INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, GPHA Al-Assist Behavioral Health Care Center 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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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(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 clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) 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 and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of personnel records, the Staffing Requirements Facility Summary Report (SRFSR) completed by the Facility Director on 8/28/12 and an interview with the clinical coordinator, the facility failed to ensure that each staff person identified as a clinical supervisor met the qualifications for the position in one of two personnel records reviewed.The findings include:The Staffing Requirements Facility Summary Report completed by the facility was reviewed on August 28, 2012. On page three of the SRFSR, the facility identified employees #3 and # 4 as clinical coordinators. During an interview, employee #4 was asked if she supervised the clinical staff and she replied that she did. Employee #4 - The personnel record was reviewed on August 28, 2012. A review of the resume revealed that the employee did not meet the experiential requirements for the position of clinical supervisor. The employee, having received a Masters Degree in Human Services in 2011, lacked documentation verifying the completion of two years of clinical experience in a health or human service agency, which includes 1 year of working directly with a chemically dependent person. The previously held positions listed on the resume are as follows:Development InstructorCounselorMinistries-Founder/CounselorEntry & Quality Assurance ManagerAssistant CoordinatorProcessor/Administrative AssistantService RepresentativeCounselor/Day ProgramClinical experience was not included in any of the job descriptions listed. The employee's resume was reviewed by two licensing supervisors after the inspection, who determined that the required clinical experience was not documented.
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Plan of Correction
L 0029:
Corrective Action:
The employee listed will be restricted from providing any supervisory duties under this program until such time that she meets the experiential requirements for a supervisory position.
In addition, the employee will participate in the next scheduled Drug and Alcohol Clinical Supervisory Training Part I offered by the State of PA. The employee completed Part II in 2011.
The Coordinator of Behavioral Healthcare Services and HR Director will make certain that no one will be hired for future employment prior to meeting the experiential requirements.
Person Responsible:
Coordinator of Behavior Health and HR Director
Time Frame for Completion: Completed
August 30, 2012
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to ensure the facility was in good repair at all times. The findings include: A physical plant inspection was conducted on August 28, 2012 at 11:30 AM. The wood ceiling near the back exit from the first floor was rotted and in need of repair. The paint was peeling from the ceiling. The clinical director was present during the inspection and confirmed the findings.
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Plan of Correction
Re: P PI79
Corrective Action:
The Director of Behavioral Health coordinated the repair of the wood ceiling with the Maintenance Department. The rotted wood 3x5 ceiling was removed and replaced with fired rated sheetrock. In addition, the molding around the door frame near the ceiling near the back exit from the first floor has been removed and replaced. Installed new steel door and frame. Replace sheetrock at the bottom of the stairwell exterior wall.
Monitoring: Security Guards will be responsible for conducting rounds daily to ensure the grounds and facility are clean, safe, sanitary and in good repair. Maintenance Department and Clinical Coordinator conducts weekly facility physical plant inspections on interior and exterior to ensure that all areas of the physical plant remain in safe, sanitary and good repair at all times.
Persons Responsible:
Security Officer
Clinical Coordinator
Director of Maintenance
Time frame for Completion:
Completed/ Monitoring ongoing
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709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on a review of administrative documentation, a letter issued to The Department from the facility director, and a conversation with the facility director; the facility failed to identify the CEO, who reports to the governing body and carries out the project's administrative duties, as the project director.The findings include:On August 22, 2012 a review of administrative documentation revealed that the employee identified as the project director, employee # 1, does not report to the governing body/Board of Directors, but reports to the CEO. The project's CEO is ultimately responsible to the governing body. A letter dated October 28, 2011 from the facility to the Department identified the CEO as qualifying for the position of project director, however the facility did not identify the CEO as the project director in any of the documentation presented during the licensing inspection.The facility director, employee # 2 was interviewed regarding the findings, at which time she confirmed that the employee identified as the project director is not officially responsible to the governing body.
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Plan of Correction
Plan of Correction:
Standard in Noncompliance
709.22(d)(1) LINCENSURE Governing Body
In effort to comply with regulation 709.22(d)(1) the written findings from August 22, 2012 were discussed once again with the Director of Behavioral Health, Chief Executive Officer, and the Governing Body. It was unanimously decided that based on 709.22(d)(1) regulations and reporting structure of the organization. The Chief Executive Officer is the only person responsible to the governing body and reports directly to the Board of Directors; therefore moving forward, the CEO will be the project director for our Drug and Alcohol Program.
Correction time: Completed
Monitoring is on-going
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician for 24-hour emergency medical and psychiatric coverage.The findings include:The letters of agreement were reviewed on August 23, 2012. No letter of agreement regarding 24- hour emergency medical and psychiatric coverage was documented. The facility produced a letter signed by employee #1, identified as the Project Director, which stated that she would ensure emergency medical and psychiatric services would be provided if needed by one of the project's clients. Employee # 1 is not a physician. There was no written agreement for 24 hour emergency medical and/or psychiatric services with a licensed hospital or physician.
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Plan of Correction
Plan of Correction:
Standard
709.24(d) TREATMENT/REHABILITATION MANAGEMENT
In an effort to maintain compliance with regulation 709.24(d)
The Director of Behavioral Healthcare will make obtain that formal Letters of Agreement with Licensed hospitals and Physicians for 24-hour emergency medical and psychiatric coverage are obtained for Al-Assist Beahvioral Healthcare Center and GPHA Inc. Al-Assist Behavioral Healthcare Center.
The Director of Behavioral Healthcare will develop a written letter of agreement for 24-hour emergency medical and psychiatric coverage.
The Clinical Coordinator wiill forward the letter of agreement to Medical Doctors and Psychiatrists for their signature of acceptance.
Upon retrievemnet of the signed letter of agreements for 24-hour emergency medical and psychiatric coverage. The Clinical Coordinator will fax the completed letters of agreement to DDAP prior to November 30, 2012.
In addition, the Quality Assurance Coordinator will contact surrounding Hospitals to obtain formal Letters of Agreement indicating 24-hour emergency medical and/or psychiatric coverage.
Upon retrievement of the signed letter of agreements for 24-hour emergency medical and psychiatric coverage. The Quality Assurance Coordinator will collaborate with the Clinical Coordinator to fax the completed letters of agreement to DDAP prior to December 15, 2012.
Annually, In November, request for 24-hour emergency psychiatric and medical coverage will be forwarded to licensed physicians, psychiatrist and hospitals.
Completion Date: 12/15/2012
Monitored:
24-hour emergency care coverage will be monitored by the Director of Behavioral Health and Quality Assurance Department periodically to ensure complaince.
Correction time-frame for formal written letters of agreements with 2 or more Medical Providers: November 30, 2012 and Hospital December 15, 2012.
Monitoring on-going
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709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on a review of the policy and procedure manual and client intake documentation, the project failed to document a client rights policy indicating the client has the right to appeal a decision limiting access to his records to the project director.The findings include:The policy and procedure manual and client intake documentation was reviewed on August 22, 2012. There was no documentation of the clients' right to appeal a decision limiting access to his records to the project director. The facility director was interviewed on August 22, 2012 and confirmed this policy was not in the project's policy and procedure manual.
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Plan of Correction
Plan of Correction:
Standard in Noncompliance
709.30(4)LINCENSURE Client Rights
In effort to comply with regulation 709.30(4)the written findings from August 22, 2012 were discussed with the Executive staff. As a result of the discussion and in review of the existing policy of Client's Rights. A revision was made to include the following language: The Client has the right to appeal a decision limiting access to his/her records to the project director.
Notice of the revised Client's Rights policy has been posted at the facility highlighing the revision.
Revised policy has been placed in the Program's operating Manual.
Revised policy is included in the intake package for new admits and in the client's annual update packages.
Person Responsible:
Director of Behavior Health
Time Frame for Completion: Completed
Monitoring: Quality Assurance Department randomly. |
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 a psychosocial evaluation that included a clinical assessment of the client's assets and strengths, support systems, coping mechanisms, negative factors that may affect treatment, attitude towards treatment, and the counselor's conclusions and/or impressions. The findings include:The policies and procedures manual was reviewed on August 22, 2012. Seven client records were reviewed on August 28, 2012. Five of seven client records, specifically client records # 1, 2, 5, 6, and 7 did not include documentation of a psychosocial evaluation that was inclusive of an assessment of the client's assets and strengths, support systems, coping mechanisms, negative factors that may affect treatment, attitude towards treatment, and/or the counselor's conclusions and/or impressions. Client #1 was admitted to treatment on May 21, 2012. The psychosocial evaluation was completed on June 12, 2012 but did not include a clinical assessment of the client's assets and strengths, support systems, coping mechanisms, and the negative factors that can affect treatment. Client #2 was admitted to treatment on July 30, 2012. The psychosocial evaluation was completed on August 8, 2012 but did not include a clinical assessment of the client's assets and strengths, coping mechanisms, and the negative factors that can affect treatment. Client #5 was admitted to treatment on January 23, 2012 and discharged on June 4, 2012. The psychosocial evaluation was completed on January 27, 2012 but did not include a clinical assessment of the client's assets and strengths, support systems, coping mechanisms, the negative factors that can affect treatment, the client's attitude towards treatment, and the counselor's conclusions and impressions.Client #6 was admitted to treatment on August 18, 2011 and was discharged on October 17, 2011. The psychosocial evaluation was completed on August 26, 2011, but did not include a clinical assessment of the client's assets and strengths, support systems, coping mechanisms, the negative factors that can affect treatment, the client's attitude towards treatment, and the counselor's conclusions and impressions.Client #7 was admitted to treatment on December 9, 2011 and discharged on June 25, 2012. The psychosocial evaluation was completed on March 21, 2012 but did not include a clinical assessment of the client's assets and strengths, support systems, and coping mechanisms.The findings were reviewed with the clinical supervisor and clinical director prior to the exit interview.
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Plan of Correction
Corrective Action:
Plan of Correction:
Standard in Noncompliance 709.91(b)(6)LINCENSURE Intake and Admission:
In effort to comply with regulation 709.91(b)(6)the written findings from August 22, 2012
The Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will provide training to all Drug/Alcohol Counselors on the Comprehensive Bio-psychosocial Evaluation, which will include the following areas:
-time frame for completing the CBE
-instructions for fully completing the medical section
-instructions for fully completing the drug/alcohol history section
-instructions for fully completing the personal history section
-required components to be assessed when completing CBE's.
-strategies for ensuring that CBE's are evaluative and reflect the Counselor's
conclusions/impressions.
Additionally, the Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct weekly random record reviews to ensure that all CBE's are done in accordance with GPHA, Inc.'s policies and procedures and DDAP standards.
Charts Currently out of Compliance:
Counselor (s) Client Record's deemed out of compliance will be required to revisit the psychosocial evaluation with their Client in an effort to gather comprehensive information from the client to formulate a comprehensive assessment of the client's assets and strengths, support systems, coping mechanisms, negative factors that may affect treatment, attitude towards treatment, and the counselor's conclusions, impressions and prognosis.
Persons Responsible:
Clinical Coordinator and Quality Assurance Coordinator
Time Frame for Completion:Training Completed
Correction of Existing Charts: November 23, 2012
Monitoriny: Ongoing: Clinical Coordinator and Quality Assurance
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