INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 9, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Life Management, 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:
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Plan of Correction
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to document a confidentiality policy and procedure compliant with 4 Pa. Code subsection 255.5.
The findings included:
4 Pa. Code subsection 255.5 (a)(6), states: "Projects may disclose with the consent of a client, in writing, the information to employers of a client to further the rehabilitation of a client; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Such information shall be limited to whether the client has or is receiving treatment with the project."
The facility policy and procedure manual was reviewed as part of the annual onsite licensing inspection of March 5 - 6, 2012. Policy # 60,006, section C, subsection 2, letter f, exceeded 4 Pa. Code subsection 255.5 (a)(6), as it allowed for the following: "Life Management may disclose with the client's consent, the information to employers of a client to further the client's rehabilitation; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Information released shall be limited to that provided for in subsection 4.a. in this section."
Subsection 4.a. states: " Nature of Client Information to be Disclosed. a. Information released to judges, probation or parole officers, insurance company, health or hospital plan or government officials, pursuant to section C.2.a-i of this section, is for the purpose of determining the advisability of continuing th client in treatment with Life Management and shall be restricted to the following:
i. Whether or not the client isn't in therapy
ii. The prognosis of the client
iii. The nature of the project
iv. A brief description of the client's progress
v. A short statement as to whether the client has relapsed into drug or alcohol abuse and the
frequency of such relapse."
The project's Confidentiality policy permits for the release of information under ii, iv, and v, which is restricted under 4 PA Code 255.5(a)(6).
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Plan of Correction
The policy regarding compliance with PA Code 255.5 will be revised and reviewed by Project Director and placed in policy and procedure manual by 4/15/2012. All staff will be informed at the next weekly staff meeting following the placement of the revised policy into the Policy and Procedure Manual. Facility Director will ensure complaince. |
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
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
The findings include:
On March 6, 2011 three personnel records were reviewed to verify that all personnel on all shifts had been trained to perform assigned tasks during emergencies. The facility failed to document the completion of emergency training in one of three personnel records reviewed, specifically employee # 4.
Employee # 4 was hired as a counselor on May 6, 2009 and relocated to the Pottstown facility in October 2011. However, personnel record # 4 did not include documentation of emergency training for the new location.
The findings were confirmed by the Site Director during the exit interview.
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Plan of Correction
All staff will be re-trained for emergency procedures at a staff training on 4/10/12. Record of training will be placed in all employee files, including Employee #4.
All future hires and transfers will be trained by facility director or their designee prior to beginning work at the location. The facility director will ensure compliance for all new hires and transfers. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records and the facility ' s policies and procedures, the facility failed to document a comprehensive treatment plan to include proposed types of supportive services.
The findings include:
The project ' s policy titled Treatment Management; 60,029; Section C. Comprehensive Treatment Plan (709.92.a), Effective 1/10/11 states:
The Comprehensive Treatment Plan is an individual treatment and rehabilitation plan developed in collaboration with each patient and their assigned Primary Counselor. The plan shall include, but not be limited to, written documentation of:
a.defined
b.defined
c. Proposed type of support services. Services may include medical, psychiatric or mental health services, financial, legal, AA, NA, etc. (709.9.2a.3.).
On March 9, 2012 four client records were reviewed for comprehensive treatment plans, that included support services. One out of four client records lacked documentation of a treatment plan that included a proposed type of support service, specifically client record # 3.
Client #3 was admitted on December 20, 2011 and discharged on February 8, 2012. The comprehensive treatment plan was documented on December 28, 2011; however it did not include a proposed type of support service for client #3.
The findings were confirmed by the Site Director during the exit interview.
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Plan of Correction
Facility Director reviewed treatment plan management with all staff on 4/3/2012, and review will be documented in supervision notes for each therapist.
Ongoing compliance will be ensured via monthly chart audits by facility director. |
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 a review of personnel training records and a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that each counselor receive at least 25 clock hours of training annually.
The findings include:
According to the Staffing Requirements Facility Summary Report, the facility training year runs from January 1, 2011 to December 31, 2011.
On March 10, 2012 one counselor ' s record was reviewed for training hours. One out of one counselor record did not document 25 clock hours of training for the 2011 training year, specifically counselor #4.
Employee # 4 was hired as a counselor on May 6, 2009. Employee # 4 had only 23 documented clock hours of training during January 1, 2011 through December 31, 2011.
On March 10, 2012 an interview was held with the Site Director in which an inquiry was made if employee #4 had any additional documentation of training hours for the 2011 training year, the inspector was advised there may be additional hours but were unable to provide verification of the additional hours for employee #4.
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Plan of Correction
Employee #4 did have additional hours of training that were not in employee's file. These hours have been added to employee's file. Future compliance with trainings for all staff will be monotired by facility director via regular (at least quarterly) reviews of all employees' training hours. |