INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 18-21, 2008 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 and a plan of correction is due on September 23, 2008.
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Plan of Correction
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705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based upon a physical plant inspection conducted on August 20, 2008, it was observed that the facility failed to maintain all structures on the grounds of the facility so as to be free from any danger to health and safety.
Findings:
1. Wooden railings for the exterior stairs required sanding to ensure safety against splinters.
2. The exterior stair to the left of the first floor rear exit door when leaving the building, lacked a railing and guard on the side closest to the building to provide protection from falling.
3. The slab of concrete at the bottom of the stair mentioned in number 2 above was not level with the slab adjacent to it, nor was the slab adjacent to it level with the ground to ensure safety from tripping.
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Plan of Correction
1. The Executive Director and Operations Manager will contract with a local construction outfit to make the necessary building repairs, which will include sanding the wooden railings, adding a second rail to the exterior stair to the left of the first floor rear exit door, and level the concrete to eliminate the tripping hazard.
2. These repairs will be completed by 1 November 2008. Completion will be monitored by the Executive Director and Operations Director.
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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 upon a review of nine personnel records on August 18 & 19, 2008, eight required documentation that the staff received instruction in the use of fire the extinguisher upon staff employment. The facility failed to provide documentation in six of eight records reviewed.
Findings:
The facility lacked documentation to verify that employees were instructed in how to use the fire extinguisher in personnel records #1, 2, 3, 5, 7 & 8.
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Plan of Correction
1. The Operations Director has scheduled a fire extinguisher and safety training for 25 September 2008 for all staff. Current staff have had the training previously, but this will serve as a review of the emergency policy, where exits are, and how to operate a fire extinguisher.
2. The Operations Director is creating an employee orientation program that will include fire extinguisher and safety training during the first week of employment.
3. DASBV will be in compliance with this regulation by 25 September 2008, and it will be monitored by the Operations Director.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based upon a review of the facility's fire drill record on August 20, 2008, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
Findings:
The exit route used was not documented in any of the fire drills conducted from January 2008 through August 20, 2008.
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Plan of Correction
1. The Operations Director will modify the fire drill log so that it includes a space for documenting the exit route being used for each drill.
2. The Operations Director made the modification to the fire drill log on 17 September 2008, and the Operations Director is responsible for monitoring compliance with this regulation.
3. DASBV will be in compliance with this regulation by 31 October 2008.
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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 a review of the facility's fire drill record on August 20, 2008 the facility failed to prepare alternate exit routes to be used during fire drills.
Findings:
The exit route used was not documented in any of the fire drills conducted from January 2008 through August 20, 2008; therefore, it was not possible to determine if the facility had prepared and practiced using alternate exits.
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Plan of Correction
1. The Operations Director will make a modification to the fire drill log so that it clearly documents the exit route used during a drill.
2. The Operations Director will ensure that exit routes are alternated each month.
3. The Operations Director will monitor compliance with this regulation. DASBV will be in compliance with this regulation by 31 October 2008.
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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 upon a review of the facility's 2006 - 2007 annual report and an interview with the facility director, both occurring on August 20, 2008, the facility failed to complete their annual report by February in accordance with their policy and procedures and they failed to make the general public aware of the availability of the annual report.
The findings were:
The facility had not completed the annual report for the 2006-2007 fiscal year until April 2008.
The facility lacked documentation to verify that they made the general public aware of the availability of the annual report for the year ended June 30, 2007.
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Plan of Correction
1. The Executive Director is scheduling with the financial auditors to have the next financial audit completed in October 2008.
2. The Executive Director will have the next Annual Report completed in December 2008 and presented to the Board on 22 December 2008.
3. After Board approval of the report, the Executive Director will place an announcement in the local newspaper and on the agency web site of a date to be determined, where the Annual Report will be made available to the public.
4. The Executive Director will is responsible for monitoring compliance with this regulation. The Executive Director will make the Annual Report dated 22 December 2008 available to the public in Jnauary 2009.
5. DASBV will be in compliance with this regulation by 1/31/2009.
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709.22(e)(2) 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:
(2) A financial statement of income and expenses.
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Observations
Based upon a review of the facility's 2006 - 2007 annual report and an interview with the facility director, both occurring on August 20, 2008, the facility failed to make available to the public an annual report which includes, but is not limited to: A financial statement of income and expenses.
Finding:
The facility did not include a financial statement of income and expenses in the annual report for the 2006-2007 fiscal year.
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Plan of Correction
1. The Executive Director will add an addendum to the Annual Report dated April 2008 that includes a financial statement for the 06-07 fiscal year. The addition of this addendum will be approved by the Board of Directors on 22 September 2008. The addendum will be placed in the Policy and Procedure Manual with the April 2008 Annual Report after the Board meeting.
2. The Executive Director will ensure that all future Annual Reports include a fiancial statement of income and expenses.
3. The addendum will be added on 22 September 2008.
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709.26(a)(12) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(12) Employe grievances.
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Observations
Based upon a review of the facility's Policy and Procedures Manual on August 18 & 19, 2008, the facility failed to provide a complete policy and procedure for grievances.
Findings:
The facility failed to identify timeframes for each step of the grievance process, grievance issues, steps of appeal, required time frames for each step and who has authority of resolution.
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Plan of Correction
1. The Executive Director and Operations Director will develop modifications to the Employee Grievance policy.
2. These modifications will be presented to the Board at the 22 September 2008 Board meeting.
3. At the 22 September 2008 Board meeting, modifications to the Employee Grievance Procedure will be approved.
4. The Executive Director will then distribute a copy of the new policy to all staff within 1 week of the Board meeting.
5. The Executive Director is responsible for monitoring compliance of this regulation. DASBV will be in compliance with this regulation by 10/31/2008.
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709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based upon a review of nine personnel records on August 18 & 19, 2008, eight of nine personnel records were reviewed for documentation of reference checks. Four of the eight records reviewed lacked documentation of the reference checks.
Finding:
Personnel records #3, 4, 7 & 8 lacked documented reference checks.
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Plan of Correction
1. The Operations Director issued a memo to all employees requesting the names of at least 2 professional references on 17 September 2008.
2. The Operations Director will complete / have at least 2 reference checks or letters of reference on all current employees.
3. The Operations Director will ensure that a minimum of 2 reference checks / letters of reference are completed on all new employees before their first day of work.
4. The Operations Director is responsible for monitoring this regulation. All current employees will have reference checks / letters of reference completed by 31 October 2008.
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709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based upon a review of nine personnel records on August 18 & 19, 2008, three of nine personnel records reviewed lacked the salary history information.
Finding:
Personnel records #1, 2 & 3 lacked salary history information.
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Plan of Correction
1. The Operations Director will create a salary history form and add it to the personnel files of all employees.
2. Previous administrations did not document employee salary histories, so these salary histories will start with the current salaries/hourly rates of all employees. Any future changes to employee salaries will be documented on the salary history form.
3. The Operations Director is responsible for monitoring compliance with this regulation. DASBV will be in compliance with this regulation by 30 September 2008.
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based upon a review of facility documentation on August 20, 2008, the facility failed to make appropriate use of the Qualified Service Organization Agreements (QSOA) with other entities.
Findings:
The facility had executed QSOA forms with schools, other treatment facilities, insurance companies, criminal justice entities, children and youth agencies and the single county authority. Releases of information are required for releases to any of these entities and the use of QSOA documents instead of releases of information is a violation of the regulations at 28 Pa. Code Subsection 709.28(c) and 42 C.F.R. Part 2, Subpart C, Subsection 2.31.
This is a repeat deficiency from the inspection ending on October 4, 2007.
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Plan of Correction
1. All documents titled "QSOA" were removed from the Policy and Procedure Manual on 2 September 2008.
2. Going by the explanation given by the surveyors at the site visit, there are no agencies with whom DASBV needs to have a QSOA in place with at this time.
3. The Executive Director will gather samples of Referral Agreement Letters, and create a Referral Agreement Letter to distribute to entities, such as schools, other treatment facilities, insurance companies, criminal justice entities, children and youth agencies, and the single county authority. These will be updated every 2 years and kept in the Policy and Procedure Manual. Releases of Information will be the only forms used to permit communication with these entities.
4. The Executive Director will monitor compliance. DASBV will be in compliance by 10/1/2008.
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Base upon a physical plant inspection and an interview with employee #5, both occurring on August 20, 2008, the facility failed to secure client records within locked storage containers.
Findings:
The files for the closed records, which were located in the employee lounge/lunchroom, were unlocked at the time of the inspection. This lounge/lunchroom is shared with other occupants of the building who are not employees of the facility. Information obtained during the interview with employee #5 revealed that the normal procedure is to unlock the files in the morning and then lock them at the close of business each day. There are times when individuals who are not employees of the facility could be alone with the unlocked files.
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Plan of Correction
1. On 21 August 2008, the Executive Director instructed the Records Specialist to keep the client files secured at all times in the locked storage container.
2. If a therapist needs a file, he/she will see the Records Specialist who will then unlock the storage container. The storage container will immediately be re-locked once the therapist has obtained the information he/she was looking for.
3. The Operations Director will monitor the Records Specialist for compliance with this regulation. DASBV is in compliance with this regulation as of 21 August 2008.
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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 upon a review of 14 client records on August 20 & 21, 2008, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in five of fourteen records reviewed.
Findings:
Client records #1, 9 & 10 contained consent forms that failed to identify if the information was being disclosed by the facility or obtained by the facility. The forms titled "Authorization For Release of Records or Information" stating, "I hereby give permission to Value Behavioral Health of Pennsylvania Inc. and the Beaver Valley Office to disclose or obtain (neither was checked off) information from Drug and Alcohol Services of Beaver Valley did not indicate if the information was being received or disclosed.
Client record #2 contained a consent to release information that did not include the purpose for the release.
Client record #14 lacked a consent to release information for information released to an employment agency.
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Plan of Correction
1. The Executive Director held an in-service staff meeting on 17 September 2008 and addressed the issue of incomplete releases of information.
2. All staff were instructed to make sure the releases clearly state whether information is to be released or obtained.
3. All staff were instructed to make sure the Purpose section of the release of information was completed on all releases.
4. All staff were instructed that no information is to be faxed to any entity that did not have a signed release of information form in the client's chart.
5. The Clinical Supervisor and the Executive Director are responsible for monitoring compliance with this regulation. DASBV will be in compliance with this regulation as of 9/19/2008.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) 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
Based upon a review of 14 client records on August 20 & 21, 2008, 13 client records required that an individual treatment plan be developed. The facility failed to complete the individual treatment plan within 60 days of the preliminary treatment plan as per facility policy in two of thirteen client records reviewed and the facility failed to provide individualized treatment plans in three of thirteen records reviewed.
Findings:
Client record #1 contained a preliminary treatment plan developed on May 5, 2008; however, the individual treatment plan was not developed until July 21, 2008.
Client record #4 contained an individual treatment plan developed on June 3, 2008; however, based upon the date of the preliminary treatment plan, the individual treatment plan should have been completed on May 9, 2008.
Client records #1, 4 & 5 contained treatment plans that were not individualized and were nearly identical from client record to client record.
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Plan of Correction
1. DASBV will have a full-time Clinical Supervisor starting on 6 October 2008. The Clinical Supervisor and Executive Director will work with the therapists to create more efficient methods for them to track when their clients' treatment plans are due.
2. Preliminary Treatment Plans will be completed by the end of the 2nd session.
3. Comprehensive / Master Treatment Plans will be completed within 30 days of the Preliminary Treatment Plan.
4. Treatment Plan Updates will be completed every 60 days from the date on the Comprehensive Treatment Plans.
5. The Clinical Supervisor will be responsible for monitoring compliance with this regulation. DASBV will be in compliance with this regulation by 12/1/2008.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based upon a review of 14 client records on August 20 & 21, 2008, 6 client records required that treatment plan updates be developed. The facility failed to complete the treatment plan updates within 60 days of the comprehensive individualized treatment plan in two of six client records reviewed.
Findings:
Client record #2 should have had a treatment plan updates documented by May 20, 2008 and July 20, 2008, however, there were no treatment plan updates in the record.
Client record #14 should have had a treatment plan update documented by July 28, 2008, however, there was no treatment plan update in the record.
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Plan of Correction
1. DASBV will have a full-time Clinical Supervisor starting on 6 October 2008. The Clinical Supervisor and Executive Director will work with the therapists to create more efficient methods for them to track when their clients' treatment plans are due.
2. Preliminary Treatment Plans will be completed by the end of the 2nd session.
3. Comprehensive / Master Treatment Plans will be completed within 30 days of the Preliminary Treatment Plan.
4. Treatment Plan Updates will be completed every 60 days from the date on the Comprehensive Treatment Plans.
5. The Executive Director conducted an in-service with staff on 17 September 2008 on individualizing treatment plans. The Clinical Supervisor will review each treatment plan and update to ensure that plans are addressing individual treatment needs.
6. The Clinical Supervisor will be responsible for monitoring compliance with this regulation. DASBV will be in compliance with this regulation by 12/1/2008.
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709.93(a)(2) 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:
(2) Medication records.
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Observations
Based upon a review of 14 client records on August 20 & 21, 2008, eight client records required documentation of medication records for the clients. The facility failed to document the dosage and/or frequency of client medications in five of eight client records reviewed.
Findings:
Client records #3 & 7 did not list the dosage for the medications that the client was taking.
Client records # 2, 9 & 14 did not list the dosage or the frequency of use for the medications that the client was taking.
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Plan of Correction
1. The Executive Director conducted an in-service on 17 September 2008 on the accurate documentation of medications. Medication documentation must include dosage and frequency. Any medication changes during the course of treatment at DASBV must also be documented.
2. The Executive Director and Clinical Supervisor will modify the psychosocial assessment and other medication documentation forms so that current medications are separated from previous medications.
3. The Clinical Supervisor is responsible for monitoring compliance with this regulation. DASBV will be in compliance with this regulation by 12/1/2008.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based upon a review of 14 client records on August 20 & 21, 2008, 7 client records were required to include case consultations. The facility failed to complete the case consultations on a quarterly basis in accordance with the standards in seven of seven client records reviewed.
Findings:
Client records #2, 4, 7, 9, 11 & 14 did not have any documented case consultations.
Client record #6 contained a case consultation that was not completed until after the due date.
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Plan of Correction
1. The Case Consultation Policy at DASBV will be reviewed with all staff at the October 2008 staff meeting.
2. Case Consultations are to be completed at the same time as Treatment Plan Updates. Therapists are to schedule time with the Clinical Supervisor or Executive Director to perform the Case Consults. It is the responsibility of the therapist to monitor due dates and schedule the consults.
3. The Clinical Supervisor is responsible for monitoring compliance with this regulation. DASBV will be in compliance with this regulation by 11/15/2008.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based upon a review of 14 client records on August 20 & 21, 2008, 4 required that follow-ups be completed within 30 days of discharge. The facility failed to document follow-up attempts in four of four client records where required.
Findings:
Client #2 was discharged on July 16, 2008 and there was no follow-up contact documented as of August 21, 2008.
Client #4 was discharged on July 3, 2008 and there was no follow-up contact documented as of August 21, 2008.
Client #11 was discharged on June 3, 2008 and there was no follow-up contact documented as of August 21, 2008.
Client #14 was discharged on June 30, 2008 and there was no follow-up contact documented as of August 21, 2008.
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Plan of Correction
1. DASBV will have an Evaluation Therapist / Aftercare Caseworker starting on 6 October 2008.
2. It will be the responsibility of this staff member to make the appropriate aftercare contacts and ensure that the DASBV aftercare contact policy is followed. Aftercare contacts must be made within 30 days of discharge.
3. The Clinical Supervisor will be responsible for monitoring compliance with this regulation. DASBV will be in compliance with this regulation by 11/15/2008.
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709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based upon a review of facility policies and procedures on August 18 & 19, 2008, the facility failed to document who is responsible, the method and frequency of contact and the
manner of documentation for follow-ups conducted on clients that are referred to an an outside resource upon discharge.
Findings:
The policy only addressed clients who are discharged and are not referred to any other agency upon discharge. The policy and procedure is incomplete.
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Plan of Correction
1. DASBV will have an Evaluation Therapist / Aftercare Caseworker starting on 6 October 2008.
2. It will be the responsibility of this staff member to make the appropriate aftercare contacts and ensure that the DASBV aftercare contact policy is followed. Aftercare contacts must be made within 30 days of discharge. If a client is to be referred to another agency, the staff member will have the client sign a release for that agency. The staff member will call that agency and schedule the appointment for the client. The staff member will call the referral agency within 7 days after the scheduled appointment to see if the client attended the appointment. If the client did, aftercare contact will stop. If the client did not, the staff member will contact the client and see if DASBV can provide further assistance in helping the client attend the initial appointment with the other agency.
3. The Clinical Supervisor will be responsible for monitoring compliance with this regulation. DASBV will be in compliance with this regulation by 11/30/2008.
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