy did not address staff members responsible for the plan or the time frame for completion of the plan.
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Plan of Correction
Beginning March 12, 2008, Facility Director will revise the aftercare policy to state the person responsible for completion of the aftercare plan is the primary therapist with input from the client. The aftercare plan will be completed 7 days prior to scheduled discharge date. If the client leaves before the scheduled discharge date the aftercare plan will be completed the day of the clients discharge. Facility Director will redesign the aftercare form to identify the person responsible for completion of the plan and the time frames required for completion of the plan. This revised form wil be reviewed and discussed at the monthly AOD managers meeting in February. This form will begin to be used by March 1, 2008. |
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
Based on a review of administrative materials the facility failed to document that the Medical Director was the physician of record approved for Medical Assistance billing purposes.
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Plan of Correction
Sr. Program Manager is coordinating with Director of Clinical Support to insure a signed provider agreement with the Department of Public Welfare and comply with code 55 Pa. Code part III relating to Medical Assistance Manual. On 1/ 30/08 the Director of Clinical Support has submitted documentation to the Department of Public Welfare for the FamilyLinks Medical Director to be physician approved for Medical Assistance billing.
Completion Date: April 1, 2008
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