INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5, 2006 to June 7, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 12, 2006.
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Plan of Correction
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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
There were no transcripts or other documentation for staff member #13 to verify the major for which the degree was granted.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
The hot water tap in the staff bathroom did not produce warm or hot water.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.81(b)(3)(i) LICENSURE Medical History
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
In 3 out of 4 clinical charts reviewed, specifically #19, 20 and 21, the medical histories were documented beyond the time frame established by facility policy and procedure. There was no documentation for symptoms/illnesses.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.81(b)(3)(ii) LICENSURE D & A History
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
In clinical charts #19, 20 and 21, the drug and alcohol histories were completed late according to facility policy and procedure. There was no documentation regarding the client's perception of use.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.81(b)(3)(iii) LICENSURE Personal History
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
In 3 out of 4 clinical charts reviewed, specifically #19, 20 and 21, the personal histories were late according to facility policy and procedure. In clinical chart #17 the personal history was missing several required elements.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.81(b)(6) LICENSURE Psychosocial Evaluation
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
In 4 out of 4 clinical charts reviewed, specifically #17, 19, 20 and 21, the psychosocial evaluation was mostly historical in nature and was missing most of the required elements. In addition, the psychosocial evaluations in clinical charts 19, 20 and 21 were late per facility policy and procedure.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.81(b)(7) LICENSURE Preliminary Tx Plan
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
In 2 out of 4 clinical charts reviewed, specifically #19 and 20, the preliminary treatment plan was late according to facility policy and procedure.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.82(a)(3) LICENSURE Mngt of Treatment Services
711.82. Treatment and rehabilitation services.
(a) The project shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the development, approval and ongoing management of treatment/rehabilitation services for clients.
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Observations
Multiple policies were identified in the manual regarding timeframes for the completion of clinical documentation. The clinical supervisor was questioned in order to confirm the correct timeframes.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.82(c) LICENSURE Individualized Tx Plan
711.82. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
In 4 out of 4 clinical charts reviewed, specifically #17, 19, 20 and 21, the comprehensive treatment plans did not contain realistic or measurable short and long-term goals. In addition, the comprehensive treatment plans were not individualized.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.82(d) LICENSURE Tx Plan Updates
711.82. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
In clinical chart #21, the treatment plan update did not include a review of the client's progress as it relates to the stated treatment plan goals. In addition, the treatment plan update was missing in clinical chart #20.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.83(a)(7) LICENSURE Follow-up Information
711.83. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
In clinical chart #21, there was no documentation of follow-up. According to program policy the follow-up should have occurred on May 31, 2006.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.83(c)(2) LICENSURE Informed/Voluntary Consent
711.83. Client records.
(c) Confidentiality.
(2) 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
In 4 out of 4 clinical charts reviewed, specifically #17, 19, 20 and 21, the general consent to release information form contained a parent signature line. In addition, the consent to release protected health information form contained a statement indicating that the privacy rule was not in affect regarding re-disclosure of patient protected health information.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.83(c)(2)(ii) LICENSURE Specific Information Disclosed
711.83. Client records.
(c) Confidentiality.
(2) 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:
(ii) The specific information disclosed.
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Observations
In clinical chart #17, the consent to release information form did not indicate what information was to be released.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.85(b) LICENSURE Efficient Retrieval of Data
711.85. Uniform Data Collection System.
(b) A data collection shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
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Observations
The current data collection system does not allow for the efficient retrieval of data in order measure the project's performance.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.91(b)(3)(i) LICENSURE Medical History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
In 6 out of 12 clinical charts reviewed, specifically #1, 2, 3, 5, 8 and 12, the medical histories were completed late according to facility policy and procedure. In addition, the medical histories did not include client's symptoms/illnesses.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.91(b)(3(ii) LICENSURE D & A History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
In 7 out of 12 clinical charts reviewed, specifically #1, 3, 5, 8, 12, 18 and 23, the drug and alcohol histories were completed late according to facility policy and procedure. In addition, in clinical charts, #1, 2, 3, 5, 8, 12, 16, 18, 22 and 23 the drug and alcohol history did not include the client's perception of use. In clinical charts #2, 5 and 6 the the drug and alcohol history did not address prior treatment attempts.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.91(b)(3)(iii) LICENSURE Personal History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
In 7 out of 12 clinical charts reviewed, specifically #1, 2, 3, 4, 6, 8 and 12, the documentation in the personal histories did not consistently include family, employment, education, recreational and sexual information. In addition, the personal histories in clinical charts #1, 2, 3, 5, 8, 12, 18 and 23 were late according to facility policy and procedure.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
In 8 out 12 clinical charts reviewed, specifically #1, 2, 3, 5, 8, 12, 18 and 23, the psychosocial evaluations were late according to facility policy and procedure. In addition, in clinical charts #2, 3, 4, 5, 6, 8, 16, 18, 22 and 23 the psychosocial evaluations were primarily historical rather than evaluative and did not address several of the required areas.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.91(b)(7) LICENSURE Preliminary Treatment Plan
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
In 6 out of 12 clinical charts reviewed, specifically #1, 2, 3, 6, 8 and 12, the preliminary treatment plan was late according to facility policy and procedure.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.92(a)(3) LICENSURE Mngt of Treatment Services
711.92. Treatment and rehabilitation services.
(a) The project shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the development, approval and ongoing management of treatment/rehabilitation services for clients.
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Observations
Multiple policies were identified in the manual regarding timeframes for the completion of clinical documentation. The clinical supervisor was questioned in order to confirm the correct timeframes.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
In 5 out of 12 clinical charts reviewed, specifically #1, 2, 3, 8 and 12, the comprehensive treatment plan was late according to facility policy and procedure. In addition, the comprehensive treatment plan did not include realistic and measurable short and long-term goals or support services in clinical charts #18, 22 and 23.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
In 4 out of 5 clinical charts reviewed, specifically #1, 3, 7 and 8, the treatment plan update did not include the client's progress in the last 60 days as it related to the treatment plan goals for that time period.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.93(a)(2) LICENSURE Record of Services Provided
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes all information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(2) Record of services provided.
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Observations
In clinical charts #1 and 6, the record of services was missing. In addition, in clinical charts #2, 4 and 12, the record of services was incomplete with dates missing when compared to the progress notes.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
In clinical chart #22, the aftercare plan did not include realistic goals with timeframes or support services.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
There was no documentation of follow-up in clinical charts #4, 5, 7, 8, 12 and 22.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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
In 13 out of 13 clinical charts reviewed, specifically #1, 2, 3, 4, 5, 6, 7, 8, 12, 16, 18, 22 and 23, the patient's rights form contained a signature line for the parent/guardian. In addition, in clinical charts #1, 2, 5 and 8, the consent to release information form used by the WPIC Adolescent Substance Abuse Treatment Program contained a parent signature line. The consent to release protected health information form contained a parent signature line. The consent to release protected health information form misinforms clients/patients with a statement alleging the privacy rule is not in effect for the re-disclosure of information.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. Client records.
(c) Confidentiality.
(2) 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:
(ii) The specific information disclosed.
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Observations
In clinical chart #16, specific information disclosed to SSI for disability determination exceeded the restrictions imposed by 4 Pa. Code subsection 255.5(b).
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
In clinical charts #1, 2 and 4, the client was not offered a copy of the signed consent to release information form.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.95(b) LICENSURE Efficient Retrieval of Data
711.95. Uniform Data Collection System.
(b) A data collection system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
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Observations
The current data collection system does not allow for the efficient retrieval of data in order measure the project's performance.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.96(a) LICENSURE Written Termination Notice
711.96. Notification of termination.
(a) The project director shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
In clinical charts #4 and 12, there was no documentation that the Project Director notified the client of a decision to involuntarily terminate the client's treatment.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |