INITIAL COMMENTS
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This report is a result of an administrative review of the written report of the findings of an on-site licensure renewal inspection conducted on September 25, 2013, and September 26, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the administrative review of findings from the on-site inspection, Harbor Counseling 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 administrative review:
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Plan of Correction
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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 a review of the Staffing Requirements Facility Summary Report form completed by the facility on September 12, 2013, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings included:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed during the onsite licensing renewal inspection. Based on the total number of hours per week that the facility reported the employees devoted to their clients, the work week hours and the total number of clients assigned to the following employees on September 12, 2013 employees # 3 and 8 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by a 35 hour standard workweek.
The number of hours per week devoted by Employee # 3 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 2 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee #3 had 5 active clients.
Employee # 3 (2/35 = .06 FTE; 5 clients/.06 FTE = 83:1 caseload)
The number of hours per week devoted by Employee # 8 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 1 hour per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee #8 had 6 active clients.
Employee # 8 (1/35 = .03 FTE; 6 clients/.03 FTE = 200:1 caseload)
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Plan of Correction
The number of hours per week devoted by each of these employees as reported on the Facility Summary Report were entered incorrectly by Business Manager (both of these employees recently announced their leaving Harbor employ and their hours were in flux in the interim). Program Director has reviewed the form and corrected the hours as follows: 4 hours per week for employee #3 (rather than 2) and 3 hours per week for employee #8 (rather than 1). Additionally, both of these part-time employees will no longer be employed by the facility as of 11/30/13, and their caseloads are in the process of being discharged or transferred to recently hired full-time staff. As of this date employee #3 has 3 active clients (rather than 5) and employee #8 has 4 active clients (rather than 6). By 11/30/13 all of their existing caseloads will be discharged or transferred to recently hired full-time clinicians. Program Director will ensure compliance by reviewing all client:staff ratios on 12/2/13 with Business Manager. Ongoing compliance will be monitored by Program Director and Business Manager through joint monthly review of licensing checklist. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 F.
The findings included:
The physical plant inspection took place on September 25, 2013. At 10:19 a.m. the water temperature was tested in the bathroom in the main building and it read higher than 130 F; the business office staff were informed and the facility was requested to lower the water temperature. The water temperature was tested again at 11:20 a.m. and the temperature read 140 F. The temperature was addressed with the facility director who stated the temperature had been decreased. Upon further review, the facility director noted he had actually turned the temperature from hot to very hot; it was adjusted. At 1 p.m., the water tested at 138 F; the receptionist was informed. At 4:20 p.m., the water tested at 130 F; the receptionist was informed. On September 26, 2013, at 9:50 a.m. the water temperature tested below 120 F.
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Plan of Correction
Program Director has identified the correct setting on the water heater, and labeled the heater with a notice clearly indicating the correct setting, with a warning not to change the current correct setting. Office Manager will monitor monthly along when fire drills are conducted and will document in log. |
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 the physical plant inspection, the facility failed to ensure that fire extinguishers are inspected and approved annually by a fire extinguisher company.
The findings included:
On September 26, 2013, at 10:30 a.m. the location of the discharge records was observed. The discharge records are located in the basement. The fire extinguisher located in the basement had not been annually inspected.
The findings were observed and confirmed with the receptionist.
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Plan of Correction
There was an additional fire extinguisher in the annex building which was not part of the original inventory, and this threw off the inspector's count of extinguisher inventory. Inspector has returned, inspected and approved the previously un-inspected extinguisher. Business Manager has ensured that the inspector now has a corrected and current inventory of facility fire extinguishers. Using internal master inventory list, Business Manager will monitor and visually confirm inspection of all extinguishers at annual inspection. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel and training records, the facility failed to document that each employee received fire extinguisher training upon hire in one of one record.
The findings included:
Six personnel records were reviewed on September 25, 2013. One personnel record was reviewed for documentation of fire extinguisher training upon hire.
Personnel record # 6, the employee was hired on August 1, 2012. Fire extinguisher training was not documented at the time of the review.
The findings were reviewed and confirmed by the facility director.
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Plan of Correction
Fire extinguisher training and documentation of the training has been completed for personnel record #6. This had not been done previously because the employee only works two hours per week three weeks per month. Program Director and Business Manager now understand that all employee-related regulatory standards apply to all employees, regardless of how limited their employment might be, and will be responsible for ensuring that all appropriate standards are complied with for all employees henceforth. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based upon the review of the fire drill records, the facility failed to conduct fire drills during normal staffing conditions.
The findings included:
Fire drill logs for the time period of September 2012 to August 2013 were reviewed. Twelve months of fire drill logs were reviewed for two buildings. In the Main building, eight of twelve fire drills were documented on a Wednesday between 11:45 a.m. and 4:00 p.m. In the Annex building, 9 of 12 fire drills were documented on a Wednesday between 10:00 a.m. and 2:00 p.m.
The documentation was reviewed with the facility director. The facility director stated Wednesday is a reduction in staff due to services in the evening. There was no documentation of evening fire drills. The fire drills were conducted during reduction in staffing conditions.
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Plan of Correction
Program Director has informed all staff of the requirements for compliance with this standard, and the fire drill procedures have been changed to ensure compliance. Office Manager will monitor compliance through monthly review of the fire drill logs. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel and training records, the facility failed to document that all personnel on all shifts are trained to perform assigned tasks during emergencies, in one of one personnel record.
The findings included:
Six personnel records were reviewed on September 25, 2013. One personnel record was reviewed for documentation of emergency training upon hire.
Personnel record # 6, the employee was hired on August 1, 2012. Verification of this training was not documented for the employee at the time of the review
The findings were reviewed and confirmed by the facility director.
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Plan of Correction
Business Manager conducted emergency training with the employee in question, and ensured that documentation was added to personnel record #6. This employee had a very limited role, working only two hours per week three weeks per month as an assist to a lead therapist. Program Director and Business Manager now understand that all employee-related regulatory standards apply to all employees, regardless of how limited their employment might be, and will be responsible for ensuring that all appropriate standards are complied with for all employees henceforth. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based upon the review of the fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings included:
Fire drill logs for the time period of September 2012 to August 2013 were reviewed. Twelve months of fire drill logs were reviewed for two buildings. The Main building fire drill logs identified the use of the front, back and side exits on all logs. The Annex building fire drill logs identified the use of only the front exit on all logs.
The findings were reviewed and confirmed by the facility director.
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Plan of Correction
Program Director has informed all staff of the requirements for compliance with this standard, and the fire drill procedures have been changed to ensure compliance. Office Manager will monitor compliance through monthly review of the fire drill logs. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based upon the review of the fire drill records, the facility failed to conduct the drills on different days of the week and on different staffing shifts.
The findings included:
Fire drill logs for the time period of September 2012 to August 2013 were reviewed. Twelve months of fire drill logs were reviewed for two buildings. The Main building fire drill logs identified fire drills occurring on eight Wednesdays, three Fridays and one Tuesday. The Annex building fire drill logs identified fire drills occurring on nine Wednesdays, two Fridays and one Tuesday. There were no drills performed during the facility's evening hours.
The findings were reviewed and confirmed by the facility director.
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Plan of Correction
Program Director has informed all staff of the requirements for compliance with this standard, and the fire drill procedures have been changed to ensure compliance. Office Manager will monitor compliance through monthly review of the fire drill logs. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative documentation, the facility failed to make available to the public an annual report.
The findings included:
On September 26, 2013, the facility's administrative documentation was reviewed that included the annual report. The facility was required to provide confirmation that an annual report was made available to the public.
The 2011 - 2012 annual report was provided and reviewed during the inspection; however, the facility failed to verify how the annual report was made available to the public.
The findings were reviewed and confirmed by the facility director that they had not made the annual report available to the public..
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Plan of Correction
Program Director has developed a licensing checklist that will be reviewed monthly. The checklist includes public notice of availability of annual report. Additionally, Business Manager has included annual reminder in her Outlook program to further ensure compliance. Documentation will of public notice will be included with the Annual Report. Public notice for this year's Annual Report has already been made available. |
709.26(d)(1) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(1) The application for employment.
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Observations
Based on a review of personnel records, the facility failed to ensure the inclusion of all documentation as required within one of five personnel records.
The findings included:
Six personnel records were reviewed on September 25, 2013. Five personnel records were reviewed for the required documentation.
Personnel record # 6 did not contain documentation of reference results, salary information and annual work performance evaluation. The record documented a hire date of August 1, 2012. Reference results and salary information were not documented at the time of the review. A work performance evaluation was required by August 1, 2013. A work performance evaluation was not documented at the time of the review.
The findings were reviewed and confirmed with the facility director.
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Plan of Correction
Program Director has ensured that reference results and salary information have been added to personnel record #6. Agency annual performance evaluations are conducted every year in October, and this has been completed by Program Director and included in personnel record #6. This employee had a very limited role, working only two hours per week three weeks per month as an assist to a lead therapist. Program Director and Business Manager now understand that all employee-related regulatory standards apply to all employees, regardless of how limited their employment might be, and will be responsible for ensuring that all appropriate standards are complied with for all employees henceforth. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on a review of personnel records, the facility failed to document efforts to advise staff of their rights in one of one personnel record.
The findings included:
Six personnel records were reviewed on September 25, 2013. One personnel record was reviewed for documentation of advising staff of their rights.
Personnel record # 6 did not contain documentation of the staff member having been advised of their employee rights.
The findings were reviewed and confirmed with the facility director.
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Plan of Correction
Program Director has ensured that documentation of advising employee of her rights has been added to personnel record #6. This employee had a very limited role, working only two hours per week three weeks per month as an assist to a lead therapist. Program Director and Business Manager now understand that all employee-related regulatory standards apply to all employees, regardless of how limited their employment might be, and will be responsible for ensuring that all appropriate standards are complied with for all employees henceforth. |
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
Based on a review of personnel records, the facility failed to document written job descriptions which contained the employee's and supervisor's dated signatures in two of three personnel records.
The findings included:
Six personnel records were reviewed on September 25, 2013. The facility failed to obtain the required documentation of a signed job description in personnel records # 5 and 6.
Employee # 5 was hired on January 24, 2011, as a counselor assistant. The employee is currently functioning as a Certified Recovery Specialist. The only documentation of a signed job description was for the position of counselor assistant..
Employee # 6 was hired on August 1, 2012 as a Certified Recovery Specialist. There was no documentation of a signed job description in personnel record # 6.
The findings were reviewed and confirmed with the facility director.
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Plan of Correction
Program Director has ensured that current job descriptions with dated signatures are now included in personnel records #5 and #6. Program Director and Business Manager will both monitor ongoing compliance with this regulatory standard by conducting review of personnel records of all new employees and internal transfers by reviewing relevant personnel records within 30 days of hire or transfer. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in four of ten records. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in one of ten records reviewed.
The findings included:
Ten client records were reviewed on September 26, 2013. Eight records were from the outpatient treatment activity with two records reviewed from the partial hospital activity. The facility failed to ensure that an informed and voluntary consent to release information was obtained in four of ten records reviewed, # 3, 6, 9 and 10. The facility also failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in one of ten records, # 6.
A review of client record # 3 revealed the involvement of the client in a prison group. The record did not contain a consent to release information to the prison as the client would be identified by prison staff as participating in drug and alcohol services due to the services being provided on-site at the prison.
A review of patient record # 6 revealed a consent to release information to the employer that permitted the nature of the services provided, short statement of relapse and the patient's prognosis. The information permitted exceeded the limitations imposed by Pa Code 255.5 (b).
A review of client record # 9 revealed a consent to release information with the information to be disclosed listed as an individual's name. The facility failed to ensure that the client was fully informed of information to be disclosed.
A review of patient record # 10 revealed information was disclosed to an insurance company. A consent to release information to the insurance company was not documented in the client record at the time of the review.
The findings were reviewed and confirmed by the facility director.
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Plan of Correction
Regulatory standards regarding confidentiality and informed consents to release information will be reviewed during a scheduled staff meeting with all clinical and support staff on 11/26/13. A new Clinical Supervisor has been hired and will have responsibility for ongoing monitoring of compliance through regular reviews of client records. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to document a detailed history that included medical, drug or alcohol history, and personal history in five of ten records reviewed.
The findings included:
Ten client records were reviewed on September 26, 2013. Eight records were from the outpatient treatment activity with two records reviewed from the partial hospital activity. All records were reviewed for client histories. The facility failed to document a drug and alcohol history that included the client's perception of use in client record # 10. The facility failed to document detailed personal histories in client records # 5, 6, 7 and 8.
Client record # 5 failed to include a detailed family, educational, and sexual history.
Client record # 6 failed to include a detailed family and sexual history.
Client record # 7 failed to include a detailed sexual history.
Client record # 8 failed to include a detailed family history, employment and educational history.
The findings were reviewed and confirmed by the facility director.
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Plan of Correction
Regulatory standards regarding detailed client histories will be reviewed during a scheduled staff meeting with all clinical and support staff on 11/26/13. A new Clinical Supervisor has been hired and will have responsibility for ongoing monitoring of compliance through regular reviews of client records. |
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 upon a review of client records, the facility failed to document a psychosocial evaluation that included an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, client's attitude toward treatment and the counselor's conclusions/impressions in four of ten records.
The findings included:
Ten client records were reviewed on September 26, 2013. Eight records were from the outpatient treatment activity with two records reviewed from the partial hospital activity. All records were reviewed for psychosocial evaluations.
Client # 2 was admitted on January 18, 2013, and discharged on June 8, 2013. The psychosocial evaluation failed to document an assessment by the counselor that included the client's assets/strengths, coping mechanisms, and negative factors. The documentation did not include an evaluation by the clinician for the required components.
Client #7 was admitted on March 12, 2013, and discharged on June 4, 2013. The psychosocial evaluation failed to document an assessment by the counselor that included the client's assets/strengths, coping mechanisms, negative factors, client's attitude toward treatment and counselor conclusions/impressions. The documentation did not include an evaluation by the clinician for the required components.
Client # 8 was admitted on February 28, 2013 and discharged on July 10, 2013. The psychosocial evaluation documented a composite picture of the client. The documentation did not include an evaluation by the clinician for the required components to include the client problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, client's attitude toward treatment and the counselor's impressions/conclusions.
These findings were reviewed and confirmed with the facility director.
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Plan of Correction
Regulatory standards regarding the components of a full psychosocial evaluation will be reviewed by the Program Director during a scheduled staff meeting with all clinical and support staff on 11/26/13. A new Clinical Supervisor has been hired and will have responsibility for ongoing monitoring of compliance through regular reviews of client records. |
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 the review of client records, the facility failed to document a complete client record that included progress notes, discharge summary and follow up information in six of ten records reviewed
The findings included:
Ten client records were reviewed on September 26, 2013. Six client records did not include all of the required components, # 1, 2, 3, 4, 5 and 6.
In client record # 1, the client was admitted on March 8, 2013, and discharged on August 15, 2013. The record did not contain follow up information at the time of the review.
In client record # 2, the client was admitted on January 18, 2013, and discharged on June 8, 2013. The client record contained a note of April 28, 2013, that identified the client had relocated. The client was discharged six weeks later with no additional services after March 8, 2013. The record did not contain follow up information at the time of the review.
In client record # 3, the client was admitted on April 8, 2013. The record of service entries documented that services occurred on the following dates, but there was no documentation of progress notes for those dates. Outpatient individual notes were missing for 4/22, 7/1 and 8/29.
In client record # 4, the client was admitted on July 12, 2013. The record of service entries documented that services occurred on the following dates, but there was no documentation of progress notes for those dates. An outpatient individual note was missing for 8/2.
In client record # 5, the client was admitted on May 24, 2013. The record of service entries documented that services occurred on the following dates, but there was no documentation of progress notes for those dates. An outpatient individual note was missing for 8/1.
In client record # 6, the client was admitted on July 18, 2013. The record of service entries documented that services occurred on the following dates, but there was no documentation of progress notes for those dates. An outpatient individual note was missing for 9/9.
The findings were reviewed and confirmed with the facility director.
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Plan of Correction
Regulatory standards regarding the components of a complete client record will be reviewed during a scheduled staff meeting with all clinical and support staff on 11/26/13. A new Clinical Supervisor has been hired and will have responsibility for ongoing monitoring of compliance through regular reviews of client records. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of the client records, the facility failed to provide a physician signature on a treatment plan and a treatment plan update in one of one client records.
The findings include:
Ten client records were reviewed on September 26, 2013. Eight client records were from the Outpatient treatment activity. One client record was funded through the office of medical assistance and was required to include documentation of a physician's signature on the initial treatment plan. There was no documentation of the physician's signature on the initial treatment plan in client record #6.
In client record #6, the client was admitted to treatment on March 12, 2013, and discharged on June 4, 2013. The initial treatment plan was documented on March 12, 2013. There was no documentation of the physician signature on the initial treatment plan.
The findings were reviewed and confirmed with the facility director.
This is a repeat deficiency from the August 22-23, 2012, on-site renewal inspection.
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Plan of Correction
Relevant regulatory standard and standards for compliance will be reviewed by the Program Director during a scheduled staff meeting with all clinical and support staff on 11/26/13. A new Clinical Supervisor has been hired and will have responsibility for ongoing monitoring of compliance through regular reviews of client records. |
709.14(a) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
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Observations
Based on a review of administrative documentation, the facility failed to comply with the Department approved capacity for the outpatient treatment activity.
The findings included:
The facility reported an outpatient census of 142 clients on the "Staffing Requirements Facility Summary Report". The Department approved capacity for the outpatient treatment activity was 120 clients. The facility is exceeding its authorized outpatient capacity of 120 clients.
The findings were reviewed and confirmed by the facility director.
This is a repeat deficiency from the August 22-23, 2012, on-site renewal inspection.
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Plan of Correction
Facility has discharged or referred clients as clinically appropriate and as of 11/15/13 reduced the client census to 120. Program Director and Business Manager will monitor ongoing compliance through joint monthly review of client checklist. Additionally, a request was submitted to DDAP on July 12, 2013 requesting an increase in our licensed capacity from 120 to 175 based on community need and staff availability. |