INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on November 9-10, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Parkside Recovery was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on observation, at the time of the project's site visit, the facility failed to provide the Department licensing representatives with the plan documenting the qualifications and training of staff.
The findings include:
On November 2, 2011 at approximately 9:00 AM, the Department licensing representatives requested the Staffing Requirements Facility Summary Report. The facility did not present the completed Staffing Requirements Facility Summary Report until November 2, 2011 at approximately 2:15 PM.
The findings were confirmed by the project director on November 2, 2011.
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Plan of Correction
Effective 11/08/2011, the facility will collaborate with internal resources to ensure completion of the Staffing Requirements Facility Summary Report prior to the on-site inspection. This will be monitored by the Executive Director and the Program Director |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the review of personnel records, the facility failed to document a minimum of 12 clock hours of training annually for the project director.
The findings include:
On November 8, 2011, the project director's personnel record was reviewed for documentation of 12 clock hours of training for the 2010 training year. The project director's personnel record contained documentation of only 6 hours of completed training during the 2010 training year.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
Effective 11/08/2011 all completed education certificates and training evaluation forms will be submitted to the Human Resources Department immediately upon completion. All training hours are tracked by the Director of Training and provided to each Program Director to ensure compliance. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on the review of the policy and procedure manual and minutes of the board of directors' meetings, the project director failed to present the policy manual to the governing body at least annually for approval.
The facility's policy manual and board of directors meeting minutes were reviewed on November 8, 2011. The facility's policy manual was not signed-off by the governing body, and the board of directors meeting minutes did state whether the policy manual had been reviewed and approved by the governing body.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
Effective 11/4/2011 the project director submitted the policy manual to the governing body for approval. This will occur at the annual report board meeting ongoing to maintain compliance. |
709.26(a)(4) 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:
(4) Employe benefits.
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Observations
Based on the review of the facility's policy manual, the facility failed to develop personnel policy to address employee benefits.
The findings include:
The facility's policy manual was reviewed on November 8, 2011. The facility's policy manual did not address employee benefits (eligibility, cost to employee, continuity after separation, etc.).
The policy manual mentioned a "fringe benefit program" , but the details of this program were not included in the policy manual.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
Effective 11/04/2011 the policy was updated to include the details of the fringe benefits program. This was confirmed by the project director prior to 11/08/2011. Effective 11/04/2011 the updated policy has replaced the previous policy in the policy and procedure manual. |
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 on the review of personnel records, the facility failed to document salary information in personnel records.
The findings include:
On November 8, 2011 , six personnel records were reviewed for documentation of salary information. The facility did not document starting salary and all salary increases/decreases in five of six records reviewed, specifically, personnel records # 1, 2, 3, 5 and 6.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
Effective 11/08/2011 all starting salary and all salary increases/decreases will be filed in the personnel files and monitored by the appropriate human resources personnel. All existing salary information will be filed by the human resources department clerical staff by 12/31/2011. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation to include a composite picture, problems/needs, assets/strengths, support systems, coping mechanisms, negative factors,attitude toward treatment and/or the counselor's conclusions/impressions.
The findings include:
On November 9-10, 2011, eleven client records were reviewed for psychosocial evaluations. The facility failed to document a psychosocial evaluation to include a composite picture, problems/needs, assets/strengths, support systems, coping mechanisms, negative factors,attitude toward treatment and/or the counselor's conclusions/impressions
in eleven out of eleven client records reviewed, # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11.
Client # 1 was admitted on 5/18/11. The psychosocial evaluation in client record # 1 dated 4/18/11 did not include the client's assets and strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client ' s appearance and behavior during the initial interview.
Client # 2 was admitted on 7/18/11. The psychosocial evaluation in client record # 2 dated 8/4/11 did not include the client's assets and strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client ' s appearance and behavior during the initial interview.
Client # 3 was admitted on 7/20/11. The psychosocial evaluation in client record # 3 dated 8/8/11 did not include the client's assets and strengths, support systems, coping mechanisms, and negative factors.
Client # 4 was admitted on 7/5/11. The psychosocial evaluation in client record # 4 dated 7/21/11 did not include the client's assets and strengths, negative factors, coping mechanisms, conclusions regarding the client's appearance and behavior during the initial interview, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 5 was admitted on 9/7/11. The psychosocial evaluation in client record # 5 dated 9/15/11 did not include the client's assets and strengths, negative factors, support systems, coping mechanisms, conclusions regarding the client's appearance and behavior during the initial interview, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 6 was admitted on 5/10/11. The psychosocial evaluation in client record # 6 dated 5/27/11 did not include the client's assets and strengths, negative factors, support systems, and coping mechanisms.
Client # 7 was admitted on 6/16/11, but client # 7's record did not contain a psychosocial evaluation at the time or review.
Client # 8 was admitted on 8/1/11, but client # 8's record did not contain a psychosocial evaluation at the time or review.
Client # 9 was admitted on 4/13/11. The psychosocial evaluation in client record # 9 dated 5/10/11 did not include the client's assets and strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client's appearance and behavior during the initial interview.
Client # 10 was admitted on 3/23/11. The psychosocial evaluation in client record # 10 dated 4/7/11 did not include the client's assets and strengths, support systems, coping mechanisms, and negative factors.
Client # 11 was admitted on 3/24/11. The psychosocial evaluation in client record # 11 dated 4/18/11 did not include the client's assets and strengths, coping mechanisms, and negative factors.
The findings were confirmed by the clinical supervisor on November 10, 2011.
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Plan of Correction
Effective 12/02/2011 all clinical staff will be updated in their training to document a psychosocial evaluation to include a composite picture, problems/needs, assets/strengths, support systems, coping mechanisms, negative factors,attitude toward treatment and/or the counselor's conclusions/impressions.This will be presented by a clinical supervisor during regular weekly training sessions by 12/23/2011. Psychosocial Evaluations will be reviewed with clincians during regular clinical supervision ongoing with the clinical supervisor. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document treatment plans to include type and frequency of treatment and rehabilitation services.
The findings include:
On November 9-10, 2011, treatment plans in eleven client records were reviewed for type and frequency of treatment and rehabilitation services. The facility did not document treatment plans to include type and frequency of treatment and rehabilitation services in five out of eleven client records records reviewed, # 1, 2, 9, 10 and 11.
Client # 1 was admitted on 5/18/11. The treatment plan in client # 1's record dated 5/31/11 did not include type and frequency of treatment and rehabilitation services.
Client # 2 was admitted on 7/18/11. The treatment plan in client # 2's record dated 8/11/11 did not include type and frequency of treatment and rehabilitation services.
Client # 9 was admitted on 4/13/11. The treatment plan in client # 9's record dated 5/10/11 did not include type and frequency of treatment and rehabilitation services.
Client # 10 was admitted on 3/23/11. The treatment plan in client # 10's record dated 4/7/11 did not include type and frequency of treatment and rehabilitation services.
Client # 11 was admitted on 3/24/11. The treatment plan in client # 11's record dated 5/3/11 did not include type and frequency of treatment and rehabilitation services.
The findings were confirmed by the clinical supervisor on November 10, 2011.
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Plan of Correction
Effective 12/02/2011 all clinical staff will be updated in their training to document treatment plans to include type and frequency of treatment and rehabilitation services.This will be presented by a clinical supervisor during regular weekly training sessions by 12/23/2011. Treatment plans will be reviewed with clincians during regular clinical supervision ongoing with the clinical supervisor to ensure the type and frequency of treatment and reghabilitation services is clearly identified.. |
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 on the review of client records, the facility failed to document treatment plan updates to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in seven out of ten records.
The findings include:
On November 9-10, 2011, ten client records requiring treatment plan updates were reviewed. The facility did not document a treatment plan update to include an assessment of the client's progress in 7 of 10 client records reviewed, # 1, 2, 5, 6, 8, 9 and 10.
Client # 1 was admitted on 5/18/11. The treatment plan update in client # 1's record dated 8/30/11 did not include an assessment of progress.
Client # 2 was admitted on 7/18/11. The treatment plan update in client # 2's record dated 8/11/11 did not include an assessment of progress.
Client # 5 was admitted on 9/7/11. The treatment plan update in client # 5's record dated
10/5/11 did not include an assessment of progress.
Client # 6 was admitted on 5/10/11. The treatment plan update in client # 6's record dated 11/2/11 did not include an assessment of progress.
Client # 8 was admitted on 8/1/11. The treatment plan update in client # 8's record dated 10/16/11 did not include an assessment of progress.
Client # 9 was admitted on 4/13/11. The treatment plan update in client # 9's record dated 6/30/11 did not include an assessment of progress.
Client # 10 was admitted on 3/23/11. The treatment plan update in client # 10's record dated 5/10/11 did not include an assessment of progress.
The findings were confirmed by the clinical supervisor on November 10, 2011.
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Plan of Correction
Effective 12/02/2011 all clinical staff will be updated in their training to document treatment plan updates to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan. This will be presented by a clinical supervisor during regular weekly training sessions by 12/23/2011. Treatment plans will be reviewed with clincians during regular clinical supervision ongoing with the clinical supervisor to ensure treatment plan updates include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan. |