INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 4 & 5, 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 July 2, 2007.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
The personnel file for employee #1 was not available for review at the time of the licensing visit, therefore it was not possible to verify that the educational requirements for the position are met.
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Plan of Correction
A copy of the project director's personnel file (employee #1) will be kept and updated along with all the other Susquehanna Center's D&A personnel files by the HR Director for Susquehanna Center and will be readily available for inspection at any time throughout the year. The project director's personnel and training file will be on site by 8/20/07. |
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
Individual training plan for employee #1 was not available due to the personnel file not being a the facility at the time of the licensing visit.
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Plan of Correction
The project director's individual training plan will be kept at the Shamokin office along with the other employee training files. The project director has been apprised of the training requirements and he (employee #1) will draft his own training plan which will be reviewed quarterly by the facility director. This protocol will remain the same if a new project director is named. The project director's training file will be on site by 8/20/07. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Two of two employees requiring the mandatory TB/STD training had not received the training within the first year of employment.
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Plan of Correction
All Susquehanna Center D&A employees that do not have documentation stating that they have attended TB/STD training within the last two years will be mandated to attend the next TB/STD training that becomes available during the current licensure year. The facility director will advise employees of upcoming trainings and will also notify the project director of available trainings. |
709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
Based upon documentation reviewed on June 5, 2007, it was not possible to verify that employee #1 met the educational requirements for the position of Project Director. There was no personnel file available to review, nor was there a copy of the diploma and/or transcripts. The only available documentation was a resume.
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Plan of Correction
A copy of the project director's personnel file (employee #1) will be kept and updated along with all the other Susquehanna Center's D&A personnel files by the HR Director for Susquehanna Center and will be readily available for inspection at any time throughout the year. The personnel file will contain copies of diplomas and/or transcripts. In addition this information plus any completed trainings will be kept in the project directors training file which will be kept on site at the Shamokin Office. The project director's personnel and training file will be on site by 8/20/07. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Individual staff performance evaluations were missing for 2 of 8 employee records reviewed, #1 & 3.
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Plan of Correction
Our Human Resources Department will notify the Program Director when an employee is 2 months prior to their hire anniversary date (annual performance evaluation due date). The Program Director will then schedule a meeting to review the employee's performance. Once the review is completed, typed and signed, the original will be forwarded to the Human Resources Department and copies will be given to the employee and placed in the on site personnel file. In the event an original performance is not forwarded to the Human Resources Department by two weeks following the performance review due date, Human Resources will contact the Program Director to determine its status. The Executive Director of Susquehanna Center will be given a monthly listing of all overdue performance evaluations. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Due to the facility not having employee #1's personnel file available at the time of the survey, it was not possible to determine if there was a signed job description identifying the job title and delineating the tasks and responsibilities of the job along with the requisite skills, knowledge and experience.
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Plan of Correction
A copy of the project director's personnel file (employee #1) will be kept and updated along with all the other Susquehanna Center's D&A personnel files by the HR Director for Susquehanna Center and will be readily available for inspection at any time throughout the year. In addition, the project director's individual training plan will be kept at the Shamokin office along with the other employee training files. Signed copies of the employee's job description will be kept in both the personnel file and the training file.
The project director's personnel and training file will be on site by 8/20/07.
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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
Psychosocial evaluations in two of five client records reviewed were either incomplete or non-evaluative.
Client record #1 contained many one word answers and did not provide an evaluative assessment of the client.
Client record #2 contained an evaluation that was not completed.
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Plan of Correction
A monthly quality checklist/audit of client records will be conducted by the facility director or a masters level counselor to insure that regulations regarding intake procedures and documentation are met; specifically a completed Psychosocial evaluation that includes a quality evaluative assessment. In addition, all employees will be trained by August 31, 2007, on required file documentation, completeness and quality documentation. |
709.92(a) 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:
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Observations
One of five client records reviewed, # 4, lacked an individualized comprehensive treatment plan.
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Plan of Correction
A monthly quality checklist/audit of client records will be conducted by the facility director or a masters level counselor to insure that each client has a comprehensive individual treatment plan. If applicable, the audit will verify that an updated plan has been completed with the 60 day timeframe. In addition, all employees will be trained by August 31, 2007, on required file documentation, completeness and quality documentation. |
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
One of three client records reviewed lacked a treatment plan update, #5.
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Plan of Correction
A monthly quality checklist/audit of client records will be conducted by the facility director or a masters level counselor to insure that each client has a comprehensive individual treatment plan. If applicable, the audit will verify that an updated plan has been completed withint the 60 day timeframe. In addition, all employees will be trained by August 31, 2007, on required file documentation, completeness and quality documentation. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Medication records in three of five client records reviewed, #1, 2 & 5, failed to list the dose and/or frequency of use of the medications.
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Plan of Correction
A monthly quality checklist/audit of client records will be conducted by the facility director or a masters level counselor to insure that medication records on clients accurately reflect the dosage and frequency of all medications. In addition, all employees will be trained by August 31, 2007, on required file documentation, completeness and quality documentation. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Progress notes in one of five client records reviewed, #1, failed to identify action steps, the counselor's plan, and/or client assignments or tasks relevant to treatment.
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Plan of Correction
A monthly quality checklist/audit of client records will be conducted by the facility director or a masters level counselor to insure that progress notes are legible, identify the counselor's plan, action steps and the client's tasks and assignments relevant to treatment. In addition, all employees will be trained by August 31, 2007, on required file documentation, completeness and quality documentation. |
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
One out of five client records reviewed, #1, lacked a case consultation.
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Plan of Correction
A monthly quality checklist/audit of client records will be conducted by the facility director or a masters level counselor (appointed by the facility director) to insure that case consultations are being conducted at the appropriate intervals and documented in the client's file. In addition, all employees will be trained by August 31, 2007 on required file documentation, completeness and quality documentation. |
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
One of one client records reviewed, #6, lacked action steps with time frames for identified goals.
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Plan of Correction
A monthly quality checklist/audit of client records will be conducted by the facility director or a masters level counselor (appointed by the facility director) to insure that when applicable, there is an aftercare plan that includes action steps with goals and timeframes. In addition, all employees will be trained by August 31, 2007, on required file documentation, eompleteness and quality documentation. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
The discharge summary in one of one client records reviewed, #6, failed to identify the services offered.
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Plan of Correction
A monthly quality checklist/audit of client records will be conducted by the facility director or a masters level counselor (appointed by the facility director)to insure that any discharge summaries identify all services that are offered. In addition, all employees will be trained by August 31, 2007, on required file documentation, completeness and quality documentation. |