INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30 through July 2, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A.R.S. of Lancaster, LP 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 August 1, 2008.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of ten personnel records on June 30, 2008, one of one was required to participate in documented monthly meetings with her supervisor. The facility failed to document monthly clinical supervision meetings for the time period of October 2007 through March 2008 for personnel record # 2.
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Plan of Correction
The Executive Director will provide monthly individual supervision to all Clinical Supervisor. Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level. ARS Governing Body has determinedthat Executive Director will meet at a minimum monthly or more with Clinical Supervisor and meetings will be documented in ARS Lancaster Managers Meeting Log Book.
It is the Executive Directors responsibility to maintain compliance in this area. |
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
Based on a review of ten personnel records on June 30, 2008, seven were required to meet the qualifications for the position of counselor. The facility failed to ensure in one of seven personnel records reviewed, specifically # 7, that the counselor met at least one of the groups of qualifications. Employee #7 has a Bachelor of Arts degree in Political Science.
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Plan of Correction
The Executive Director will ensure that employees will meet qualifications for the position of counselor. The Executive Director will examine each candidates background including education and credentials to determine if the candidate meets PA requirements. If there is any question on the potential candidate the executive director will submit to the state and wait for response. |
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 ten personnel records on June 30, 2008, ten out of ten were required to have an assessment of staff training needs. The facility failed to document an assessment of staff training needs for the current training year of 2008 in five personnel records, #1, 4, 5, 9, and 10.
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Plan of Correction
The clinical supervisor will conduct annually a staff training needs assessment on every employee. This will be documented in every employees personnel record. Which will be locked in the executive directors office. The executive director will ensure full compliance with this. |
704.11(a)(2) LICENSURE Overall Training 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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's staff development program on June 30, 2008, the Project Director failed to develop an overall plan to address the training needs of agency personnel. The overall training plan for the year 2008 addressed only 9 hours of training.
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Plan of Correction
The executive director (project director) will develop an overall training plan that will address the training needs of the agency personnel. The training plan will include all PA required trainings. The clincal supervisor will bethe employee resonsible to ensure compliance with employee training attendance. The plan will be developed and implemented by July 25, 2008. |
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 the facility's staff development program on June 30, 2008, the Project Director was required to develop an annual evaluation of the facility's overall training plan. The Project director failed to document an annual evaluation of the overall training plan for the year ending 2007.
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Plan of Correction
The executive director (project director) will develop an annual evaluation of the facilities overall training plan for the year ending 2007 and then thereafter. The executive director is thresponsible for the compliance of this. The evaluation of the overall training plan for year 2007 will be completed by 8/04/2008. |
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
Based on a review of ten personnel records on June 30, 2008, ten of ten records were required to have a written individual training plan. The facility failed to document individual training plans for the training year 2008 in ten records, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
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Plan of Correction
The executive director will develop an individual training plan for every employee this will be completed by 8/8/08 then yearly thereafter. The executive director is responsible for compliance in this area. |
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
Based on a review of ten personnel records on June 30, 2008, four were required to have completed a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted disease and other health related topics training using a Department of Health approved curriculum. The facility failed to provide documentation for the completion of that required training in three personnel records, #6, 9 and 10.
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Plan of Correction
The executive director will ensure all required staff members will complete a minimum of 6 hours of HIV/AIDS and a minimum of 4 hours of TB, Hep. and STD related trainings using a DOH approved curriculum. This will be completed by 9/1/2008. The ecxecutive director is responsible for compliance in this issue. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of ten personnel records on June 30, 2008, one was required to have completed at least 12 clock hours of training annually. The facility failed to provide documentation that the clinical supervisor completed at least 12 clock hours of training for the 2007 training year in one of one personnel records, #2.
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Plan of Correction
The clinical supervisor will review all employees training hours and ensure all employees meet or exceed PA minimum requirements for annual trainings calernder year 2008 and then therafter. It is the executive directors responsibility to ensure compliance. All staff with meet minimum PA required clock hours or more by the end of the 2008 calender year. |
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 ten personnel records on June 30, 2008, two were required to have completed at least 25 clock hours of training annually. The facility failed to provide documentation in one of two records, #6, of the completion of at least 25 clock hours of training for the 2007 training year. Record #6 contained only two of the required 25 hours of training documentation.
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Plan of Correction
The clinical supervisor will review all employees training hours and ensure all employees meet or exceed PA minimum requirements for annual trainings calernder year 2008 and then therafter. It is the executive directors responsibility to ensure compliance. All staff with meet minimum PA required clock hours or more by the end of the 2008 calender year. |
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 compliance plan presented on June 30, 2008, the facility failed to comply with the client/counselor ratios during primary care hours. The full-time equivalency counselor caseload for counseling was 37:1.
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Plan of Correction
The executive director will ensure that the facility will maintain a 35:1 ratio or below. A staff member was hired and is being trained and ratio is below mandated 35:1.
POC is completed in this area. |
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
Based on a review of ten personnel records on June 30, 2008, ten were required to to have documentation of staff training in the use of the fire extinguisher within seven days from the date of employment. The facility failed to document in ten records, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10, training in the use of the fire extinguisher.
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Plan of Correction
The executive director is responsible for compliance in this area. All new staff members will be trained in the use of fire extiguishers within seven days from the date of employment. All staff will be trained or retrained on the proprer use of fire extinguishers by 8/8/08. The executive director has designated a health and safety officer to provide trainings within 7 days from date of employment. The executive director will review all new personnel files by the 7th day of employment to ensure compliance. |
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 on June 30, 2008, the facility failed to conduct unannounced fire drills at least once a month. The fire drill record was missing documentation of unannounced fire drills for the months of May and June 2008.
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Plan of Correction
a health and safety officer will be appointed and unannounced fire drills will be completed at a minimum of once per monthly. The documentation will be completed and kept in the health and safety drill binder. The executive director is responsible for compliance in this. |
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
Based on a review of ten personnel records on June 30, 2008, ten were required to have documentation of training to perform assigned tasks during emergencies within seven days from the date of employment. The facility failed to document in ten records, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10, training of assigned tasks during emergencies.
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Plan of Correction
The executive director is responsible and will ensure that all new employees will be assigned tasks and trained upon them during emergencies. These trainings will occur within seven days from the date of emoployment. The executive director will ensure a training is conducted by 07/25/2008 for all employees. Each employee will be assigned tasks to perform during emergencies at the time of training. Documentation will be placed in the health and safety drill log. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of fire drill records on June 30, 2008, the facility failed to conduct fire drills on different days of the week, at different times of the day. The fire drill record indicated that from September 2007 through April 2008 fire drills were conducted between 7:26 AM and 9:41 AM only. In addition, the fire drill record was missing documentation of the day and time for May and June 2008.
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Plan of Correction
The executive director will designate a health and safety officer which will then conduct fire drills on different days of the week and at different times of the day. The correct documentation will be placed in the health and safety drill log book.The executive director is assigned to ensure compliance with this requirement. In addition proper documentation for May and June will be put in drill logs. This will be completed by 7/25/2008. |
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
Based on a review of fire drill records on June 30, 2008, the facility failed to set off a fire alarm or smoke detector during each drill. There was no documentation in the fire drill record indicating that the fire alarm or smoke detector was operative during monthly fire drills from September 2007 through June 2008.
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Plan of Correction
The designated health and safety officer will complete monthly fire drills at different times and different days of the week and will set of smoke detectors and/or fire alarms and document in the health and safety drill log that the equipment was in working order during each drill. It is the executive director that will ensure dcompliance with this issue. Corrections will be made by 8/8/08. |
709.22(d)(3) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(3) Describing the project's organizational structure.
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to provide an accurate description of the project's organization structure. The organizational chart provided was last updated in February 2007. This did not reflect the current facility structure and staff composition.
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Plan of Correction
A new organizational chart has been developed, it reflects current facility structure and staff composition. The executive director is responsible to remain compliant with this. Corrected 7/20/2008 |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to document that the Project Director prepared and annually updated the project's policies and procedures by dated signature. The written manual has not been updated since March 15, 2006.
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Plan of Correction
The executive director (project director) will update the project's policies and procedures by 8/21/08 and will do annually thereafter. These will be signed and dated to verify review and updates. It is the executive directors reponsibility to comply in this area |
709.24(a) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to document that the governing body adopted a written plan for the coordination of client treatment and rehabilitation services. The project's policies and procedures manual was not signed and dated by the current governing body.
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Plan of Correction
The ARS governing body will develop a written plan for the coordination of patient treatment and rehabilitation services. The chairman of the ARS governing body will seek approval and sign on behalf of the governing body. This will be completed by 8/8/08 and then annually thereafter and will be documented in policy and procedure mannual. It is the executive directors responsibility to ensure compliance of this area. |
709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to renew written letters of agreement with primary referral sources. All written letters of agreement, with the exception of the emergency medical and psychiatric, expired April 2008.
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Plan of Correction
the executive director will renew letters of agreements with its primary referall sources. These letters will be obtained by 8/22/08 and will be renewed annually. Thety will be kept in the QSAP binder in the executive directors office. It is the responsibility of the executive director to comply with this. |
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 financial documents submitted on July 1, 2008, the project failed to obtain an annual audit that includes the opinion of an independent public accountant. The project presented a financial review for the year ending 2007. The financial review was missing the opinion of an independent public accountant and was not an audit.
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Plan of Correction
ARS Lancaster is a limited partnership which is structured the same as an S corporation. We believe due to the similarities ARS Lancaster qualifies to be exempt on having an annual audit with an opinion from an independent public accountant required . ARS has requested a finding on this and still is awaiting outcome. ARS requests to defer the corective action plan on observation #0169 until the Commonwealth of Pennsylvania has provided a written decision. |
709.26(a)(3) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(3) Wage and salary administration.
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to implement written policies and procedures for wage and salary administration.
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Plan of Correction
The executive director will update current policies and procedures to reflect policies for wage and salary administration. This will be completed by 8/8/08. It is the executive directors responsibility for compliance in this area. |
709.26(a)(5) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(5) Working hours.
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to implement written policies and procedures for working hours.
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Plan of Correction
The executive director will update current policies and procedures to reflect policies for working hours. This will be completed by 8/8/08. It is the executive directors responsibility for compliance in this area. |
709.26(a)(6) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(6) Vacation and sick leave.
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to implement written policies and procedures for vacation and sick leave.
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Plan of Correction
The executive director will update current policies and procedures to reflect policies for vacation and sick leave. This will be completed by 8/8/08. It is the executive directors responsibility for compliance in this area. |
709.26(a)(8) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(8) Disciplinary actions.
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to implement written policies and procedures for disciplinary actions.
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Plan of Correction
The executive director will update current policies and procedures to reflect policies for disciplinary actions. This will be completed by 8/8/08. It is the executive directors responsibility for compliance in this area. |
709.26(a)(9) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(9) Supervision of staff.
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to implement written policies and procedures for supervision of staff.
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Plan of Correction
The executive director will update current policies and procedures to reflect policies for staff supervision. This will be completed by 8/8/08. It is the executive directors responsibility for compliance in this area. |
709.26(a)(11) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(11) Employe accidents and safety.
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to implement written policies and procedures for employee accidents and safety.
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Plan of Correction
The executive director will update current policies and procedures to reflect policies for employee accidents and safety. This will be completed by 8/8/08. It is the executive directors responsibility for compliance in this area. |
709.26(b) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to document that the governing body adopted a written policy to implement and coordinate personnel management. The project's policies and procedures manual was not signed and dated by the current governing body.
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Plan of Correction
The ARS governing body will adopt a written policy to implement and coordinate personnel management. The policies regarding personnel management will be reviewed and approved by the governing body and the governing body chairman will sign and date. This will be completed by 08/22/08. It is the executive directors responsibility to comply with this. |
709.26(c)(2) LICENSURE Personnel Management
709.26. Personnel management.
(c) The project director shall develop written policies and procedures to provide for ongoing staff training and staff evaluation. Documentation shall include, but is not limited to:
(2) Plans for addressing these needs.
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to adopt written policy regarding the dissemination of employment information to project staff.
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Plan of Correction
The executive director will update current policies and procedures to reflect policies for dissemination of employment information to project staff. This will be completed by 8/8/08. It is the executive directors responsibility for compliance in this area. |
709.26(c)(3) LICENSURE Personnel Management
709.26. Personnel management.
(c) The project director shall develop written policies and procedures to provide for ongoing staff training and staff evaluation. Documentation shall include, but is not limited to:
(3) A mechanism to collect feedback on training completed.
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to adopt written policy regarding the orientation of new employees.
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Plan of Correction
The executive director will update current policies and procedures to reflect policies for the orientation of new employees. This will be completed by 8/8/08. It is the executive directors responsibility for compliance in this area. |
709.26(c)(4) LICENSURE Personnel Management
709.26. Personnel management.
(c) The project director shall develop written policies and procedures to provide for ongoing staff training and staff evaluation. Documentation shall include, but is not limited to:
(4) An annual evaluation of the overall training program.
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to adopt written policy regarding the dissemination of employment information to project staff.
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Plan of Correction
The Executive director has adopted a written policy regarding the dissemination of employment information to project staff. It is the executive directors responsibility to remain compliant in this area. Completed poc
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709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of ten personnel records on June 30, 2008, ten were required to have documentation for reference investigations. The facility failed to document the results of reference investigations in eight of ten records, #1, 3, 4, 5, 6, 7, 8 and 10.
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Plan of Correction
The executive director will ensure that all existing employees and future employess will have documentation for reference investigations completed and in their personnel file, which will be locked securely in executive directors office. This will be completed by |
709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based on a review of ten personnel records on June 30, 2008, ten were required to have documentation of salary information. The facility failed to document salary information in nine of ten records, #1, 2, 3, 5, 6, 7, 8, 9 and 10.
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Plan of Correction
The executive director will ensure documentation of employees salary information for all current and future employees. This information will be found in the employees personnel files. It is the executive directors responsibility to comply with this. This will be completed by 08/08/08 |
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.
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Observations
Based on a review of ten personnel records on June 30, 2008, eight were required to have work performance evaluations. The facility failed to document work performance evaluations in seven of eight records where required, #1, 3, 6, 7, 8, 9 and 10.
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Plan of Correction
The executive director will ensure that all current and future employees will have work performance evaluations completed and in their personnel files. The evaluations will be done on an annual basis thereafter. It is the executive directors responsibility to ensure compliance in this area. This will be completed by 8/8/08. |
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:
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Observations
Based on a review of ten personnel records on June 30, 2008, ten were required to have documentation demonstrating the project's efforts toward informing staff of their employee rights. The project failed to document that staff were informed of their employee rights in ten of ten records, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
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Plan of Correction
The executive director will ensure that all existing and future employees are informed of their employee rights. This will be documented by a signed acknowledgement and placed in the employees personnel file. It is the executive directors responsibility to comply with this. This will be completed by 08/08/08 |
709.26(e)(2) 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:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to develop written policies regarding the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from his records.
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Plan of Correction
The executive director has developed a written policy within the employee rights section of the ARS HR Manual regarding the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from their record, all employees were notified of this as well. It is the executive directors responsibility to ensure compliance in this area. POC completed |
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.
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Observations
Based on a review of the project's policies and procedures manual on June 30, 2008, the project failed to develop written policies regarding the employee's right to submit rebuttal data or memoranda to his own records.
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Plan of Correction
The executive director has developed a written policy within the employee rights section of the ARS HR Manual regarding the employee's right to submit rebuttal data or memoranda to his own records.
all employees were notified of this as well. It is the executive directors responsibility to ensure compliance in this area. POC completed |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of ten personnel records on June 30, 2008, ten were required to have written job descriptions specific to the employee's position. The project failed to document job descriptions in four of ten personnel records, #1, 2, 4 and 5.
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Plan of Correction
The executive director will ensure all current and future employees records will have written job descriptions specific to their position. This will be completed by 8/8/08. The executive director is assigned to maintain compliance oon this |
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
Based on observations made during the licensing inspection, the facility failed to ensure confidentiality of client identity and records. On June 30, 2008, a group treatment sign-in sheet containing full client names was seen in the break room on the copier machine for anyone to observe.
In addition, on July 2, 2008, confidential client-related conservations between employees and clients were heard taking place in the waiting area for anyone to hear.
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Plan of Correction
The executive director will designate the clinical supervisor to perform a HIPPA/42 CFR Part 2 Confidentiality training. Topics to be covered will include but not limited to:Patient identifying information, patients right to confidentiality. All ARS staff will be required to attend, documentation of attendance will be placed in employees personnel file. This will be completed by 8/15/2008. It is the executive directors responsibility to ensure confidetiality requirements are met. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of nine client records, one was required to have a written notice of a decision to involuntarily terminate the client's treatment at the project. The project failed to notify the client, in writing, of an involuntary termination in record #6.
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Plan of Correction
The executive director has developed a form for involuntary termination and has had the clinical supervisor instruct the clinical staff of proper use. All current and future patients will be notified in writing of involuntary termination, prior to patient termination process to begin. The Clinical Supervisor is responsible for compliance in this area. POC Completed |
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.
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Observations
Based on a review of nine client records, one was required to document that the client was given an opportunity to request reconsideration of of the project's decision to involuntarily terminate the client's treatment. The project failed to provide documentation in client record #6 that the client was given the opportunity to request reconsideration.
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Plan of Correction
The executive director will assign the clinical supervisor to oversee that every patient being involuntarily terminated will have the oppertunity to request reconsideration. Aclinical staff training will be presented on this issue as well as discussions during individual clinical supervision. A training will be held by 8/22/08. It is the clinical supervisors responsibility to remain compliant in this area. |
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 nine client records, four were required to have drug and alcohol histories. The facility failed to document a complete drug and alcohol history in four of four records reviewed, #2, 3, 5 and 9. The drug and alcohol histories were missing lengths and patterns of use. In addition, the client's perception of use was inconsistently documented.
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Plan of Correction
The execyutive director will have the clinical supervisor do a complete review of all patients within 72 hours of admittance to ensure completion of drug and alcohol histories. A training for clinicians will be developed on complete intake and admission documentation skills. This will be completed by 8/22/08. It is the clinical supervisors responsibility to ensure compliance withg this issue. |
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 nine client records, four were required to have personal histories. The facility failed to document a complete personal history in four of four records reviewed, #2, 3, 5 and 9. The personal histories contained unanswered questions and one-word responses with no clarification regarding family, legal employment/vocation, recreation and sexual information.
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Plan of Correction
The execyutive director will have the clinical supervisor do a complete review of all patients within 72 hours of admittance to ensure completion of drug and alcohol histories. A training for clinicians will be developed on complete intake and admission documentation skills.
The training will address but is not to proper completion of personal histories and clarification regarding family, legal employment/vocation, recreation and sexual information.
This will be completed by 8/22/08. The clinical supervisor is responsible for compliance inthis area. |
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 nine client records on July 1 and 2, 2008, five were required to have a psychosocial evaluation. The facility failed to document a complete psychosocial evaluation in records #2, 3, 4, 5 and 9. The psychosocial evaluations were primarily historical documents with client stated comments rather than a clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, client's attitude toward treatment, and overall impressions/conclusions.
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Plan of Correction
The executive director will have the clinical supervisor do a complete review of all patients charts within 72 hours of admittance to ensure completion of drug and alcohol histories. A training for clinicians will be developed on complete intake and admission documentation skills. The training will address but is not limited to completeing psychosocial evaluations where a clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, client's attitude toward treatment, and overall will be utilized instead of patients perceptions. This will be completed by 8/22/08. The clinical supervisor is responsible for compliance inthis area.
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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 nine client records, five were required to have individualized short and long-term goals in the treatment and rehabilitation plan. The facility failed to document individualized and measurable short and long-term goals in the treatment and rehabilitation plan in three records, #2, 3 and 8. Goals #1 and 2 were identical in records #2, 3 and 8. In addition, the individual treatment and rehabilitation plan was focused primarily on financial issues rather than clinical and medical concerns.
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Plan of Correction
The executive director will assign the clinical supervisor to ensure that all treatment plans will be individualized as well as addressing long and short term goals. ARS feels that financial responsibility is part of the Commonwealth's requirement and will continue to address these issues but will ensure that clinical and/or medical concerns are also addressed. A clinical staff training will be completed by he clinical supervisor by 08/15/2008. The clinical supervisor is responsible for compliance in this area. |
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 nine client records, five were required to have proposed support services listed on the individual treatment and rehabilitation plan. The facility failed to document proposed support services in two of five individual treatment and rehabilitation plans, #5 and 9. In addition, client records #2 and 3 failed to address support services identified in the histories and psychosocial evaluation.
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Plan of Correction
The executive director will assign the clinical supervisor to ensure that all treatment plans will be individualized as well as addressing the requirement of proposed support services in treatment plans as as in histories and psychosocial evaluations. clinical staff training will be completed by he clinical supervisor by 08/15/2008. The clinical supervisor is responsible for compliance in this area.
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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 nine client records, seven were required to have treatment plan updates. The facility failed to document a complete treatment and rehabilitation plan update at least every 60 days in five of seven records where required, #1, 3, 4, 5 and 8. The assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan was missing. In addition, goals were continued when all the objectives were met and no new objectives were added.
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Plan of Correction
The executive director will assign the clinical supervisor to ensure that all treatment plan updates are done minimally every 60 days where required. The clinical supervisor will ensure that the assessment of the patient's progress in relationship to the stated goals of the treatment plan will be included. In addition, when goals and objectiveare met and new objectives will be added when necessary. A clinical staff training will be conducted addressing these areas by 08/15/2008. It is the clinical supervisors resonsibility for compliance in this area.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of nine client records on July 1 - 2, 2008, eight were required to have progress notes. The facility failed to document complete progress notes in six of eight client records, #2, 3, 4, 5, 6 and 9. Progress notes for individual counseling sessions were missing the clinician's assessment. The individual progress notes focused primarily on financial payment arrangements to the facility by the client. Client records # 2 and 5 were missing group notes for the month of June 2008. Group progress notes were missing individual assessments in client records #2, 4, 5 and 9.
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Plan of Correction
The executive director will assign the clinical supervisor to ensure that all progress notes will be completed. The clinical supervisor will ensure that the the clinicians assessment will be included in the progress note. ARS will continue to document financial interventions in the progress notes but will also include clinical and medical issues where needed. The clinical supervisor will ensure all group progress notes will be included in the patient's chart. A clinical staff training will be conducted addressing these areas by 08/15/2008. It is the clinical supervisors resonsibility for compliance in this area. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of nine client records, two were required to have aftercare plans. The facility failed to document complete aftercare plans in two of two records, #4 and 6. The aftercare plans were missing goals with timeframes. In addition, the contact person and the reentry process was missing.
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Plan of Correction
The executive director will assign the clinical supervisor to ensure that complete aftercare plans are in place. The aftercare plans will include goals with timeframes as well as the contact person and reentry process documented. the clinical supervisor will conduct a clinical inservice training by 08/15/2008. It is the clinical supervisors responsibility to ensure compliance in this area. |
709.93(b) LICENSURE Client records
709.93. Client records.
(b) The project shall develop and maintain client records on standardized project client record forms.
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Observations
Based on a review of nine client records, nine were required to have standardized project client record forms. The facility failed to provide for a standardized psychosocial evaluation form in three of three client records where required, #3, 4 and 5.
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Plan of Correction
The executive director has assigned the clinical supervisor to ensure that ARS will utilize a standardized psychosocial evaluation form, all clinical staff will be trained on the use of this form by 08/15/2008. It is the clinical supervisors responsibility to ensure compliance in this area. |
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 documentation presented on June 30, 2008, the project failed to provide a current signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III.
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Plan of Correction
The executive director will ensure that a current and signed provider agreement with the Department of Public Welfare that complies with 55 Pa. Code Part III, is available on site at all times. This will be competed by 08/15/2008. It is the executive director's responsibility to ensure compliance in this area.
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