INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 13-15, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Services of Beaver Valley, Inc 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.
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to document individual training plans as per facility policy, in seven of eight personnel records.
The findings include:
Eight personnel records were reviewed on November 13-15, 2012. Per facility policy, training plans are to be completed by June 30 of each year. The facility's training year is July 1 through June 30. Training plans were reviewed for the 2012-2013 training year and were due to be completed no later than June 30, 2012. Training plans were not documented per policy in personal records # 1, 2, 3, 5, 6, 7 and 8.
Employee # 1 was hired on November 24, 2008. Although there was documentation that the 2012-2013 training plan had been completed, the plan did not document a completion date. It could not be determined that the training plan was completed as per agency policy.
Employee # 2 was hired on October 8, 1987. Although there was documentation that the 2012-2013 training plan had been completed, the plan did not document a completion date. It could not be determined that the training plan was completed as per agency policy.
Employee # 3 was hired on December 28, 1987. Although there was documentation that the 2012-2013 training plan had been completed, the plan did not document a completion date. It could not be determined that the training plan was completed as per agency policy.
Employee # 5 was hired on August 11, 2010. Although there was documentation that the 2012-2013 training plan had been completed, the plan did not document a completion date. It could not be determined that the training plan was completed as per agency policy.
Employee # 6 was hired on September 28, 1992. Although there was documentation that the 2012-2013 training plan had been completed, the plan did not document a completion date. It could not be determined that the training plan was completed as per agency policy.
Employee # 7 was hired on November 1, 2012. Although there was documentation that the 2012-2013 training plan had been completed, the plan did not document a completion date. It could not be determined that the training plan was completed as per agency policy.
Employee # 8 was hired on November 1, 2011. Although there was documentation that the 2012-2013 training plan had been completed, the plan did not document a completion date. It could not be determined that the training plan was completed as per agency policy.
The facility director was interviewed on November 15, 2012 and confirmed the findings.
|
Plan of Correction
All Individual training plans have been dated. A checklist has been developed and will be placed in each employee file to insure the manager of the personnel files does not overlook DDAP requirements. The manager of employee records will be responsible for correcting current charts and will maintain employee charts according to DDAP policy. The executive director will review employee charts two times per year in January and in July to insure all employee records are current and meet standards. All reviews will be documented on the checklist. |
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.
|
Observations
Based on the review of personnel records, the facility failed to document fire extinguisher training upon staff employment in three of three records.
The findings include:
Eight personnel records were reviewed on November 13-15, 2012. Three personnel records required documentation of instructions in the use of a fire extinguisher upon employment.. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records # 4, 7 and 8.
Employee # 4 was hired on June 1, 2012. A certificate indicating the completion of the fire extinguisher training present in the employee file did not contain the employee's name, signatures or dates of completion.
Employee # 7 was hired on November 1, 2012. A certificate indicating the completion of the fire extinguisher training present in the employee's file did not contain the employee's name.
Employee # 8 was hired on November 16, 2011. A certificate indicating the completion of the fire extinguisher training present in the employee's file did not contain the employee's name.
The facility director was interviewed on November 15, 2012 and confirmed the findings.
|
Plan of Correction
All employee records have been corrected to indicate fire extinguisher training has been provided. All training forms indicate the employee's name, their signature and the date of training. A checklist has been developed and will be placed in the employee's chart to insure that the manager of personnel files does not overlook DDAP requirements. The executive director will review all personnel charts two times per year, in January and July, to insure all employee records are current and meet standards. These reviews will be recorded on the checklist form.
|
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:
|
Observations
Based on the review of the annual report, the facility failed to make the annual report for the 2010-2011 fiscal year available to the public at the end of the fiscal year.
The findings include:
The annual report for the 2010-2011 fiscal year was reviewed on November 13, 2012. The facility's fiscal year is July 1- June 30. The 2010-2011 annual report was not made available to the public until March 2, 2012.
The facility director was interviewed on November 15, 2012 and confirmed the findings.
|
Plan of Correction
The executive director has amended the Drug and Alcohol Services of Beaver Valley's policy from a February due date to a September due date. The executive director is responsible for completing the annual report and placing the public notice in the newspaper. The annual report is reviewed by the board of directors and signed by the president of the board. The policy change will also be reviewed by the board of directors and signed by the board president. |
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:
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of specific information contained in the client record in three of three clients records.
The findings included:
Eighteen client records were reviewed on November 13-15, 2012. Twelve client records were reviewed for compliance with obtaining an informed and voluntary consent for the release of specific information in the client record. Three client records included documentation that information was sent to the Department of Public Welfare in order to verify the client's eligibility status.
The facility failed to obtain an informed and voluntary consent for the disclosure of specific client information in client records # 6, 11 and 12. The client records included documentation that information was sent to the Department of Public Welfare in order to verify the client's eligibility status. There was no documentation in the client records listed, that a written consent to release the information had been obtained from the client prior to the release of the information.
The facility director was interviewed on November 15, 2012.
|
Plan of Correction
Drug and Alcohol Services of Beaver Valley's admission procedures include a verification of a client's insurance. Billing department personnel have been trained on obtaining client consents before verifying insurance information. The paper consent will be placed in the clients chart and there will be a message maintained on the clients computer page as well. During regular case reviews, the clinical supervisor will check that the consents are in both locations.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation which included client problems and needs, assets and strengths,support systems, coping mechanisms, negative factors and counselor conclusions/impressions in seven of twelve client records.
The findings include:
Eighteen client records were reviewed on November 13-15, 2012. Twelve records reviewed required documentation of a psychosocial evaluation. The psychosocial evaluation in client records # 2, 3, 4, 5, 6, 7 and 8 did not include the client's problems and needs, assets and strengths,support systems, coping mechanisms, negative factors and counselor conclusions/impressions
Client # 2 was admitted on March 6, 2012. The psychosocial evaluation was completed on March 6, 2012. The psychosocial evaluation consisted of historical and client reported information and was not an evaluation of the historical information collected.
Client # 3 was admitted on May 7, 2012. The psychosocial evaluation was completed on April 20, 2012. The psychosocial evaluation consisted of historical and client reported information and was not an evaluation of the historical information collected.
Client # 4 was admitted on July 2, 2012. The psychosocial evaluation was completed on June 26, 2012. The psychosocial evaluation consisted of historical and client reported information and was not an evaluation of the historical information collected.
Client # 5 was admitted on July 17, 2012. The psychosocial evaluation was completed on July 5, 2012. The psychosocial evaluation included historical and client reported information and was not a evaluation of the historical information collected.
Client # 6 was admitted on August 9, 2012. The psychosocial evaluation was completed on August 2, 2012. The psychosocial evaluation consisted of historical and client reported information and was not an evaluation of the historical information collected.
Client # 7 was admitted on July 9, 2012. The psychosocial evaluation was completed on July 9, 2012. The psychosocial evaluation consisted of historical and client reported information and was not an evaluation of the historical information collected.
Client # 8 was admitted on July 6, 2012. The psychosocial evaluation consisted of historical and client reported information and was not an evaluation of the historical information collected.
The facility director and clinical supervisor were interviewed on November 15, 2012 and did not dispute the findings.
|
Plan of Correction
The Psychosocial Evaluation has been created and is in use (the created date is 12/04/2012). All recommended areas in the policy have been included. Counselors will complete a Psychosocial Evaluation within the first 30 days of treatment. The completed Psychosocial Evaluation will be reviewed and monitored by the clinical supervisor during regular case reviews. |
709.94(d) LICENSURE Project management services
709.94. Project management services.
(d) The project shall develop a written client aftercare policy.
|
Observations
Based on the review of the policy and procedure manual, the facility failed to document a written client aftercare policy.
The findings included:
The policy and procedure manual was reviewed on November 13, 2012. There was no documentation of a written client aftercare policy.
The facility director was interviewed on November 13, 2012 and confirmed the findings.
|
Plan of Correction
The written aftercare policy has been added to the policy and procedure manual. The policy includes:
* Counselor and client will develop the aftercare plan together
* the aftercare plan will be developed during the last scheduled session.
* they will follow the format on the aftercare form
* the counselor will ensure that all areas of the aftercare plan are completed.
Casework is reviewed by the clinical supervisor to insure policy compliance. The executive director is responsible for maintaining the policy and procedure manual. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
|
Observations
Based on the review of the policy and procedure manual, the facility failed to document a written client follow-up policy.
The findings included:
The policy and procedure manual was reviewed on November 13, 2012. There was no documentation of a written client follow-up policy.
The facility director was interviewed on November 13, 2012 and confirmed the findings.
|
Plan of Correction
The follow-up policy has been added to the policy and procedure manual. The policy includes:
*within one week after discharge the counselor will document a summary of treatment services, including the reason for treatment services offered and provided, response to treatment, and client's status at discharge
*the primary counselor is responsible for making follow-up contacts
*contacts will occur by telephone or written correspondence
*follow-ups will be made 30 days after discharge when an outside referral is not scheduled
*follow-ups will be made within one week after discharge when a client is referred to additional outside resources
*counselors will obtain a written consent from the client inorder to contact the referral resource within one week, inorder to determine the disposition of the referral
*all contacts are documented in progress notes and maintained in the client record
Casework is reviewed by the clinical supervisor to insure policy compliance. The executive director is responsible for maintaining the policy and procedure manual. |