INITIAL COMMENTS
|
This report is a result of an on-site licensing inspection conducted on July 9-10, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Axiom Family Counseling Services, Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel and training records, the facility failed to provide documentation of STD/TB training within one year of hire in one of one personnel records reviewed.
The findings include:
Two personnel records were reviewed on July 9-10, 2012. Per regulation, staff persons shall receive a minimum of four hours of TB/STD training and six hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first two years of employment.
Employee #1 was hired December 8, 2010 and was the sole employee at the facility, serving as the project/facility director and counselor until June 1, 2012. This employee was required to obtain four hours of TB/STD training by December 8, 2011. Employee # 1 completed the TB/STD training on May 1, 2012.
An interview with a facility representative / board member was conducted on July 10, 2012 at which time the aforementioned information was confirmed.
|
Plan of Correction
The Project created an Employee Training Tracking Form to document the HIV and STD/TB trainings of each employee and ensure that each employee meets the requirement of completing HIV and STD/TB training within one year of hire.
The Project Director will complete and monitor the Employee Training Tracking Form to ensure that each employee meets the requirement of completing HIV and STD/TB training within one year of hire. |
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.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel records.
The findings include:
Two personnel records were reviewed on July 10, 2012. One employee was a new hire and annual training was not yet due. The other employee was the sole employee up until June 1, 2012 and served as the project/facility director and counselor. This personnel record required the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 1.
Employee # 1 was hired on December 8, 2010. The facility training year is from January - December. Employee # 1 completed 15 clock hours of annual training from January 2011 through December 2011.
An interview with a facility representative / board member took place on July 10, 2012 at which time the aforementioned information was confirmed.
|
Plan of Correction
The Project created an Employee Training Tracking Form to document the annual trainings of each employee and ensure that each employee meets the requirement of 25 clock hours per year.
The Project Director will complete and monitor the Employee Training Tracking Form to ensure that each employee meets the training requirements for their job classification in each year of employment. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
|
Observations
Based on a review of the 2011 annual report, the governing body failed to make available to the public the 2011 annual report.
The findings include:
The 2011 annual report was reviewed on July 9-10, 2012. The facility is publicly funded and required to make available to the public an annual report. The 2011 fiscal year ended on December 31, 2011. The governing body failed to make the 2011 annual report available to the public, as required.
An interview with a facility representative/board member was conducted on July 10, 2012, at which time it was reported that the annual report would be made public via the facility's website. The website was inoperable when the attempt was made to view the annual report.
|
Plan of Correction
The Board of Directors will make the annual report available to the public via the internet.
The ability to access the annual report will be monitored by the Board of Directors to ensure that there are no technical difficulties that limit the access of the annual report to the public.
The annual report will be made available to the public through the website (www.axiomfamily.com/annualreport). In the event of techinical difficuilties with the corporate website, the annual report will also be made available to the public via hardcopy in the clinic. |
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.
|
Observations
Based on a review of administrative documents, the facility failed to complete an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The administrative documents were reviewed on July 9-10, 2012. The project's fiscal year is January - December. An annual audit of financial activities was due to be completed at the end of the project's fiscal year. There was no documentation of an annual audit for calendar year January 1, 2011 through to December 31, 2011 as of July 10, 2012.
An interview with facility staff / board member took place on July 10, 2012 at which time it was confirmed that no annual audit for 2011 had been completed.
|
Plan of Correction
The Board of Directors and the Project Director will hire an independent auditor that will complete a financial audit of the Project's financial activities with 3 months of the end of the Fiscal Year.
If the Project meets the requirements of Licensing Alert 01-11, February 2011 regarding Financial Audits, the Project will provide the Department of Health with an exception request to this regulation within 1 month of the Fiscal Year end date to ensure adequate time for a ruling on the exception request.
The Project Director and the Board of Directors will forward an exception request to this regulation witin 1 month of the Fiscal Year end. |
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.
|
Observations
Based on a review of personnel records, the facility failed to document an annual performance evaluation in one of one personnel records.
The findings include:
Two personnel records were reviewed on July 9-10, 2012. One employee had not yet been employed for one year. One personnel record required the documentation of an annual evaluation. There was no annual performance evaluation documented in personnel record #1.
Employee #1 is the project/facility director and was hired on December 8, 2010. An annual performance evaluation was due to be completed by December 8, 2011. There was no performance evaluation documented in personnel record #1.
An interview with a facility representative / board member was conducted on July 10, 2012 at which time it was confirmed that no performance evaluation had been completed for employee #1.
|
Plan of Correction
The Project updated its Employee Record Checklist to ensure that the Annual performance is completed on a yearly basis for each employee of the Project.
The Project Director and/or the Human Resources Director will monitor the completeness of all Employee Records to ensure that the Annual performance is completed for each employee of the Project. |
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:
|
Observations
Based on a review of client records, the facility failed to document releases of information consistent with 42 C.F.R., Subpart B, (a), which states that any disclosure made under these regulations must be limited to that information which is necessary to carry out the purpose of the disclosure in one of one client records.
The findings include:
One client record was reviewed on July 10, 2012. That client record contained a release of information signed by the client to a local pharmacy and included permission for the drug and alcohol facility to release the bulk of the client record, including the behavioral health information, to the pharmacy where the purpose for the release of information was to provide the pharmacy with a list of client medications. This behavioral health information exceeded what was necessary to carry out the purpose of the disclosure.
An interview with a facility representative / board member took place on July 10, 2012. The aforementioned information was confirmed.
|
Plan of Correction
The Project updated the process in which written releases are obtained from clients and any disclosure made by the Project will be limited to that information which is necessary to carry out the purpose of the disclosure.
The Project Director completed a training with all employees of the Project that detailed the disclosure regulations.
The Disclosure Training will be made part of the new employee orientation to ensure that all clinical and support employees are aware of the disclosure rules of 42 C.F.R., Subpart B (a) |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document an evaluative composite picture of the client in relationship to the collected historical data in one of one client records.
The findings include:
One client record was reviewed on July 10, 2012. The content of the evaluation in client record #1 consisted of a summary of the historical data collected and statements of what the client reported without a clinical impression of the information in client records # 1.
An interview with a facility representative / board member was conducted on July 10, 2012. No additional information was provided for review which contained the clinician's assessment of the historical data.
|
Plan of Correction
The Project Director completed a training with all employees of the Project to ensure the proper documentation of the composite picture of the client in relation to the collected historical data.
The Project Director will monitor the documentation of each active client to ensure that there is a summary of historical data along with a clinical impression of the information.
This training will be made part of the new employee orientation training to ensure that all clinical employees are made aware of the requirements.
|
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records the facility failed to document a case consultation including a discussion summary and disposition in one of one client records.
Findings:
One client record was reviewed on July 10, 2012. A case consultation is required to include documentation of the summary of the discussion and a disposition. The case consultation documented in client record #1 did not include a summary of the discussion or disposition.
Client #1 was admitted June 12, 2012. A case consultation was documented on June 15, 2012. The case consultation included a signed statement by the counselor dated June 15, 2012 and a signature by the supervisor on June 25, 2012. There was no discussion or summary documented.
An interview with a facility representative / board member took place on July 10, 2012 at which time the aforementioned information was confirmed.
|
Plan of Correction
The Project Director completed a training with all employees of the Project to ensure the proper use of the case consultation notes and the documentation of the discussions.
The Project Director will monitor the Case Consultation Notes of each active client to ensure that there is a discussion summary and disposition for each consultation note.
The case consultation training will be made part of the new employee orientation training to ensure that all clinical employees are made aware of the requirements.
|