INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8-11, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Deerfield Center for Addiction Treatment 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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704.11(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
Based on a review of the facility's policy and procedure manual, the facility failed to document a training procedure which included the time frames for the required components.
The findings include:
The agency training policy and procedure was reviewed on April 8, 2013. The procedure did not document time frames for completion of the assessment of staff training needs, the overall plan, feedback, and the annual evaluation of the overall training plan.
This was discussed with the Executive Director and the Clinical supervisor and was not disputed.
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Plan of Correction
The Program Director will work with the clinical supervisor to put into place a policy outlining the method to assess staff training needs, the overall training plan, feedback process and an overall evaluation of the training received by the staff. This policy will be developed by the Program Director by May 6, 2013. The policy will be put into effect at the following staff meeting. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of staff training records, the facility failed to provide documentation of individual training plans by July 2012. This was not documented in seven of seven staff training records reviewed.
The findings include:
Seven staff training records were reviewed on April 8, 2013. Individual training plans were required in six records, and were not completed prior to the start of the training year. The facility training year is July 1, 2012 to June 30, 2013, and training plans were to be completed by July 1, 2012. All of the individual training plans reviewed were completed in February 2013.
Person represented by training record #2, was hired 7-10-2000. An individual training plan was completed on 2-5-2013 for the 2012-2013 training year.
Person represented by training record #3, was hired 9-12-2005. An individual training plan was completed on 2-8-2013 for the 2012-2013 training year.
Person represented by training record #4, was hired 5-10-2010. An individual training plan was completed on 2-15-2013 for the 2012-2013 training year.
Person represented by training record #5, was hired 4-16-2006. An individual training plan was completed on 2-8-2013 for the 2012-2013 training year.
Person represented by training record #6, was hired 3-6-2002. An individual training plan was completed on 2-14-2013 for the 2012-2013 training year.
Person represented by training record #7, was hired 5-24-2010. An individual training plan was completed on 2-14-2013 for the 2012-2013 training year.
Person represented by training record #8, was hired 7-27-2003. An individual training plan was completed on 2-14-2013 for the 2012-2013 training year.
The findings were reviewed with the Executive Director and the Clinical Supervisor and were not disputed.
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Plan of Correction
The Program Director will insure that the staff training plans are completed per the new policy and prior to the next training year. The policy will require staff to complete a summary report of the training they completed in the current training year, identify training topics they want to participate in during the new training year and develop a personalized training plan. This will be completed during the June staff meeting prior to the next training year. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on the review of the agency policy and procedure manual, the facility failed to document policies and procedures which defined the timeframe for the completion of each component of the client record.
The findings included:
The agency policy and procedure manual was reviewed April 8, 2013. Procedures failed to address the time frames for documentation of the history, psychosocial evaluation, treatment plan and discharge summary.
This was reviewed with the Executive Director and the Clinical Supervisor and was not disputed.
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Plan of Correction
The Clinical Supervisor along with the Program Director and Office Manager will work to resolve inconsistencies in the policy and procedure manuals with regards to time frames for documentation of histories, psychosocial evaluations, and treatment plan and discharge summaries. The changes to the policy and procedure manual will be completed within 30 days and the clinical supervisor will review these changes with the staff at the next scheduled staff meeting. |
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
Based on a review of the client records, the facility failed to provide a release of information form that did not include a Guardian signature line, and a signed release of information form prior to information being disclosed.
The findings include:
A parent/guardian signature line was included on the release of information form. A parent/guardian signature is not mandated by state law and cannot be required. Three client records were reviewed on April 11, 2013, and all three records had release of information forms that included a Guardian signature line. In addition, one record did not document a release of information form for a funding source.
Client record #1 - The client was admitted to treatment on 10-24-2012 and discharged on 1-2-2013. A release of information form was not documented for an insurance company, but information was disclosed. Release of information forms for the spouse, and the probation officer were signed on 9-26-2012, and included a guardian signature line.
Client record #2 - The client was admitted to treatment on 2-20-2013 and discharged on 3-13-2013. Release of information forms for the insurance company, the spouse, and the probation officer were all signed on 2-6-2013, and included a guardian signature line.
Client record #3 - The client was admitted to treatment on 2-27-2013. Release of information forms for the two insurance companies, the clients mother, and the probation officer were all signed on 2-13-2013, and included a guardian signature line.
The findings were reviewed with the Clinical Supervisor and were not disputed.
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Plan of Correction
The Clinical Supervisor will see that the ROI form is corrected by having the Guardian Signature line removed. (This has already been completed.) Staff where informed at the time of notification that Letters from the agency need to be addressed to a person, rather than "Sir" or "Madam" (This issue has been addressed with all clinical staff".) |