INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 23, 2007 through July 25, 2007 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 August 30, 2007.
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Plan of Correction
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
The facility failed to document a complete psychosocial evaluation in three of three client records reviewed, # 1, 2 and 4. Psychosocial evaluations were historical rather than evaluative and failed to include clinical impressions and opinions regarding the client's problems/needs, assets/strengths, support systems, clients attitude towards treatment, clinical impressions/conclusions and coping mechanisms.
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Plan of Correction
The project was not in compliance with this standard because documentation lacked detail, substance and clinical impression. A redesign of the forms used for obtaining initial information as well as a revised template for the BPSH Evaluation will be completed by the Director of Clinical Services by 9/15/07. An in-service conducted by the Director of Clinical Services/Clinical Staff Training Coordinator for all clinical and nursing staff will occur on 9/22/07 on proper documentation of the information with an emphasis on the necessity on evaluation rather than repeating data. Monitoring will occur through the PI process on a monthly basis by the Director of Clinical Services and PI Coordinator. Also, responsibility for the completion of the BPSH Evaluation will rest with either nursing staff or Phase I counselor and will be reported at the first Treatment Team meeting after admission. The project will be in full compliance with this standard by 9/30/07. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
The facility failed to document follow-up information in as per facility policy in two of two client records reviewed. Follow up information was not documented in one client record, #3 and documented late in one client record, #4.
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Plan of Correction
The project was not in compliance with this standard because documentation was lacking in support of post-discharge follow-up. Clinical Staff is to be trained on 9/14/07 by the Director of Clinical Services on the proper follow-up procedure. A tracking form will be used to verify timing and content and the action will be monitored through the PI process on a monthly basis by the Director of Clinical Services and PI Coordinator. The project will be in full compliance with this standard by 9/30/07. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to document a complete psychosocial evaluation in six of six client records reviewed, # 1, 2, 3, 4, 5 and 6. Psychosocial evaluations were historical rather than evaluative and failed to include clinical impressions and opinions regarding the client's problems/needs, assets/strengths, support systems, clients attitude towards treatment, clinical impressions/conclusions and coping mechanisms.
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Plan of Correction
The project was not in compliance with this standard because documentation lacked detail, substance and clinical impression. A redesign of the forms used for obtaining initial information as well as a revised template for the BPSH Evaluation will be completed by the Director of Clinical Services by 9/15/07. An in-service conducted by the Director of Clinical Services/Clinical Staff Training Coordinator for all clinical and nursing staff will occur on 9/22/07 on proper documentation of the information with an emphasis on the necessity on evaluation rather than repeating data. Monitoring will occur through the PI process on a monthly basis by the Director of Clinical Services and PI Coordinator. Also, responsibility for the completion of the BPSH Evaluation will rest with either nursing staff or Phase I counselor and will be reported at the first Treatment Team meeting after admission. The project will be in full compliance with this standard by 9/30/07. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
The facility failed to document support services in six of six client records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
The project was not in compliance with this standard because documentation of support services was lacking on the treatment plan. On 9/14/07 the Director of Clinical Services will conduct an in-service for all clinical staff on the importance of support services and the inclusion in the treatment plans of each client. The project will be in full compliance with this standard by 9/30/07.
Monitoring will occur through the PI process on a monthly basis by the Director of Clinical Services and PI Coordinator.
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709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
The facility failed to document a complete aftercare plan in three of three client records reviewed, #4, 5 and 6. Aftercare plans failed to include personal and individualized goals.
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Plan of Correction
The project was not in compliance with this standard because documentation of aftercare plan lacked consistency across records. An in-service will be conducted on 9/14/07 by the Director of Clinical Services for clinical and aftercare staff on the content and process of the Aftercare Plan and a review of the plan will be built into the treatment team reviews. The project will be in full compliance with this standard by 9/30/07. Monitoring will occur through the PI process on a monthly basis by the Director of Clinical Services and PI Coordinator. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on the physical plant inspections conducted July 25 and July 26, 2007 and staff interviews, the facility failed to notify the Department of the change in authorized maximum capacity. The facility was licensed for a capacity of 83 beds for the non-hospital residential activity. During the physical plant inspection on July 25, 2007, there were only 80 beds identified for the non-hospital residential activity. The project director stated that one bedroom was converted into a therapist's office and the three beds were removed from this room. On July 26, 2007, a second physical plant inspection was conducted. During this inspection, the Human Resource Director showed the inspector three rooms (#224, #228 and #229) on the second floor men's dormitory where beds had been added since the previous day. These rooms had contained only three beds each on July 25, 2007, but now contained four beds in each room.
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Plan of Correction
Due to low census numbers in July, three beds were removed temporarily to allow for needed maintenance of rooms (painting, carpet cleaning, etc.) Beds had not been replaced prior to inspection. Beds were replaced during inspection and reviewer was asked to re-inspect these rooms to demonstrate compliance with licensed capacity and physical plant requirements, which inspector approved. This reduction in beds was temporary and not permanent. In the case of future changes in bed capacity, CEO will be responsible to assure compliance with 709.14, which will include notifying the Department utilizing approved Department forms within 90 days of the occurrence of changes in bed capacity. Additionally, the CEO shall report to the Board of Governors any bed capacity changes as well as adherence to Department standards and procedures.
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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
Based on review of employee records, the facility failed to ensure employees met the qualifications for the position of counselor. Employee #6 and 9 did not have the required experience for the position of a counselor.
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Plan of Correction
The project was not in compliance with this standard because the interpretation of the employee's experience by the project management team was not consistent with the standard.
Employee's # 6 and # 9 have been immediately reassigned to Counselor Assistant status until they meet the required experience to qualify for Counselor. The employees will sign Counselor Assistant job descriptions and will receive Counselor Assistant supervision as outlined in standard. Director of Clinical Services will monitor supervision to assure compliance.
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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.
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Observations
Based on the review of personnel records, the facility failed to document supervision for one of one counselor assistant. Weekly supervision and direct observation was not documented for employee #9.
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Plan of Correction
The project was not in compliance with this standard because documented supervision was monthly, not weekly.
Employee # 9 will receive direct supervision with documentation in support to meet Standard. The supervision will take place for six months until the employee can be promoted to Counselor. Director of Clinical Services will monitor supervision to assure compliance.
Effective immediately.
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
The facility failed to document an assessment of staff training needs in thirteen of twenty five records reviewed, #1, 5, 6, 8, 11,12, 15,16, 18, 19, 22, 23 and 25.
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Plan of Correction
The project was not in compliance with this standard as a result of misinterpretation of the standard. An assessment of staff training needs will be distributed to all employees on an annual basis. The needs assessment form will be placed in the employees personnel file. Human Resource Director will audit files on quarterly basis to assure compliance. The project will be in full compliance with this standard by 9/15/07. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to ensure documentation of feedback forms in twenty-five of twenty-five training records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 25.
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Plan of Correction
The project was not in compliance with this standard as a result of misinterpretation of the standard. An existing mechanism is in place to collect feedback. Data was colleted and reported to Board of Governors and utilized to implement yearly staff Development Plan. The Human Resource Director will ensure feedback forms on all in-services will be distributed and placed in personnel files. The project will be in full compliance with this standard by 9/15/07. |
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
The facility failed to document individual training plans for employees in ten of twenty five records reviewed, #11, 12, 15, 16, 17, 18, 19, 22, 23 and 25..
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Plan of Correction
The project was not in compliance with this standard as a result of misinterpretation of the standard. Individual training plans will be completed with all staff annually. Human Resource Director will audit files on quarterly basis to assure compliance. The project will be in full compliance with this standard by 9/15/07. |