INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, 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 .
|
Plan of Correction
|
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on review of personnel records employee # 4 is not receiving clinical supervision as required for a counselor assistant. Documentation was not provided for weekly supervision notes relating to the counselor assistant.
|
Plan of Correction
Information and documentation collection requirements were inadvertently overlooked. Recording deficiencies have been remediated and procedures instituted to prevent recurrence as of 11/15/2007. Staff training has been conducted to ensure continued compliance. Such compliance will be overseen and enforced by the Project Director. |
704.12(b) & (c) & (d) LICENSURE Counselor Asst/Exceptions
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(b) Counselor assistants. Counselor assistants may be included in determining FTE ratios when the counselor assistant is eligible for a caseload.
(c) Exemption for transitional living. Specific client/staff ratios are not required for transitional living facilities.
(d) Exceptions. A project director may submit to the Department a written petition requesting an exception to the client/staff and client/counselor ratios in this section. The petition shall describe how the characteristics of the program and its client mix support the request for the exception and shall be approved by the governing body. Granting the petition shall be at the discretion of the Department. Long-term residential facilities and halfway houses which include a client's participation in schooling or employment as part of a treatment day are examples when requests for exceptions will be considered.
|
Observations
Based on review of personnel records, it was determined that necessary documentation for supervision and clinical skills was missing and that the clinical hours provided by employee #4 could not be counted toward the client to counselor ratio.
|
Plan of Correction
Documentation requirements were inadvertently overlooked. Recording deficiencies have been corrected and procedures instituted to prevent recurrence as of 11/30/07. Staff training has been conducted to ensure compliance. Documentation compliance will be enforced by the Project Director. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
|
Observations
Based on review of the client records it was determined that the facility failed to document the clients' medication on a daily basis. Medications prescribed to be taken on a daily basis were not documented in accordance with those directions. The facility failed to document whether the client had refused the medication or had not shown up to get the medication. The reason the client had not received the medication was not documented. This was a deficiency in three out of three client records reviewed.
|
Plan of Correction
Client medication dispensing documentation was not routinely and adequately recorded. A documentation procedure for noting daily drug disbursements and reasons for missed medications has been instituted as of 11/15/07. Staff training has been conducted to ensure continued compliance. Such compliance will be overseen by the Project Director. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on review of client records, it was determined that the facility failed to correctly document the psychosocial evaluation. In client records #1, 2, 3 and 4 evaluations were completed prior to the personal histories being documented. In client record # 1 the psychosocial evaluation was completed on 7/19/07 but the client history upon which the psychosocial evaluation was to be based was not completed until 7/31/07. In client record #2 the psychosocial evaluation was completed on 6/26/07 while the client histories were not completed until 7/9/07. In client record # 3 the psychosocial evaluation was completed on 7/6/07 while the histories were not completed until 7/10/07. In client record # 4 the psychosocial evaluation was completed on 6/21/07 while the history was not completed until 6/22/07. The psychosocial evaluation is an assessment tool that is to be based on the collected historical information.
|
Plan of Correction
Client personal history information was not routinely recorded and dated for all clients prior to completion of the individual psycho-social evaluation assessment. A documentation procedure for recording and dating personal history information prior to completion of the psycho-social assessment has been instituted. Staff training has been conducted to ensure full compliance by 12/15/07. On-going compliance will be overseen and enforced by the Project Director. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
|
Observations
Based on review of client records it was determined that the facility failed to individualize the comprehensive treatment plans. In three out of four comprehensive treatment plans reviewed the comprehensive treatment plans were not individualized in client records # 2, 3, and 4. In addition, in 3 out of 4 of the comprehensive treatment plans reviewed it was determined that the comprehensive treatment plans were documented prior to the histories being completed. In client records # 1, #2, and # 3 the histories were not documented until after the comprehensive treatment plans had been documented and initiated. All histories should be documented prior to the execution of the individualized comprehensive treatment plan.
|
Plan of Correction
Personal history information was not routinely recorded and dated prior to completion of the individualized treatment plan. A documentation procedure for recording and dating personal history information prior to completion of the individualized treatment plan has been mandated. Staff training has been conducted to ensure continued compliance and compliance will be overseen and enforced by the Project Director on a regular basis. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on review of client records it was determined that the facility failed to review the client's progress on treatment plan updates. Treatment plan updates failed to include an assessment of progress in relationship to the previously stated comprehensive treatment plan goals and objectives stated in 4 out of 4 client records reviewed, # 1, # 2, # 3, and # 4.
|
Plan of Correction
Client progress in relation to stated goals and objectives was not adequately reviewed and updated for all clients. A structured documentation procedure for recording, and dating, client progress in relation to prior goals/objectives has been instituted. Staff training has been conducted to ensure continued compliance and compliance will be overseen and enforced by the Project Director. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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.
|
Observations
Based on reviews of client records it was determined that the facility failed to document complete records of services. In client records # 1, # 2, #3, and # 4 dates of significant client contacts were missing from the records of service. In client record # 1 a group therapy session conducted on August 2nd was missing from the record of service. A therapy group conducted on August 8, 2007 was not documented on the record of service. In client record # 2, groups sessions were not documented on the records of services for June 28, 2007, July 19, 2007, July 27, 2007, and August 30, 2007. In client record #3 groups sessions were not documented for July 13, 2007, July 27, 2007 and August 3, 2007. In client record # 4 group sessions were not documented for September 7, 2007.
|
Plan of Correction
Client services information was not routinely recorded and dated for all clients.
A mandated procedure for recording, and dating, facility activities and client "Records of Service" has been instituted. Staff training has been conducted to ensure continued compliance and compliance will be overseen and monitored by the Project Director.
|
709.53(a)(5) LICENSURE Progress Notes
709.53. 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.
|
Observations
Based on review of client records it was determined that the facility failed to documented the data, assessment and plan on group therapy notes on four out of four client records reviewed, client records # 1, 2, 3, and 4. In client record #1 assessments were lacking in in a two therapeutic groups. In client record #2 assessments were lacking in several group notes. In client record # 3 assessments were lacking in several group notes. In client record # 4 assessments were lacking in several group notes.
|
Plan of Correction
Individual client data, assessment, and plan information was not regularly documented for group sessions. A more comprehensive documentation procedure for recording and dating client information is being devised and will be implemented beginning 12/3/07. Staff training will be conducted to ensure continued maintenance of group session notes; compliance will be overseen and enforced by the Project Director. |