INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 31, 2012 and November 1, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tradition House 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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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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 assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in six of six client records. The findings include:Six client records were reviewed on October 31, 2012 and November 1, 2012. All records were reviewed for psychosocial evaluations.The psychosocial evaluations in client records #1, 2, 3, 5 and 6 did not include an evaluation of the client's assets/strengths and how they would impact treatment. The psychosocial evaluations in client records #1, 2, 3, 5 and 6 did not include an evaluation of the client's support systems and how they would relate to treatment. The psychosocial evaluations in client records #1, 2, 3, 5 and 6 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 #1, 2, 3, 5 and 6 did not include an evaluation of the client's negative factors and how they would impact treatment. The psychosocial evaluations in client records #1, 2, 3, 5 and 6 did not include an evaluation of the counselor conclusions/impressions of the client. Also, per the facility policy, psychosocial evaluations are to be completed within 5 days of the client's admission date.Client #4 was admitted on January 3, 2012 and discharged on May 1, 2012. The psychosocial evaluation was to be completed by January 6, 2012. At the time of the inspection, there was no documentation of client # 4's psychosocial evaluation.An interview with the facility director on November 1, 2012 confirmed the findings.
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Plan of Correction
Facility Director will conduct an in-service with the counselors by 12/7/2012 to review psychosocial evaluation documentation, to include evaluation of the client's assets/strengths, coping mechanisms, support systems, negative factors towards treatment, and the counselor conclusions/impressions of the client. Facility director will also review timeline in which this is required to be completed, to include dating the document. Compliance to this standard will be met via monthly chart monitors of both open and closed charts by the Facility Director. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of client records, the facility failed to provide treatment plan updates in four of six client records.The findings include:Six client records were reviewed on October 31, 2012 and November 1, 2012. Treatment plan updates were required in six client records. Per the facility policy, the treatment plan updates are due every 30 days from the date of the comprehensive treatment plan. The facility did not document treatment plan updates in client records #1, 4, 5 and 6.Client #1 was admitted on July 19, 2012. The comprehensive treatment plan was documented on July 19, 2012, and the treatment plan updates were due on August 19, 2012, September 19, 2012 and October 19, 2012. The October 19, 2012 update was not documented in Client #1's record. Client #4 was admitted on January 3, 2012 and discharged on May 1, 2012. The comprehensive treatment plan was documented on January 6, 2012, and the treatment plan updates were due on February 3, 2012, March 3, 2012 and April 3, 2012. The April 3, 2012 update was not documented in Client #2's record. Client #5 was admitted on February 27, 2012 and discharged on July 13, 2012. The comprehensive treatment plan was documented on February 28, 2012, and the treatment plan updates were due on March 28, 2012, April 28, 2012. May 28, 2012 and June 28, 2012. The May 28, 2012 update was not documented in Client #5's record. Client #6 was admitted on April 16, 2012 and discharged on August 17, 2012. The comprehensive treatment plan was documented on April 17, 2012, and the treatment plan updates were due on May 17, 2012, June 17, 2012 and July 17, 2012. The July 17, 2012 update was not documented in Client #6's record. An interview with the facility director on November 1, 2012 confirmed the findings.
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Plan of Correction
Facility Director will conduct an in-service with the counselors by 12/7/2012 to review treatment plan review guidlines and due dates of every 30 days from the date of the comprehensive treatment plan. Compliance to this standard will be met via monthly chart monitors of both open and closed charts by the Facility Director. |
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, the facility failed to ensure that each counselor met the qualifications for the position in one of three personnel records.The findings include:Six personnel records were reviewed on October 2-3, 2012. Three personnel records were required to include documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel record # 4.Employee # 4 was hired as a counselor assistant on March 26, 2012 and promoted to counselor on June 27, 2011. The employee met the education requirement with a bachelor degree. The employee's resume did not document that the employee had the required 1 year of clinical experience. Employee #4's personnel record only show documentation of 9 months of clinical experience.The human resource staff was interviewed on October 3, 2012 and confirmed the findings
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Plan of Correction
Facility director met with employee #4 on 10/10/2012 to review the required 1 year clinical experience prior to promotion from a counselor assistant to a counselor. As a result, employee #4 has been reverted back to a counselor assistant and will remain so for a period of 3 months to fulfill said clinical experience requirement. Facility Director will ensure complaince to this standard via monthly supervision and documentation. Said documentation will be forwarded to Human Resource Coordinator to be place in employee's HR record to further ensure compliance. |
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 a review of personnel records, a review of the facilities policy and procedures manual, the facility failed to document a mechanism to collect feedback on completed training in two of six records.The findings include:Six personnel records were reviewed on October 2-3, 2012. Per the facility's policy, feedback forms are to be documented after every training. The facility failed to document the submission of feedback forms in employee records # 3 and 4.Human resource personnel was interviewed on October 3, 2012 and confirmed the findings.
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Plan of Correction
Beginning October 22, 2012, Human resource coordinators will ensure that training evaluations for all trainings are placed in each individual's employee file. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance. |
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
Based on a review of personnel and training records, the facility failed to provide documentation of a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in three of eight personnel records. The findings include:Eight personnel records were reviewed on October 2-3, 2012. Eight personnel records required documentation of HIV/AIDS and/or tuberculosis, sexually transmitted diseases and other health related topics training. Employee records # 6, 7 and 8 did not include documentation of the completion of the required training. Employee # 6 was hired on October 6, 2010. Tuberculosis and sexually transmitted diseases and other health related topics training and HIV/AIDS training was due to be completed by October 6, 2012. There was no documentation that the employee had completed the TB/STD or HIV/AIDS training as of November 1, 2012. Employee # 7 was hired on October 23, 2010. Tuberculosis and sexually transmitted diseases and other health related topics training and HIV/AIDS training were due to be completed by October 23, 2012. There was no documentation that the employee had completed the TB/STD or HIV/AIDS training as of November 1, 2012. Employee # 8 was hired on June 14, 2010. Tuberculosis and sexually transmitted diseases and other health related topics training and HIV/AIDS training were due to be completed by June 14, 2012. There was no documentation that the employee had completed the TB/STD or HIV/AIDS training as of November 1, 2012. The human resource staff was interviewed on October 3, 2012 and the facility director interviewed on November 1, 2012 and on both dates they confirmed the findings.
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Plan of Correction
Facility Director will ensure employees #6, 7, 8 will attend the next HIV/AIDS training on 11/15/2012 and the next STD/TB training on 11/27/2012, both at Pyramid's Copporate office. Facility Director will follow-up with Human Resource Coordinators and employees after said training date to ensure attendance. Human Resource Coordinators will monitor all employee files quarterly to ensure compliance with mandatory training requirements. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project director and the facility director in one of two personnel records.The findings include:Fifteen personnel records were reviewed on October 2-3, 2012. The facility's training year is January- December. The facility's 2011 training year was reviewed. Two personnel records required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1. Employee # 1 has been the project director since July, 1999. There were no training hours documented for the 2011 training year. The human resource staff was interviewed on October 3, 2012 and confirmed the findings.
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Plan of Correction
Employee #1, Project Director, will complete 12 hours of training by November 30, 2012. Human Resource Coordinator will ensure completion. Human Resource Coordinators will monitor employee files quarterly, to include the Project Director, in order to ensure annual training compliance. |