INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 6 through 7, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Counseling Alternatives Group 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 September 5, 2008.
|
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 an August 6 through 7, 2008 review of six employee records, the facility failed to ensure that one employee obtained HIV/AIDS training within the first year of employment.
Finding:
The facility did not document HIV/AIDS training within the first year of employment for employee # 4.
|
Plan of Correction
Employee #4 will find and attend HIV/AIDS training by 11/15/08. The project director will speak to her about this issue and make sure that she follows up. Discussions about this issue will be documented and placed in her personnel file as will her certificate of completion. |
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.
|
Observations
Based on an August 6 through 7, 2008 review of five employee records, the facility failed to document fire extinguisher training within the first 7 days of employment for one of two new employees.
Finding:
The facility did not document the provision of fire extinguisher training within seven days of the hire date for employee # 5.
|
Plan of Correction
Employee #5 will be trained in the use of the fire extinguisher by the clinical supervisor by September 5, 2008. A copy of the confirming document shall be placed in their file. |
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.
|
Observations
Based on an August 6 through 7, 2008 review of five employee records, the facility failed to document emergency procedures training within the first 7 days of employment for one of two new employees.
Finding:
The facility did not document emergency procedures training for employee # 5 within seven days of the date of hire.
|
Plan of Correction
Employee #5 shall be trained by the clinical supervisor in emergency training techniques by September 5, 2008. Documentation of such training shall be placed in their file. |
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.
|
Observations
Based on an August 6 through 7, 2008 review of facility documents, the facility failed to ensure that no more than one employee sat on the governing body at any time.
Finding:
The facility had formerly been a partnership and has since registered as a corporation. All five partners are now shareholders and members of the Board of Directors, the governing body.
|
Plan of Correction
No action was taken when the former partners, now counselor/owners reviewed their incorporation papers and saw that the articles allowed all of them to be on the Board of this for-profit organization.
Two individuals shall be picked to sit on the Board and the director will also sit on the new Board. They will meet once a year, on the first friday of december to review the goals and fiscal report of the agency. |
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 an August 6 through 7, 2007 review of seven client records, the facility failed to obtain an informed and voluntary consent from the clients for disclosure of information to Medical Assistance in two of five client records reviewed for that standard.
Finding:
Consent to release information forms for releases of information to the Office of Medical Assistance were missing from client records # 2 and 5.
|
Plan of Correction
Since all MA clients sign a statement giving us permission to (a) bill Medical Assistance and to (b) give Medical Assistance a diagnosis and since we say the giving of incidental information (birth date, medical card number and address, etc.) on a client information form,as part of the billing process we did not have our clients sign an additional release of information.It is understood that conversations about additional information with this agency would require a release of information. Since it is the reviewer's understanding that the two signatures (permitting us to file a bill and giving a diagnosis) are not sufficient, the following will occur:
Clients #2 and 5 will be asked to sign a seperate release of information form by their clinicians. Clinicians will be informed of this requirement and will ask all clients to sign an additional release of information for all and any insurance sources. Files will be reviewed randomly by the clinicl supervisor and the project director over the course of the next three months. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
|
Observations
Based on a review of seven client records, five client records were reviewed for consent to release information forms. The facility failed to thoroughly document whether or not the client was offered a copy of the consent to release information form.
Finding:
Documentation in three of five client records was missing whether or not clients were offered copies of consents to release information, specifically client records # 1, 2 and 4.
|
Plan of Correction
Clinicians for clients #1,2 and 4 will be asked to find out if the clients wish copies of the paperwork. The clinical director will ask them if this was done by 9/5/08. In addition a review of this requirement will be presented at the clinical staff meeting on 9/3/08 by the clinical director. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
|
Observations
Based on an August 6 through 7, 2008 review of facility records the facility failed to have a data collection and record keeping system that allows for efficient retrieval of data needed to obtain client records for review.
Finding:
The facility had difficulty procuring records in a timely fashion because the record keeping system did not state when the client was admitted and what type of client they are, i. e. drug and alcohol or mental health.
|
Plan of Correction
The facility has a system that includes information on date admitted, date of end of treatment and manner of termination. The facility does not have a system that identifies type of client (dependent, co-dependent, etc).
Two systems have been put in place. The project director has created a form for the includes name of client, admission date, closing date, client number and type of client. This form has been placed in the client list book that is in the locked file room.
In addition the administrative assistant is working on an Excell spread sheet that will include the same information for all clients admitted after 9-1-08. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
Based on an August 6 through 7, 2008 review of seven client records, five client records were reviewed for medical histories. The facility failed to thoroughly document medical histories in three of five client records.
Finding:
Documentation of medical histories was missing from client records # 4 and 5.
|
Plan of Correction
Clients #4 and 5 will be asked by their clinicians to fill out medical histories by 9-2-08. They will be placed in the respective files. These files will be checked by the clinical director by 9-15-08.
In addition a review of the regulation on medical information and medial histories will be discussed by the clinical director at the clinical staff meeting on 9-3-08.
|
709.93(a)(3) 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:
(3) Record of services provided.
|
Observations
Based on an August 6 through 7, 2008 review of seven client records, the facility failed to document records of service in two of seven client records reviewed.
Finding:
Documentation of records of services was missing from client records # 4 and 5.
|
Plan of Correction
The clinicians for clients # 4 and 5 will fill out records of service for clients #4 and 5. the clinical director will review these forms by 9-2-08.
In addition, the clinical director will review the need for and completion of the record of service form at the clinical meeting on 9-2-08.
The clinical director and the project director will randomly check files for the completion of that form for the next three months. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on an August 6 through 7, 2008 review of seven client records, two client records were required to document follow up attempts. The facility failed to document follow up information in two of two client records where required.
Finding:
Documentation of follow up attempts was missing from client records # 6 and 7.
|
Plan of Correction
The clinicians for clients #6 and 7 will be asked tofollow up on their clients via sending a follow-up form via mail. This will be done by 9-2-08. The clinical supervisor will follow up to make certain that this has been done by 9-15-08.
In addition the clinical director will review the need for follow up and the procedure at the clinical meeting on 9-2-08. During the next three months the clinical director and project director will randomly check for follow-up documentation in randomly selected files of all clients close within the past year. |