INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 22- 23, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Harbor Counseling 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.
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Plan of Correction
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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 personnel and training records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in one of two personnel records reviewed.
The findings include:
Nine personnel records were reviewed on August 22, 2012. Two of the nine staff members were due to have completed the HIV/AIDS and TB/STD training. There was no documentation that employee #8 obtained the required training.
Employee #8 was hired on 1-14-2011 as a counselor. This employee was required to obtain six hours of HIV/AIDS training and four hours of TB/STD training by 1-14-2012. Employee #8 failed to obtain the training as of August 23, 2012.
The findings were reviewed with the project director and were not disputed.
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Plan of Correction
Employee #8 is a part-time staff member, a Licensed Clinical Psychologist. Failure to obtain required HIV/AIDS and TB/STD training was an oversight on the part of Program Director and Clinical Supervisor. Program Director and Clinical Supervisor will identify an available training opportunity by 10/19/12, and will make arrangements for the employee to obtain the required training by 12/31/12. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice weekly, in four of the four partial hospitalization records.
The findings include:
Ten client records were reviewed on August 23, 2012. Four of the ten client records were from the partial hospitalization activity. Four of those four records were required to include documentation of individual counseling at least twice weekly. Twice weekly individual counseling sessions were not documented in four of four partial hospitalization records.
Client # 7 was admitted on 2-17-2012 and was transferred to outpatient level of care on 5-19-2012. Documentation of two individual treatment sessions per week was not evident for the weeks of February 20, 2012; March 5, 12, 19, and 26, 2012; April 2, 9, 16, 23, and 30, 2012; and May 7 and 14, 2012.
Client # 8 was admitted on 6-12-2012. Documentation of two individual treatment sessions per week was not evident for the weeks of June 18 and 25, 2012; July 2, 9, 23 and 30, 2012; and August 13, 2012.
Client # 9 was admitted on 3-22-2012. The last date of counseling was on 4-23-2012. The client was discharged on 5-11-2012. Documentation of two individual treatment sessions per week was not evident for the weeks of March 26, 2012; and April 2, 9, 16, and 23, 2012.
Client # 10 was admitted on 4-19-2012 and the last date of counseling was on 6-8-2012. The client was discharged on 7-20-2012. Documentation of two individual treatment sessions per week was not evident for the weeks of May 7, 14, 21, and 28, 2012; and June 4, 2012.
The findings were reviewed with the project director and the clinical supervisor and were not disputed.
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Plan of Correction
Program Director, Clinical Supervisor and Clinical staff had already been aware that staffing and programming schedules were making it difficult to consistently fulfill this regulatory and clinical standard. Consequently, programming and staffing changes intended to begin addressing this deficiency were instituted beginning August 2012. Additional programming and staffing changes are scheduled to be implemented by 9/30/12 to more fully and consistently address the deficiency. The licensing standard was reviewed with all staff at a 9/4/12 staff meeting; and the plans for correction will be reviewed and finalized at a 9/18/12 staff meeting. Clinical Supervisor will monitor ongoing compliance with the regulatory standard. |
709.82(d)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(2) Group counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including group counseling, at least twice weekly in two of the four client records reviewed for the partial hospitalization activity.
The findings include:
Ten client records were reviewed on August 23, 2012. Four of the ten client records were from the partial hospitalization activity. Four of those four records were required to include documentation of group counseling at least twice weekly. Two of those four did not document group counseling at least twice weekly.
Client # 7 was admitted on 2-17-2012 and was transferred to the outpatient level of care on 5-19-2012. Documentation of two group sessions per week was not evident for the weeks of March 19 and 26, 2012; and April 2 and 16, 2012.
Client # 10 was admitted on 4-19-2012. The last date of counseling was on 6-8-2012 and the client was discharged on 7-20-2012. Documentation of two group sessions per week was not evident for the weeks of April 23, 2012; May 7, 14, 21 and 28, 2012 and June 4, 2012.
The findings were reviewed with the project director and the clinical supervisor and were not disputed.
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Plan of Correction
Program Director and Clinical Supervisor are developing programming and staffing changes to be implemented by 9/30/12 to more fully and consistently fulfill compliance with this regulatory standard. The licensing standard was reviewed with all staff at a 9/4/12 staff meeting; and the plans for correction will be reviewed and finalized at a 9/18/12 staff meeting. Clinical Supervisor will monitor ongoing compliance with the regulatory standard. |
709.22(b) LICENSURE Governing Body
709.22. Governing body.
(b) If a project is publicly funded, not more than one staff member of the project may sit on the governing body at a designated time.
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Observations
Based on a review of administrative information, the facility failed to ensure that only one staff member was a member of the Board of Directors. Two employees of the facility are also members of the Board of Directors.
Findings include:
The board minutes and the annual report revealed that the Project Director and a counselor were also members of the Board of Directors. The counselor is the Secretary of the Board of Directors.
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Plan of Correction
The Board of Directors has filed an exception request to DDAP. Pending a decision regarding our exception request, the Board has resolved that as of October 22, 2012 Douglas Candelario will not be a member of the Board of Directors, although he will continue in his role as facility Director. This will ensure that as of 10/22/12 we are in compliance with this regulatory standard, pending a ruling on our request. Upon a decision being made regarding our exception request, the Board and the facility Director will be responsible for ensuring permanent and ongoing compliance with any decision rendered by DDAP. |
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 the client records, the facility failed to provide a physician signature on a treatment plan and a treatment plan update in one of one client records.
The findings include:
Ten client records were reviewed on August 23, 2012. Seven client records were from the Outpatient treatment activity. One client record was funded through the office of medical assistance and was required to include documentation of a physician's signature on the treatment plan and the treatment plan update. There was no documentation of the physician's signature on the treatment plan and treatment plan update in client record #6.
Client record #6 - The client was admitted to treatment on 2-24-2012. The treatment plan was completed on 5-29-2012. There was no documentation of the physician signature on the 5-29-2012 treatment plan. The treatment plan update was completed on 7-30-2012. There was no documentation of the physician's signature on the 7-30-2012 treatment plan update.
The findings were reviewed with the clinical supervisor and was not disputed.
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Plan of Correction
The licensing standard was reviewed with all staff at a 9/4/12 staff meeting. The client, treatment plan, and treatment plan update in question will be reviewed with supervising physician during the scheduled 9/11/12 clincial staff meeting. Clinical Supervisor will monitor ongoing compliance with the regulatory standard. |
709.14(a) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
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Observations
Based on a review of a client records, and interviews with the project director and clinical supervisor, the facility failed to comply with the Department approved capacity for the outpatient treatment activity.
The findings include:
The facility reported an outpatient census of 87 clients on the "Staffing Requirements Facility Summary Report". The Department approved capacity for the outpatient treatment activity was 80 clients. The facility is exceeding its authorized outpatient capacity of 80 clients.
The findings were reviewed with the project director and the clinical supervisor and were not disputed.
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Plan of Correction
Harbor Counseling's Director submitted a 9/28/12 request to DDAP for an increase in our licensed capacity. Pending DDAP's decision regarding our request, Program Director and Clinical Supervisor continue to monitor and ensure that regulatory staff:client ratios are met. The Clinical Director has also been meeting weekly with clinical staff to monitor the safe and appropriate discharge and referral of existing client population in order to move into compliance with our current licensed capacity without harm to clients. Program Director will ensure that by 11/30/12 we are in compliance with whatever our approved licensed capacity is on that date. |