INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 2-4,2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, 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 and a plan of correction is due on March 6, 2009.
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Plan of Correction
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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.
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Observations
Based on the review of employee training and personnel records, the facility failed to document 25 hours of annual training for each counselor for the training year reviewed(2008).
The findings included:
Six employee training records were reviewed during the onsite licensing inspection of February 2-4, 2009. Three of the records were counselor records and were required to document 25 hours of annual training for the training year ended in December, 2008. Personnel record # 4 included documentation of only 20 hours of training for the 2008 training year.
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Plan of Correction
The project director is reponsible to ensure compliance in this area. In order to obtain and maintain compliance the staff trainings will be scheduled earlier in the year so that if there are any staff who miss trainings there will be an opportunity to make up those training hours. |
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
Based on the review of the agency client records and agency self reporting on the Staffing Requirements Facility Summary Reports, the facility failed to ensure that the client to counselor caseloads did not exceed 35:1 for each counselor
The findings included:
The Staffing Requirements Facility Summary Report was reviewed on January 26, 2009. The information caseload sizes documents that the caseload for employee # 2 was at 38:1.
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Plan of Correction
The project director is responsible to ensure that FTE Ratios remain in compliance. In order to obtain compliance the clinical supervisor who was caring a caseload of 35 will be replaced with a new counselor to maintain the current caseload and the clinical supervisor will be full time with a maximum caseload of 5 individuals. The clinical supervisor will move into the adminisatative office and she will utilize the doctors office for counseling during the days and times that the physician and physician assistant do not occupy this space. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the physical plant inspection and a review of administrative documents, the facility failed to ensure that the building grounds and yard were free from hazards.
The findings included:
Internal agency reports were reviewed and a physical plant inspection was conducted during the onsite licensing inspection of February 2-4,2009 .Administrative meeting minutes dated January 29, 2009 documented an incident of a client running into the gas pipes located at the corner of the parking lot entrance to the facility. An interview with the Project Director indicated that this occurred on a prior occasion as well.
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Plan of Correction
Our landlord is responsible to ensure the safety of facility and grounds. The landlord has been notified as well as the gas company. Upon investigation it was found that the meter should be not be on the facility property because it is the meter for next door. Steps are being taken to have the meter removed from the property and/or secured with a barrier that would enable any vehicle to come in contact with the meter. The project director will oversee and ensure that the meter is secured. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill log documentation, the facility failed to document unannounced fire drills at least once per month.
The findings included :
The fire drill documentation log included forms which indicated that 50% of fire drills conducted would be announced. Supporting documentation in the fire drill log indicated that six of the twelve months in 2008 included announced fire drills.
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Plan of Correction
The fire drill log will be updated by the project director to accurately reflect all unnannounced fire drills as well as the policy will indicate that all fire drills will be unannounced and the front desk will be trained on the updated form and policy. The project director is responsible to ensure that the above stated corrective action is implemented. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on the review of the agency fire drill log, the facility failed to document that the fire alarms were activated during each fire drill.
The findings included:
The fire drill documentation log was reviewed during the onsite licensing inspection of February 2-4, 2009. No documentation was included in the log to indicate that the fire alarm was activated for each fire drill.
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Plan of Correction
The fire drill documentation will be updated by the project director to include documentation of fire alarm activation. The project director will then provide the new form to the front desk and they will then document that the fire alarm was in fact activated. |
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:
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Observations
Based on the review of the agency policy and procedure manual on February 2, 2009, the facility failed to document that the annual report was made available to the public.
The findings included:
The agency policy and procedure manual was reviewed during the onsite licensing inspection of February 2 -6, 2009. There was no documentation to demonstrate that the annual report was made available to the public for the calendar year reviewed.
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Plan of Correction
The governing body of the organization is responsible to ensure that the annual report is made available to the public. In order t obtain compliance once the taxes are completed and recieved by the CEO the statement of income and expenses will be provided to the project director who will attach it to the annual report and ensure that an advertisement is placed in the news paper. A copy of the advertisement will be obtained and retained in the corporate records to ensure that this documentation is available in the future for any future licensing inspection. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to document complete personal histories in eight of twelve client records.
The findings included:
Twelve client records were reviewed during the onsite licensing inspection of February 2-4, 2009. Family dynamics were not documented in the family history in client records # 1, 2, 3, 4, 5, 6, 7 and 9. Employment histories were not documented in client records # 1, 2, 3, 8, 9 and 10.
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Plan of Correction
The project is responsible to ensure complaince with this regulation. The project director will review and update the intake documentation of clients personal histories and determine the need for any changes in the policies and and procedures or the intake forms. The staff will then be trained on the collection of information from clients during the intake process and be made aware of any updates or changes to policy and procedures or forms. To ensure future compliance random chart audits will be performed to review the completeness of all intake documentation. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of the client records, the facility failed to document psychosocial evaluations which provided a complete clinical assessment in the psychosocial evaluations of each client in eight of twelve client records.
The findings included:
Twelve client records were reviewed during the onsite licensing inspection of February 2-4, 2009.
Client needs which identified possible relationships, conditions and causes leading to the client's current situation were not documented on the psychosocial evaluations in client records # 1, 2, 5, 8, 9, 10 and 11.
Client strengths and assets which could contribute to the resolution of identified problems were not documented on the psychosocial evaluations in client records # 1, 3, 7, 9, 10 and 11.
Client support systems were not documented on the psychosocial evaluations in client records # 1, 3 and 7.
Negative factors that cannot be resolved through treatment, or that might inhibit treatment were not documented on the psychosocial evaluations in client records # 3, 7, 9 and 10.
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Plan of Correction
The project director is responsible to ensure compliance with this regulation. The project director will review and update all intake information collection forms and the psychosocial form and determine the need for any changes in the policies and procedures or the intake forms. The staff will then be trained on the collection of information from clients during the intake process and be made aware of any updates or changes to policy and procedures or forms. To ensure future compliance random chart audits will be performed to review the completeness of all intake documentation. |