INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 5, 2014 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.
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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
Based on a review of personnel records, the facility failed to ensure that the staff person appointed to the facility director position met the experience requirements.
The findings were:
Seven personnel records were reviewed on March 3, 2014. Employee #4 was promoted on January 1, 2014 to the facility director position. The facility director is to have 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. After a reviewed of employee #4's personnel record, the record did not show documentation that employee #4 had the required supervisory experience as required.
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Plan of Correction
Due to the DDAP Inspection on 3/5/14, The Inpatient Clinical Supervisor has assumed the position of Facility Director effective: 3/6/14. The CEO has assurred that the current Facility Director meets the qualifications for the position.
The Human Resource department will ensure that job descriptions which include qualifications for the position will be completed at the time of promotion or hire. The Human Resource department will review DDAP standards for each new hire/promotion prior to the position being offered. This will be monitored by the CEO. |
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 personnel records and interview with clinical supervisor, the facility failed to ensure that each counselor met the qualifications for the position in one of seven record reviewed.
Findings:
Seven personnel records were reviewed on March 3, 2014. Three of the seven employees were reviewed for counselor qualifications, #2, 3 and 6. In personnel record #3, the counselor did not meet the qualifications for the position of counselor based on a Associates Degree in Social Science.
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Plan of Correction
Counselor #3 was demoted by the Clinical Supervisor to a Counselor Assistant on 3/6/14, as a result of the DDAP inspection. The Counselor Assistant will not be promoted to counselor until they meet the qualifications for the position of Counselor by obtaining her CAAC or completing her Bachelor's Degree in a related field. Employee number 3 will receive supervision from the Clinical Supervisor. Promotion to a Counselor will be approved by the CEO.
The Human Resource department will review DDAP standards to ensure degrees are in related fields. Employment/promotion will not be offered until this verification is completed. The CEO will monitor this action. |
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 a review of personnel records and an interview with the facility director, the facility failed to document the completion of 25 clock hours of annual training required for counselors in three of seven personnel records.
The findings include:
Seven personnel records were reviewed on March 3, 2014. Three personnel records pertained to counselors. One personnel records required the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 6.
Employee # 6 was hired on February 14, 2011 and promoted to counselor on July 2012. The facility training year is from July 1 through June 30. Employee # 6 only completed 18 clock hours of annual training from July 2012 through June 2013.
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Plan of Correction
The Director of Operations will monitor all personnel training hours to ensure that necessary training hours are completed within the annual training year. Employee number 6 currently has 18 training hours since July 1,2013. |
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 provide a psychosocial evaluation to include the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and/or counselor conclusions and impressions in seven of ten records reviewed.
The findings include:
Seven client records were reviewed February 5, 2014. Eight of the seven were reviewed for a psychosocial evaluation, #1, 2, 3, 4, 5, 6, 7 and 8.
The psychosocial evaluations in client records # 3, 4, 6, 7 and 8 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records # 3, 6, 7 and 8 did not include an evaluation of the client's support systems.
The psychosocial evaluations in client records # 2, 3, 5, 6, 7 and 8 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records # 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the negative factors of the client.
The psychosocial evaluations in client records # 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the counselor conclusions/impressions of the client.
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Plan of Correction
The Clinical Supervisor will be training all staff during bi-weekly staff meetings on the paperwork process. Peer supervision will be implemented during said staff meetings at which time staff will review each other's work and note areas on the psychosocial evaluations that are missing and/or lacking information. Also during bi-weekly staff meetings, staff will be trained on how to complete a clinical evaluation of the client in terms of client strengths, assessment of client's support system/coping mechanisms, and assessing possible negative factors. Furthermore, staff will also be trained by the Clinical Supervisor at biweekly staff meetings on how to document an overall clinical conclusion and impressions. These trainings will be followed up by the clinical supervisor in individual supervision sessions with counselors and counselor assistants on at least a weekly to biweekly basis. |
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 include the type and frequency of treatment and rehabilitation services in six of ten client records.
The findings include:
Ten client records were reviewed on March 5, 2014. Eight were reviewed for comprehensive treatment plans, # 1, 2, 3, 4, 5, 6, 7 and 8. Six of the eight records, #2, 3, 4, 6, 7 and 8, lacked documentation for the type and frequency of treatment and rehabilitation services on the client's treatment plan.
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Plan of Correction
Through biweekly staff meetings, staff will be trained by the Clinical Supervisor on how to detail the frequency of action steps within the treatment plan as well as how to accurately document the treatment modality that the action steps will occur in (i.e. group or individual sessions). This will be followed up in weekly to biweekly individual supervision sessions with the counselor/counselor assistants and the Clinical Supervisor. |
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 a review of client records, the facility failed to document treatment plan updates in four of ten client records.
The findings include:
Ten client records were reviewed on March 5, 2014. Seven were required to document treatment plan updates, #1, 2, 3, 4, 5, 7 and 8. Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. Treatment and rehabilitation plans were not updated at least every 60 days in client records # 3, 4, 5 and 7.
Client #3 comprehensive treatment plan was developed on October 11, 2013. The treatment plan update was to be documented by December 11, 2013. Client #3's treatment plan update was documented on February 26, 2014.
Client #4 was admitted on October 1, 2013. The comprehensive treatment plan was developed but there was not documentation when it was completed. Client #4's the treatment plan update completed on July 3, 2014.
Client #5 comprehensive treatment plan was developed on November 7, 2013. The treatment plan update was to be documented by January 7, 2014. Client #5's treatment plan update was not documented as of the date of the licensing inspection.
Client #7 was admitted on August 20, 2013 and discharged on November 20, 2013. The comprehensive treatment plan was developed on September 9, 2013. The treatment plan update was to be documented by November 9, 2013. Client #7's treatment plan update was not documented as of the date of the client's discharge date.
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Plan of Correction
Through biweekly staff meetings, staff will be trained on treatment plan deadline policies based on the date of when the client enters treatment, this training will be completed by the Clinical Supervisor. Staff will also be trained by the Clinical Supervisor at biweekly staff meetings on how to appropriately document if a treatment plan is not completed the scheduled date. This will be followed up in individual supervision sessions with the Clinical supervisor on a weekly to biweekly basis with each counselor/counselor assistant. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to have a complete record in two of ten records reviewed.
The findings include:
Ten client records were reviewed on March 5, 2014. Five of the ten were discharged clients, #6, 7, 8, 9 and 10. Client #6 was admitted on June 21, 2013 and discharged on November 20, 2013. The record was to show documentation of a case consultation by September 21, 2013, an aftercare plan due prior to the clients discharge date, discharge summary within 7 days after the client ' s discharge and a follow-up within 30 days of the client's discharge. As of the date of the licensing inspection, there was no documentation of a case consultation, aftercare plan, discharge summary and follow-up in client #6's record.
Additionally, client #8 was admitted on November 5, 2013 and discharged on December 26, 2013. As of the date of the licensing inspection, there was no documentation of a follow-up.
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Plan of Correction
At biweekly staff meetings, staff will be re-trained by the Clinical Supervisor on the paperwork deadlines and will train the counselors/counselor assistants on how to appropriately keep track of the paperwork deadlines by utilizing the Section Index located in each section of the client file. Adherence to paperwork deadlines will be reviewed in weekly to biweekly supervision sessions with the Clinical Supervisor and the counselors/counselor assistants and documented in supervision notes.
The deficiencies will be corrected by staff reviewing all closed files and then submitting to the Clinical Supervisor for final chart inspection and closure. All staff will complete the required discharge paperwork for client's assigned to their caseload, submit the file for closure to Clinical Supervisor, if deemed all information is present, the file will then be closed and filed in discharged files. If the file is still lacking information, the client file will be returned to the staff to be fixed and re-submitted to Clinical Supervisor for re-inspection. This will occur for all current closed charts and all charts that will be closed in the future. |