INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 17 and 18, 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 May 6, 2007.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
The plan documenting the qualifications and training of staff was presented to the Department licensing representative at the time of the site visit, but did not have any of the required information recorded. The form was returned to facility staff for completion. When returned to the licensing specialists, the form was still missing a majority of the information requested.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
There was no verification of the major field of study for the bachelor's degree conferred on staff #6, therefore, it was not possible to determine if the degree qualified under the standards.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
There were no policies and procedures for the overall staff development program.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
The overall training plan developed did not include timeframes by which trainings would occur.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
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Observations
Documentation of this training was missing for five of ten personnel records reviewed, employees #1, 4, 5, 6, and 7.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Exit routes used were not documented on the log for three of four fire drills reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(c)(2) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(2) Qualifications for membership.
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Observations
Qualifications for membership were missing.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(d)(2) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(2) Identifying the project's purpose and philosophy.
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Observations
Documentation of the project's philosophy regarding drug and alcohol services was missing.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
An annual report has not been completed since 2005. This facility receives public funding and is required to develop an annual report.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(b)(2) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(2) The dissemination of employment information to project staff.
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Observations
The policy regarding the dissemination of information to staff was missing.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
There was no documentation of staff having been informed of employee rights for eight of eight staff requiring this.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
The policy requesting correction or removal of information from his/her personnel file was missing.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(e)(3) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(3) The employe's right to submit rebuttal data or memoranda to his own records.
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Observations
The policy addressing the employee's right to submit rebuttal data or memoranda to his/her personnel file was missing.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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:
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Observations
The current consent to release information form contains "release/obtain" and is consistently not clarified. The regulations do not permit a consent to obtain information and, therefore, should be removed from the forms. In addition, the current consent to release information as well as the treatment plan form, contains a line for the parent/guardian signature. State law treats minors as if they have reached the age of majority and only the minor may sign the consent in the provision of drug and alcohol treatment, therefore parental signature lines must be removed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
The purpose of the release of information was consistently incongruent with the person or agency requesting the information.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
The document provided to the clients enrolled in the Passages Program regarding the clients rights was missing the procedures to appeal a decision limiting access, how to request correction of information and how to submit rebuttal data or memoranda to their record.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(a)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(1) Criteria for admission.
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Observations
Limitations as to who the program can and cannot treat were not addressed in the criteria for admission.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The drug and alcohol histories contained minimal information. The length and patterns of use and client's perception of the effect on his/her life was not documented.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
There was minimal personal history documented in five of nine client records reviewed, #5, 6, 7, 8, 9, 10. The specific areas of family, legal, employment, education and sexual history contained very little information. There was no documentation of the client's recreational history in all records reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Seven of ten client records reviewed did not contain a psychosocial evaluation. The remaining three contained a repetition of the historical data and did not include all the areas recommended, thus did not present a composite assessment.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
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Observations
Seven of ten client records reviewed did not have comprehensive treatment plans. These included client records #1, 2, 3, 4, 6, 7, 8.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
The treatment plan updates did not discuss the progress of prior treatment goals, resolution or the reasoning for the formation of new goals in all client records reviewed that had an update documented. Updates were missing for client records # 6, 7, 8.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Medication records in the client records reviewed were missing medication dose and the frequency the client is to take the medication.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
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Observations
Services were not consistently documented according to the progress notes written. The provider and duration of the services were inconsistently documented.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Aftercare plans are completed at admission and the goals were related to the immediate treatment service process. The goals were not updated to sustain and build on progress achieved during the treatment process. Aftercare plans as documented also do not include re-entry criteria.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
A discharge summary was missing for client # 8. The discharge summaries for records # 3, 9, 10, 11, 12 did not clearly establish reasons for treatment or the client's response to the treatment process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Documentation of follow up was missing or not completed according to program policy for four of seven client records reviewed, # 8, 9, 10, 12.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |