INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6, 2006 to November 8, 2006 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 December 13, 2006.
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Plan of Correction
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Counselor assistants are being supervised by the facility director. A counselor assistant must be supervised by a full time counselor or full time clinical supervisor. Since the facility director has administrative duties, she would not be considered full time in the role of clinical supervisor even though she oversees the counseling component of the program.
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Plan of Correction
The clinic director/acting clinical supervisor was being filled by one individual.
The individual in the role as campus director of the Lebanon Treatment Center and New Perspectives of White Deer Run, will be the clinic director of the Lebanon Treatment Center. The individual in the role of clinic director/acting clinical supervisor will be the full-time clinical supervisor of the Lebanon Treatment Center and will supervise the 2 full-time counselor assistants. This will allow the 2 full-time counselor assistants to be supervised by a full-time clinical supervisor. This is now in place. |
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
Incomplete documentation was presented for the assessment of staff training needs. The assessment must be completed in accordance with agency policy. Since this program opened in May, 2006 the training assessment should have been completed at that time.
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Plan of Correction
Staff needs assessment were not completed upon the opening of the clinic.
Staff needs assessment have been completed for end of Year 2006 and Fiscal Year 2007.
The clinic director will be responsible to maintain compliance with the standard. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
No documentation of an agency training plan was presented at the time of the inspection.
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Plan of Correction
A comprehensive staff development plan wasa not completed at the time of clinic opening.
A comprehensive staff development program has been developed for end of Year 2006, and Fiscal Year 2007.
The clinic director is responsible to maintain compliance with this standard. |
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
Individual training plans were not documented for employee # 1 and #7. A training plan must be completed for each employee within one month after hire.
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Plan of Correction
Not every employee received an individual training plan upon hire.
All staff have completed an individual training plan.
Each employee upon hire will receive an individual training plan. This will be implemented within first 30 days of hire.
This will continue to be monitored by the department supervisor. The clinic director will be responsible for maintaining compliance with this standard. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
The staff to client ratio was 88:1.
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Plan of Correction
Counselor Assistans were hired without full time clinical supervision.
The individual who is in his role as campus director of the Lebanon Treatment Center and New Perspectives of White Deer Run, will be the clinic director of the Lebanon Treatment Center. The clinic director/acting clinical supervisor will be the full-time clinical supervisor of the Lebanon Treatment Center and will supervise the 2 full-time counselor assistants. This will allow the 2 full-time counselor assistants 35-1 ratio to be counted and put the Lebanon Treatment Center into compliance. This is now in place. |
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.
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Observations
Since the counselor assistants were improperly supervised their hours could not be computed in the staff to client ratio.
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Plan of Correction
Counselor Assistants were hired without full time clinical supervision.
The individual who is in his role as campus director of the Lebanon Treatment Center and New Perspectives of White Deer Run, will be the clinic director of the Lebanon Treatment Center. The individual who is clinic director/acting clinical supervisor will be the full-time clinical supervisor of the Lebanon Treatment Center and will supervise the 2 full-time counselor assistants. This will provide a full time clinical supervisor for the counselor assistants. This will allow the 2 full-time counselor assistants 35-1 ratio to be counted and put the Lebanon Treatment Center into compliance. This is now in place. |
709.31(a) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(a) If a project utilizes Department funds, it shall comply with the Department's UDCS.
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Observations
No documentation was available to demonstrate compliance with the requirements of this regulation. Documentation must be presented that the project utilizes the CIS system for clients who are funded with Department monies.
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Plan of Correction
No CIS requirement information was received from the county SCA.
The CIS has been installed in the office manager's computer, counselors have completed the CIS form, and the information is being entered into the system.
This will be continually monitored for compliance by the Clinical Supervisor. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Documentation in files reviewed was not in compliance with this regulation. The Doctor did not consistently date his signature so there was no way to verify that he was signing verbal orders within 24 hours. In instances where signatures were dated there were a number of examples of the physician not signing verbal orders within the required 24 hour window.
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Plan of Correction
The clinic physician was not consistently dating his signature.
This has been corrected by daily contact with the program physician for signature of verbal orders and printed orders.
This is now in place.
The Director of Nursing is responsible for maintaining compliance with the standard. |
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.
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Observations
Medical histories in files reviewed did not address all required areas. Family and personal medical histories were incomplete. Histories should be constructed to collect as much personal information about a client as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated. A history documenting the client's personal medical history, family medical history, and history of illness and symptoms must be documented.
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Plan of Correction
The history and physical form did not request this information.
New H and P has been implemented which includes the family medical history and patients' medical history.
This is now in place.
This will continue to be reviewed and monitored for compliance by the Director of Nursing. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Treatment plan updates in files reviewed did not consistently address progress on goals and strategies or the need for restatement of goals. The treatment plan update should include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
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Plan of Correction
The treatment plans were not specific regarding progress toward goals in treatment.
This was reviewed with staff immediately following survey.
Documentation of specific progress per specific goal is now in place. Clinical Supervisor is responsible for achieving and maintaining compliance with this standard. This will continue to be monitored during individual and group supervision. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Discharge summaries in client records # 22 and #23 did not address all required areas in sufficient detail. The reason for treatment and the client response to treatment did not provide descriptive information in accordance with the requirement of this regulation.
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Plan of Correction
The discharge summary did not specifically request this information.
Staff have been trained on the discharge summary which included reason for treatment and response to treatment needs.
This will continue to be reviewed and monitored for compliance by the Clinical Supervisor. |
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.
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Observations
Follow up was not documented in accordance with agency policy in client records # 2, #22 and #23.
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Plan of Correction
The release for follow up provided incorrect information regarding the frequency of follow up contact.
Staff have been trained on procedure for follow up for discharged patients. The release has been changed to reflect Policy of follow up contact at a year.
This will continue to be reviewed and monitored by the Clinical Supervisor for compliance wiht this standard. |