INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on April 16- 18, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Home Nursing Agency Community Services 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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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on the review of the facility policy and procedure manual, organizational chart, job description and governing body minutes, the employee who is identified as the Project Director does not have overall management responsibility for the project.
The findings include:
During the annual onsite licensing renewal inspection of April 16-18, 2012 the facility policy and procedure manual, organizational chart, job description and governing body minutes were reviewed. The person designated as the project director does not have overall management responsibility for the project. The corporation's Chief Executive Officer (CEO) has that authority and responsibility.
The findings were reviewed with the administrative staff and were disputed. Documentation provided by facility staff did not provide compelling evidence that the person identified as the Project Director met the intent of the regulation.
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Plan of Correction
Home Nursing Agency will request of their board, in July of 2012, to make the CEO Project Direcotr of the D&A program. After board has given its approval, the agency will submit a waiver requesting that the STD and HIV education be waived for the CEO. The waiver request should be completed by Aug. 10, 2012.
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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
Based on the review of employee records, the facility failed to ensure that each counselor met one of the requirements of this Chapter as they pertain to counselor qualifications.
The findings include:
Nine employee personnel and training records were reviewed during the annual onsite licensing renewal inspection of April 16-18, 2012. Six personnel and training records represented clinical staff. One of six personnel and training records did not include documentation that the employee who was designated as a counselor, had a credential that would qualify the individual for the position of counselor.
Employee personnel record # 2 included documentation of an Administration of Justice degree. This not a degree is a related field. The employee does not meet the requirements for the position of counselor.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
Effective June 8, 2012 the Clinical Services Manager will compare all resumes, diplomas and transcripts of potential hirees to BDAP/licensing regulations to ensure that new hirees meet the qaulifications for the position of counselor. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on the review of facility policy and procedure and employee personnel and training records, the facility failed to consistently collect feedback on training in accordance with written facility policy in five of nine employee training records.
The findings include:
Nine employee records and the facility policy and procedure manual were reviewed during the annual onsite licensure renewal inspection conducted from April 16-18, 2012. Training attended in the 2010-11 and 2011-12 was reviewed. Written facility policy states that a training evaluation form is to be completed after each training attended. Five of nine employee records did not demonstrate consistent use of training evaluation forms, in accordance with facility policy and procedure, in the employee and training records reviewed.
Employee #1- Documentation of training sessions attended on 10/8/10 and 10/29/10 did not include training evaluations forms.
Employee # 2- . Training sessions attended 2/25/10,4/30/10,9/14/10, 4/22/11, 10-11 to 10/14/11,10/29/11, and 1/13/12 did not include training evaluations forms.
Employee #3- Training sessions attended 2/3/12, 3/13/12, 3/16/12, 3/18/10, 1/13/10 did not include training evaluations forms.
Employee # 6- Training sessions attended 7/29/11, 9/6,7,9 & 11/2011, 10/7/11, 1/11/12, 1/15/12 did not include training evaluations forms.
Employee # 8-Training sessions attended 4/14/11 and 2/20/12 did not include training evaluations forms.
The findings were reviewed with the Project and Facility Directors who indicated that all staff consistently complete evaluation forms and that they are sent to personnel for tracking and filing. These documents were unavailable during the inspection.
This is a repeat citation.
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Plan of Correction
As of July 1, 2012 the Clinical Services Manager will track all trainings and complete a monthly audit to ensure training evaluation forms are completed correctly and within two weeks of completion of training course. In addition a qaurterly audit will be completed by the Clinical Services Manager and the Behavioral Health Support Staff Supervisor to ensure all of the training evaluations are completed and present. |
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 staff training records, the facility failed to ensure that each counselor received 25 hours of training annually.
The findings included:
Nine employee records were reviewed during the annual onsite licensure renewal inspection conducted April 16-18, 2012. Two counselors were required to have obtained 25 hours of training for the 2010-2011 training year. One of two counselors did not have the required 25 hours of documented training for the 2010-2011 training year.
Employee # 4 had only 20 hours of training at the time of the personnel record review.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
Clinical Services Manager will meet with staff on a quarterly basis and review total number of education hours to date.
The Education Plan for each staff will be reviewed at these meetings to ensure 25 hours are met during the year.
Computerized tracking of education hours will be initiated for the 12-13 year. |
709.81(b)(6) LICENSURE Intake and admission
709.81. 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 a complete psychosocial evaluation on each client.
The findings included:
The annual licensure renewal inspection was conducted April 16-18, 2012. Two partial hospitalization client records were reviewed. One of two client records failed to include documentation of a complete psychosocial evaluation.
Client record # 2- The client was admitted on 5/25/11 and discharged on 7/27 /11. The psychosocial evaluation was completed at the time of intake. The following components were missing from the evaluation: support systems available to the client; the client's coping/defense mechanisms; the client's attitude toward treatment and a composite picture of the client..
The findings were reviewed with the Project and Facility Directors and were not disputed.
This is a repeat citation.
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Plan of Correction
On May 22, 2012 D&A counselors will atend a 3-hour Daily Living Activities Functional Assessment training. This training is highly endorsed by The National Council for Community Behavioral Health and will cover assessment information and skills.
The Clinical Services Manager will work directly with assessment staff to further train in assessment skills and documentation to ensure that a full composite picture of the client is present by July 1, 2012.
Home Nursing assessment staff will complete their own psychosocial assessments for all referrals as of July 1, 2012. An assessment team meeting will be held every two months to review assessments completed and hold discussion on qaulity and areas of growth starting July 2012.
Examples given by Dept. of Health staff will be utilized extensively as part of this training to be completed. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on the review of client records, the facility failed to document the required two individual counseling sessions per week in two of two client records.
The findings include:
The annual licensure renewal inspection was conducted April 16-18, 2012. Two Partial Hospitalization client records were reviewed. Two of two partial hospitalization records reviewed failed to include documentation of two individual counseling sessions per week.
Client Record # 1. This client was admitted on 7/11/11 and discharged on 8/11/11. This individual received treatment services at the partial hospitalization level of care for the weeks of 7/11/11 and 7/25/11. Only one individual counseling session was documented for each of these weeks in the progress notes and on the record of services provided.
Client Record # 2. This client was admitted on 5/25/11 and discharged on 7/26/11. This individual received services at the partial hospitalization level of care for the weeks of 6/6/11 and 6/13/11. Only one individual counseling session was documented for each of these weeks in the progress notes and on the record of services provided.
The clinical supervisor was interviewed and acknowledged that clients were offered two individual sessions per week for one half hour or one individual session per week for one full hour and that most clients preferred to attend the single one hour session per week.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
In the Partial Hospitalization level of care, all individuals will be offered 2 separate 50 minute individual sessions per week. Documentation of sessions will be kept in the client's chart. these individual session will be conducted by an approved Partial Hospital counselor. Monthly audits will be completed by counselors from program and these audits will be reviewed monthly by the Clinical Services Manager for compliance in meeting this regulation. |
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 facility procedure manual and supplementary administrative documents presented at the inspection, the facility failed to make an annual report available to the public within six months of the end of the fiscal year.
The findings include:
The annual licensure renewal inspection was conducted April 16-18,2012. The facility policy and procedure manual was reviewed on 4/16/2012. The annual report for the fiscal year ended June 30 , 2011 was not included in the materials presented.
An interview on 4/16/2012 with an administrative team member verified that the annual report was not made available to the public within the required six month period.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The Home Nursing Agency will post a written notice in the local paper for the public to be able to view the fiscal audit by Dec. 31 of each year.
Rebecca Willnecker, Chief People Officer and her marketing staff will be responsible for ensuring that this notice is posted timely. Donna Isenberg, Director Mgt. Services, will keep all records of proof of posting.
The posting of the fiscal audit has been added to the Marketing department's annual projet plan to ensure that it is posted yearly. |
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 the facility policy and procedure manual and client records, the facility failed to document a complete personal history in ten of ten client records reviewed.
The findings included:
The annual licensure renewal inspection was conducted April 16-18, 2012. Ten outpatient client records were reviewed. The facility policy stated that "complete and accurate information regarding the client's presenting problem and history" would be documented. Ten of ten client records failed to include documentation of complete personal histories.
Client Record # 3- This client was admitted 6/7/11 and discharged on 10/26/11. The personal history was compiled at intake. The following components were missing from the personal history: family interrelationships; impact of substance abuse on education; details of the client's employment/vocational history.
Client Record # 4 - This client was admitted 10/24/11 and discharged 1/11/12. The personal history was compiled at intake. The following components were missing from the history: family interrelationships; impact of substance abuse on education; details of the client's employment/vocational history.
Client Record# 5- This client was admitted 1/26/12 and discharged 3/21/12 . The personal history was compiled at intake. The following components were missing from the history: family interrelationships; details of the client's employment/vocational history.
Client Record # 6- This client was admitted 2/21/12 and discharged 4/2/12 . The personal history was compiled at intake. The following components were missing from the history: family interrelationships; impact of substance abuse on recreational interests; details of the client's employment/vocational history.
Client Record # 7- This client was admitted 10/21/11 and was last seen on 3/29/11 . The personal history was compiled at intake. The following components were missing from the history: family interrelationships; impact of substance abuse on education.
Client Record # 8- This client was admitted 4/2/12 and was last seen on 4/12/12 . The personal history was compiled at intake. The following components were missing from the history: family interrelationships.
Client Record # 9 - The client was admitted on 2/20/12 and was last treated on 3/13/12. The personal history was compiled at intake. The following components were missing from the history: family interrelationships; impact of substance abuse on education; details of the client's employment/vocational history.
Client Record # 10 - The client was admitted on 1/19/12 and was last treated on 2/28/12. The personal history was compiled at intake. The following components were missing from the history: family interrelationships; impact of substance abuse on education; details of the client's employment/vocational history.
Client Record # 11 - The client was admitted on 1/18/12 and was last treated on 3/12/12. The personal history was compiled at intake. The following components were missing from the history: family interrelationships; impact of substance abuse on education; details of the client's employment/vocational history.
Client Record # 12 - The client was admitted on 3/12/12 and was last treated on 3/12/12. The personal history was compiled at intake. The following components were missing from the history: family interrelationships; impact of substance abuse on education; details of the client's employment/vocational history.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
By June 30th 2012, the current history form will be compared to the electronic form as given to us by BDAP through the STAR 360 electronic medical record program.
On the current history form, answers will be explained in more detail covering the areas noted in the deficiency.
The Clinical Services Manager will meet with assessment counselors by June 30, 2011 to explain deficiencies and expectations in the history documentation. Examples sent by BDAP/Licensure will be used to educate staff on proper psychosocial assessments.
Starting July 1, 2012 Home Nursing Agency assessment counselors will complete our own psychosocial assessments for all individuals referred to the program.
Starting July 2012 an assesment team meeting will held by the Clinical Services manager every two months to discuss completed assessments for educational purposes and to ensure qaulity. |
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 a complete psychosocial evaluation in eight of ten client records reviewed.
The findings included:
The annual licensure renewal inspection was conducted April 16-18, 2012. Ten outpatient client records were reviewed. The psychosocial evaluations in eight of ten client records were incomplete.
Client Record # 3- This client was admitted 6/7/11 and discharged 10/26/11. The psychosocial evaluation was completed at intake. The following components were missing from the evaluation: support systems; the client's coping/defense mechanisms; the client's attitude toward treatment and a composite picture of the client..
Client Record # 6- This client was admitted 2/21/12 and discharged 4/2/12 . The psychosocial evaluation was completed at intake. The following components were missing from the evaluation: support systems; the client's coping/defense mechanisms; the client's attitude toward treatment; a composite picture of the client and the clinical impressions of the counselor.
Client Record # 7- This client was admitted 10/21/11 and was last seen on 3/29/11. The psychosocial evaluation was completed at the time of intake. The following components were missing from the evaluation: support systems; the client's coping/defense mechanisms; the client's attitude toward treatment and a composite picture of the client.
Client Record # 8- This client was admitted 4/2/12 and was last seen on 4/12/12. The psychosocial evaluation was completed at intake. The following components were missing from the evaluation: support systems; the client's coping/defense mechanisms; the client's attitude toward treatment; a composite picture of the client and the conclusions/impressions of the counselor.
Client Record # 9 - The client was admitted on 2/20/12 and was last treated on 3/13/12. The psychosocial evaluation was completed at intake. The following components were missing from the evaluation: support systems; the client's coping/defense mechanisms; the client's attitude toward treatment; a composite picture of the client and the conclusions/impressions of the counselor.
Client Record # 10 - The client was admitted on 1/19/12 and was last treated on 2/28/12. The psychosocial evaluation was completed at intake. The following components were missing from the evaluation: support systems; the client's coping/defense mechanisms; the client's attitude toward treatment; a composite picture of the client and the conclusions/impressions of the counselor.
Client Record # 11 - The client was admitted on 1/18/12 and was last treated on 3/12/12. The psychosocial evaluation was completed at intake. The following components were missing from the evaluation: support systems; negative factors which may influence treatment; the client's coping/defense mechanisms; the client's attitude toward treatment; a composite picture of the client and the conclusions/impressions of the counselor.
Client Record # 12 - The client was admitted on 3/12/12 and was last treated on 3/12/12. The psychosocial evaluation was completed at intake. The following components were missing from the evaluation: support systems; negative factors which may influence treatment; the client's coping/defense mechanisms; the client's attitude toward treatment; a composite picture of the client and the conclusions/impressions of the counselor.
The findings were reviewed with the Project and Facility Directors and were not disputed.
This is a repeat citation.
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Plan of Correction
On May 22, 2012, D&A counselors will attend a 3 hour Daily Living Activities Functional Assessment training. This training is highly endorsed by The National Council for Community Behavioral Health and will provide detailed information on assessment.
By June 30th 2012, the current history form will be compared to the electronic form as given to us by BDAP through the STAR 360 electronic medical record program.
On the current history form, answers will be explained in more detail covering the areas noted in the deficiency.
The Clinical Services Manager will meet with assessment counselors by June 30, 2011 to explain deficiencies and expectations in the history documentation. Examples sent by BDAP/Licensure will be used to educate staff on proper psychosocial assessments.
Starting July 1, 2012 Home Nursing Agency assessment counselors will complete our own psychosocial assessments for all individuals referred to the program.
Starting July 2012 an assesment team meeting will held by the Clinical Services manager every two months to discuss completed assessments for educational purposes and to ensure qaulity.
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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment services on the treatment plans in five of thirteen client records.
The findings included:
The annual licensure renewal inspection was conducted April 16-18, 2012. Thirteen outpatient client records were reviewed. The treatment plans in five of thirteen client records failed to include documentation of the type and frequency of services to be offered to each client.
Client record # 7- The client was admitted on 10/21/11 and last treated on 3/29/12. The treatment plan in the client record did not include the type and frequency of treatment to be offered to the client.
Record # 11- The client was admitted on 1/18/12 and last treated on 3/12/12. The treatment plan in the client record did not include the type and frequency of treatment to be offered to the client.
Record # 12- The client was admitted on 3/12/11 and last treated on 3/12/12. The treatment plan in the client record did not include the type and frequency of treatment to be offered to the client.
Record # 13- The client was admitted on 2/23/11 and last treated on 4/11/12. The treatment plan in the client record did not include the type and frequency of treatment to be offered to the client.
Record # 14- The client was admitted on 1/19/12 and last treated on 4/4/12. The treatment plan in the client record did not include the type and frequency of treatment to be offered to the client.
The findings were reviewed with the Project and Facility Director and were not disputed.
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Plan of Correction
Effective April 18, 2012, all D&A counselors will complete a treatment plan form that allows for frequency and type of treatment.
The Clinical Services Manager will review treatment plans before signing for completeness and accuracy. |
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 the review of the client records, the facility failed to document support services to be offered to the client on treatment plans in five of thirteen client records.
The findings included:
The annual onsite licensure renewal inspection was conducted April 16-18, 2012. Thirteen outpatient client records were reviewed. Five of thirteen client records failed to include documentation of support services on the treatment plans.
Client record # 7- The client was admitted on 10/21/11 and last treated on 3/29/12. The treatment plan did not include documentation of the support services to be offered to the client.
Client record # 11- The client was admitted on 1/18/12 and last treated on 3/12/12. The treatment plan did not include documentation of the support services to be offered to the client.
Client record # 12- The client was admitted on 3/12/11 and last treated on 3/12/12. The treatment plan did not include documentation of the support services to be offered to the client.
Client record # 13- The client was admitted on 2/23/11 and last treated on 4/11/12. The treatment plan did not include documentation of the support services to be offered to the client.
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Client record # 14- The client was admitted on 1/19/12 and last treated on 4/4/12. The treatment plan did not include documentation of the support services to be offered to the client.
The findings were reviewed with the Project and Facility Directors and were not disputed
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Plan of Correction
Effective April 18, 2012, all D&A counselors will complete a treatment plan form that allows for type of support service and will be detailed and thoroughly completed.
The Clinical Services Manager will review all treatment plans for accuracy and completeness before signing. |