INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 7, 2010 through April 8, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Colonial House Outpatient 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 and a plan of correction is due on April 30, 2010.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on the review of the facility's policy/procedure manual and training manual, the facility failed to documented the assessment of staff training needs in six of seven personnel records reviewed.
The findings include:
Seven personnel records were reviewed on April 7, 2010. Assessment of staff training needs were required in seven personnel records reviewed for training year April 1, 2010 through March 31, 2011. An interview with the facility director was completed on April 7, 2010 during which time it was confirmed that the assessment of staff training needs had not been completed.
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Plan of Correction
THe diretor reviewed the policy manual. In the future the director will be responsible to complete the needs assessment training as stated in the polciy and procedures amnual which will be done in March. |
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
Based on the review of the facility's policy/procedure manual and training manual, the facility failed to documented the overall training plan for their training year Apri 1, 2010 through March 31, 2011.
The findings include:
The policy/procedure manual and training manual was reviewed on April 7, 2010. The overall training plan for training year April 1, 2010 through March 31, 2011 was not documented. An interview with the facility director was completed on April 7, 2010 confirmed that the overall training plan had not been documented.
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Plan of Correction
A summary will be completed and documented in the treaining book by the director of outpatient in the time frame which is stated in the policy book as March |
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 personnel records and training manual, the facility failed to documented feedback forms in three of seven personnel records reviewed.
The findings include:
Seven personnel records were reviewed on April 7, 2010. Feedback forms were required in seven personnel records reviewed for training year April 1, 2009 through March 31, 2010. Personnel records #5, 6 and 7 did not have documentation of feedback from training in the records reviewed.
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Plan of Correction
After completion of every training the staff will make a copy of the certificate of completion and turn it into the director of outpatient. The director will give the feedback form to the counsleor and have them fill it out at return it. It will then be placed in the trainig file by the director. |
704.11(a)(4) LICENSURE Evaluation of Overall 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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on the review of the facility's policy/procedure manual and training manual, the facility failed to document the annual evaluation of the overall training plan for their training year April 1, 2009 through March 31, 2010.
The findings include:
The policy/procedure manual and training manual was reviewed on April 7, 2010. The annual evaluation of the overall training plan for training year April 1, 2009 through March 31, 2010 was not documented. A interview with the facility director was completed on April 7, 2010 confirmed that the overall training plan had not been completed.
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Plan of Correction
The overall training plan for each training year will be comleted by the director of outpatient as stated in the time frame that is staed in the policy and procedures manual which is due for March of each training year. |
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
Based on the review of the facility's staffing requirements form and interview with the facility director, the facility failed to ensure that the counselor/client ration did not exceed the case load for each counselor 35:1.
The findings include:
Seven personnel records were reviewed on April 7, 2010. The case load for each counselor can not exceed 35:1. The case load for employee #5 was 48:1.
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Plan of Correction
When the caseload is over 35:1 for a counselor the client will be transfered to a counslor who is not at ratio. If this is not possible the client will be offered to be referred out. The director and the counselor will monitor this. As it stands the changes have been made and the clients have been transfered |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to maintain fire extinguishers that were operable and inspected annually.
The findings include:
A physical plant inspection took place on April 8, 2010 and during the inspection it was observed that the fire extinguishers were not updated since the last inspection of service was May 2008. One fire extinguisher was located on the first floor and the second located on the second floor of the building; neither had been inspected since May 2008.
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Plan of Correction
On 4/7/10 the company that inspects the fire extingushers was contacted by the director. They arrived that day. At that time the outpatient facility was placed on a schedule to have the extingushers inspected annually. The director of outpatient will be responsible to contact the company at the beginning of April to make sure that we are on the list to be inspected. |
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
Based on the review of client records, the facility failed to document the drug and alcohol histories in seven of ten records reviewed.
The findings include:
Ten client records were reviewed on April 8, 2010. Drug and alcohol histories were required in ten client records reviewed. The clients' length and patterns of drug and alcohol use were left blank in records 1, 3, 5, 6, 7, 8, 9. The writing in client record #10 was not discernable as the writing was illegible.
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Plan of Correction
A training was conducted by the director of outpatient on 4/26/2010 that demonstrates the correct way to complete the drug and alcohol history to include all substances that were used in the clinets life time. The training included how to document progression, decrease or other changes in using patterns and amounts. The counsleor whose handwriting was disceranble will continue to work on learning typing skills and writing clearer. Counseler wil bring the intake to the director to be reviewed and signed. |
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 a review of client records, the facility failed to document psychosocial evaluations in ten of ten client records reviewed.
The finding includes:
Ten records were reviewed on April 8, 2010. Psychosocial evaluations were required in ten records reviewed. Client records #7 and 9 did not have documentation of psychosocial evaluations in records reviewed.
Client record #1 failed to evaluate the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions of the client.
Client record #2 failed to evaluate the client's problems and needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions of the client.
Client record #3 failed to evaluate the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions of the client.
Client record #4 failed to evaluate the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions of the client.
Client record #5 failed to evaluate the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions of the client.
Client record #6 failed to evaluate the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions of the client.
Client record #8 failed to evaluate the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions of the client.
Client record #2 failed to document the client composite picture and failed to evaluate the client ' s problem and needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions of the client.
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Plan of Correction
On 4/26/2010 a staff meeting was conducted at which time the director of outpatient reviewed the observation with clinical team. The need for an evaluative assessment was stressed and explained. Counselros will bring the completed assessment to the director upon completion and it will be reviewed and then signed. Counselors have been instructed to use what their impressions/evaluation of the clients underlying problems, present problmes, assets/strengths, support system, coping mechanisms, negative factors that might inhibt treatment and the conclusion. |
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
Based on the review of client records, the facility failed to document treatment plan updates in two of three client records.
The findings include:
Ten client records were reviewed on April 8, 2010. Treatment plan updates were required in three client records reviewed #2, 8 and 10. Client records #2 and 10 contained treatment plans that could not been reviewed because the handwriting was not discernable; the updates in records # 2 and 10 could not be considered as completed as the documentation was illegible and unreadable.
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Plan of Correction
The director of outpatient met with the counselor of charts #2 and #10 and we discussed the need for legible handwriting. The director will monitor documents by this counselor for legibilty. Counselor will conintue to learn typing skills.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document complete case consultations notes in two of four outpatient client record.
Findings:
Ten client records were reviewed on April 8, 2010. Case consultations were required in four client records #1, 2, 4 and 10. Per the facility policy and procedure, case consultations are to be documented every 90 days. Case consultations notes were not documented in client records #1 and 2.
Client record #1 was admitted on 12/10/09 and as of the date of the inspection there was no documentation of a case consultation in the record reviewed.
Client record #2 was admitted on 1/5/10 and as of the date of inspection there was no documentation of case consultation in the record reviewed.
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Plan of Correction
Before 5/20/10, the director of outpatient will meet with the clinical team and review the policy for case consultation. The director will be responsible to assure that the case consults are being completed on timeduring weekly meetings and random chart reviews |
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
Based on the review of client records, the facility failed to document aftercare plans in one of five discharged records reviewed.
The findings include:
Ten client records were reviewed on April 8, 2010. Aftercare plans were required in two discharge records #8 and 10. Per the facility's policy and procedure, aftercare plans will be done on successful completions before client is discharged.
Client record #8 was admitted on 11/18/09 and discharged on 12/17/09 as a successful discharge; there is no documentation of the client's aftercare plan in client record #8.
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Plan of Correction
All records will be quality assured at time of discharge for aftercare plans by the director of outpatient. Both charts were from the same counselor and these charts are being routinley reviewed at discharge so that the agency can meet compliance. |