INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25 - 26, 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 February 15, 2007.
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Plan of Correction
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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
The staffing compliance plan was not approved by the Pinnacle board. This statement must be approved by the governing body and documented via meeting minutes or governing body sign off.
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Plan of Correction
Board meeting will address this issue on 4/24/07 |
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 outpatient overall caseload size was at 36:1.
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Plan of Correction
Staff ratio will be corrected to reflect 35:1 ratio. Supervisor will be responsible for ongoing compliance. |
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.
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Observations
No documentation was on file to verify who sits on the Pinnacle governing body. Documentation must be available to demonstrate compliance with this regulation.
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Plan of Correction
Board meeting will address this issue on 4/24/07 |
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
No criteria for qualifications for membership on the Pinnacle Board of Directors were specified.
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Plan of Correction
Board meeting will address this issue on 4/24/07 |
709.22(c)(3) 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:
(3) Criteria for continued membership.
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Observations
No criteria for continuing membership on the Pinnacle Board of Directors was specified.
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Plan of Correction
Board meeting will address this issue on 4/24/07 |
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
No method of selection for the Project Director was specified in the materials presented.
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Plan of Correction
Board meeting will address this issue on 4/24/07 |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
The manual did not include approval by the Pinnacle governing body. The manual was not complete in identifying the relationship of Pinnacle Treatment Center to Alliance Medical.
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Plan of Correction
Board meeting will address this issue on 4/24/07 |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
No documentation was presented to verify that the Project Director and the Pinnacle board collaborated in formulation of goals and objectives, written reports of project operations and a performance report on meeting goals and objectives.
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Plan of Correction
Board meeting will address this issue on 4/24/07 |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
No goals and objectives were documented for the current fiscal year. Goals and objectives should be formulated and approved prior to the beginning of each fiscal year.
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Plan of Correction
The board that was in place for '06 has been disbanded. Goals for 2007 will be approved via the board meeting. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
No performance report summarizing the progress toward meeting goals and objectives for 2006 was presented at the time of the inspection.
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Plan of Correction
The board that was in place for '06 has been disbanded |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Specific information disclosed to funding entities, GAF scores, exceeded the limitations imposed at 4 Pa. subsection 255.5(b).
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Plan of Correction
The Facility Director will develop a specific release of information limited to 255.5. The Medical Director as part of his diagnosis will provide the GAF score that will be communicated to the funders. |
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
Personal histories should 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. Personal histories in client records reviewed lacked detail on family of origin, current family constellation and employment history.
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Plan of Correction
The Facility Director and Clinical Supervisor will provide training in further development of the personal histories. Ongoing training and compliance will be monitored by the clinical supervisor. |