INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28-30, 2006 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 September 26, 2006.
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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
Employee # 5 did not meet the requirements for the position of counselor. The educational credentials presented were determined to be in an unrelated field of study. This individual will need to be supervised as a counselor assistant at the high school level.
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Plan of Correction
Counselor in question's position is now Counselor Assistant. Clinical Supervisor will provide direct observation of all clinical services provided for 90 days. Afterwards close supervision will occur for 9 months. THis will be done by Clinical Supervisor and monitored by Program Manager. Clinical Supervisor, John A.and Program Manager. Amy A. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
No documentation was presented to demonstrate that the counselor assistant is working toward meeting one of the requirements of this chapter for the counselor position. A counselor assistant is required to provide documentation to the facility director that demonstrates he/she is working toward counselor status. This information is to be documented upon completion of each calendar year.
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Plan of Correction
Memo to be given to counselor in question, stating that she needs to provide annual updates in progress towards achieving full counselor status.
Memo from counselor is to be received every January for the previous year.
Memo will be made out to director who will monitor progress. |
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.
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Observations
Individual training plans must be documented for new hires within one month of the date of employment ( see the licensing alert of May, 2005). Employee personnel records # 6, 7 and 8 did not have appropriate documentation to demonstrate that this occurred.
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Plan of Correction
Individual training plan forms for new employees will be made a part of the hire packet. Immediately after hire clinical supervisor will sit with new employee and formulate the individual plan that will be put in the training binder. Program Manager or Program Director will monitor for compliance. |
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.
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Observations
Counselors and counselor assistants must complete mandatory communicable disease training within the first year of employment. All other staff shall complete the training within the first 2 years of employment. Documentation that this training occurred was missing from employee personnel records #7, 10 and 11.
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Plan of Correction
All Discovery House staff will be given memo and copy of regulation regarding mandatory training. All personnel in need of training that are currently out of compliance will be given 6 months to be in compliance. Program Director will monitor to ensure compliance. |
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
The group room door had a window which was not covered. This permitted observation of the group session from outside the room.
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Plan of Correction
Group room door in question will be covered to prevent any outside observation. Program Manager will ensure that this is done by date indicated. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The hot water temperatures were measured at 130 degrees Farenheit. The hot water temperature is not to exceed 120 degrees Farenheit.
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Plan of Correction
Program Director will make sure that all hot water heater thermostats are set at correct temperature of no more than 120 degrees Farenheit. Program Director/Manager will check quarterly to ensure compliance. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
The client bathroom in the dosing area did not have a working exhaust fan or a window.
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Plan of Correction
Program Director will contact maintenance person and have either fan repaired or new fan installed. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
One outside stairway, which exceeded two steps, was not equipped with a handrail.
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Plan of Correction
Program Director will contact local contractor to have a secured handrail in place. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Fire extinguisher training was not documented consistently for all staff. This must be completed within seven days of hire.
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Plan of Correction
Form used to document will be added to the new employee hire packet. Program Manager will provide training within first 7 days. Program Director will monitor for compliance. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Fire procedure training was not documented consistently for all staff. This training must be completed within seven days of hire.
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Plan of Correction
Form used to document will be added to the new employee hire packet. Program Manager will provide training within first 7 days. Program Director will monitor for compliance. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Documentation was not presented for the fire alarm/smoke detector being set off during each fire drill. The facility director needs to submit a letter to the Division explaining the procedure to be used in lieu of setting off an alarm.
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Plan of Correction
Program Director will draft a letter requesting waiver regarding the setting off of fire alarm during a drill. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
The project failed to present documentation demonstrating that the governing body had approved the goals and objectives at least annually.
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Plan of Correction
Program Director will submit annual goals and objective to the Discovery House Board of Directors for approval. Plans will be submitted in December of each year for the next year. This will be documented in the Board of Directors Meeting Minutes. Program Director/Manager will monitor for compliance. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The agency policy on client confidentiality was incomplete and contained inaccuracies. The language in the policies and procedures did not distinguish between HIPAA and 42 CFR Part 2, Subparts A through E. The policy and procedure gives the impression that the Project does not recognize the distinction in the various applicable laws and regulations.
The requirements of this regulation stipulate that written procedures comply with 4 Pa. Code subsection 255.5. The procedures as presented at the inspection address only subpart (b) of subsection 255.5. The patient confidentiality notice form incorrectly states that revocations must be put in writing by the client. Clients may revoke consents to release information verbally and staff must then document the revocation in the client record. This notice also incorrectly states that client information can be released without consent to obtain legal or financial services or to another medical facility. The same form also states that Discovery House need not agree to any restrictions on disclosures of information requested by the client. All releases of information must be voluntary unless otherwise excepted by the applicable section of 42 CFR. The section of the confidentiality procedure entitled "Prohibition on Redisclosure" on page 191 of the manual is blank.
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Plan of Correction
Policy in question will be amended to comply with regulation. Program Director will monitor to ensure compliance. |
709.28(a)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(2) Staff access to client records.
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Observations
The Discovery House policy on staff access to client records lacked sufficient detail. The policy should identify by name or position who may access files. The method of access should be outlined. Since the project has an electronic system for keeping client identifying information, a detailed policy and procedure which addresses all of the requirements of the Licensing Alert of May, 2005 relating to electronic client records must be developed.
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Plan of Correction
Policy will be amended. Program Director will monitor to ensure compliance. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Client identifying information was located in an unsecured location in the basement of the clinic building. File cabinets were not locked at the time of the licensing inspection.
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Plan of Correction
Program Director will give all staff a memo regarding the importance of making sure all files cabinets are locked and secure. Administrative Assistant will be charged with checking all locks weekly. Program Manager will ensure compliance. |
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:
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Observations
One agency form presented did not comply with the intent of this regulation. The form entitled "Patient Agreement to Pay for Treatment If Third Party Coverage is denied" contains language which indicates information will be released but the form does not specify what specific information will be sent to third party sources. This constitutes a general consent to release information which does not comply with the requirements of the law. Releases without valid consents were noted in client records # 5, 8 and 9.
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Plan of Correction
The form, "Patient Agreement to pay for Treatment if Third Party Coverage is Denied" will be changed to meet regulation. Program Director will monitor for compliance. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
The list of specific information to be released was missing from consent to release information forms or was unclear on those forms found in client records # 1, 3, 5, 7 and 12.
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Plan of Correction
Program Manager will conduct in-service training on proper way to do all releases. Emphasis will be on specific information that can be released according to regulations. Program Director will monitor for compliance. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Medical histories were incomplete in records reviewed. A history documenting the client's personal medical history, family medical history, and history of illness and symptoms should be collected. Family history was not documented consistently in client records reviewed..
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Plan of Correction
In-service will be provided Clinical Supervisor on proper way to document patient history. Emphasis will be on family history. Program Manager will monitor for 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
Personal histories should collect as much personal information about a client as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated. Required areas were not addressed in detail in client records reviewed..
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Plan of Correction
In-service will be provided by Clinical Supervisor on proper way to document patient history. Emphasis will be on personal histories. Program Manager will monitor for compliance. |
709.93(a) 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:
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Observations
Client records presented were not complete. There was, in essence, a two record system used at the agency. Part of the record is electronic and part of the record is paper. This regulation requires that a complete client record be kept. It should contain all of the required components specified under this Chapter. If the agency plans to continue to use this type of system, minimally, the entire discharged record should be completed in paper copy . The agency policy states on page 202 of the manual "The paper copy of the record will be the main record". If the project intends to have a complete electronic file, policies and procedures should be developed to describe how this will occur in accordance with the Licensing Alert of May 2005 relating to Electronic Records.
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Plan of Correction
Program Director will send information regarding citation to Home Office for review and make changes to meet regulations. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
The record of of services was not accurate in the client records reviewed. There were discrepancies between electronic record documentation and paper record documentation in client records reviewed.
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Plan of Correction
Program Director will give a memo to all Discovery House staff instruction them to print a copy of the patient's entire record in the computer when a patient is discharged. This will become part of the discharge file as required in this regulation. Clinical Supervisor will monitor for compliance. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Discharge summaries did not address all areas required by this regulation. Reasons for treatment and the client's response to treatment did not give a picture of the treatment episode.
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Plan of Correction
Program Manager/Clinical Supervisor will do in-service training for all clinical staff regarding proper way to do a discharge summary. Newer clinical staff and others who request it will be sent to trainings by outside sources. Program Director will monitor for compliance. |