INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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 February 18, 2010.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy and procedure manual and an interview with the facility director, the facility failed to document an assessment of staff training needs, as required by regulation.
The findings include:
On January 20, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, the assessment forms are to be distributed to each employee on May 1, and the forms are to be returned to the clinical supervisor on May 31. The regulation requires an assessment of staff training needs to be completed as a component of a staff development program. The facility failed to document the completion of a staff training needs assessment for the July 1, 2009- June 30, 2010 training year.
The facility director/clinical supervisor was interviewed on January 21, 2010. The facility director/clinical supervisor confirmed that an assessment of staff training needs was not completed for the July 1, 2009- June 30, 2010 training year.
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Plan of Correction
Due to the transition of our QA/Compliance Co-ordinator over the last year, the training plan, including the needs assessment was overlooked. As the Compliance Officer is responsible for assuring we are up to date and in compliance with regulations, he will be responsible for notifying the Facility Director that a needs assessment is due. This will prompt him to distribute and collect the needs assessment forms to the Drug and Alcohol Staff in accordance with our policy. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy and procedure manual and an interview with the facility director/clinical supervisor, the facility failed to document an overall plan for addressing training needs, as required by regulation.
The findings include:
On January 20, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, a training plan will be completed by June 30. The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. The facility failed to document an overall training plan for the July 1, 2009 - June 30, 2010.
The facility director/clinical supervisor was interviewed on January 21, 2010. The facility director/clinical supervisor confirmed that a plan for addressing training needs of staff was not completed for the July 1, 2009- June 30, 2010 training year.
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Plan of Correction
Due to the transition of our QA/Compliance Co-ordinator over the last year, the training plan, including the needs assessment was overlooked.
As previously noted, the Facility Director will receive the needs assessment from the Drug and Alcohol staff by May 31st. The director will then develop the plan for the following fiscal year based on this information.
Due to the the brief period remaining in this fiscal year, this will go into effect May 1,2010 for the 2010/2011 fiscal year. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the policy and procedure manual and an interview with the facility director/clinical supervisor and the Quality Assurance/Compliance Coordinator, the facility failed to document an annual evaluation of the overall training plan, as required by regulation.
The findings include:
On January 20, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, an annual review of the training plan will be completed by July 31. The regulation requires an annual evaluation of the overall training plan to be completed as a component of a staff development program. The facility failed to document the completion of an annual evaluation of the overall training plan for the July 1, 2008 - June 30, 2009 training year.
The facility director/clinical supervisor and the Quality Assurance/Compliance Coordinator was interviewed on January 21, 2010. The facility director/clinical supervisor and the Quality Assurance/Compliance Coordinator confirmed that an annual evaluation of the overall training plan was not completed for the July 1, 2008 - June 30, 2009 training year.
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Plan of Correction
Due to the transition of our QA/Compliance Co-ordinator over the last year, the training plan, including the needs assessment was overlooked.
As the Compliance Co-ordinator is responsible for assuring timely compliance with regulations, he will prompt the Facility Director to review the plan for the pior year and assess its effectiveness.
Due to the the brief period remaining in this fiscal year, this will go into effect June 30, 2010 for the 2010/2011 fiscal year. |
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.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of individual training plans in five of five personnel records reviewed.
The findings include:
Five personnel records were reviewed on January 21, 2010. Individual training plans were required in five personnel records. The facility did not document individual training plans for the July 1, 2009 - June 30, 2010 training year in personnel records # 1, 2, 3, 4, and 5.
The employee represented by personal record #1 was hired November 9, 1998. An individual training plan was not completed for the July 1, 2009 - June 30, 2010 training year.
The employee represented by personal record #2 was hired November 2, 2009. An individual training plan was not completed for the July 1, 2009 - June 30, 2010 training year.
The employee represented by personal record #3 was hired June 23, 2008. An individual training plan was not completed for the July 1, 2009 - June 30, 2010 training year.
The employee represented by personal record #4 was hired June 23, 2008. An individual training plan was not completed for the July 1, 2009 - June 30, 2010 training year.
The employee represented by personal record #5 was hired June 14, 2004. An individual training plan was not completed for the July 1, 2009 - June 30, 2010 training year.
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Plan of Correction
As noted previously, the planning and evaluation for training was not completed for this fiscal year due to an oversight.However, training was provided in accordance with individual needs, though not documented in that manner.
An individual training needs assessment and plan will be developed for each drug and alcohol therapist prior to each new fiscal year. The plan will be done concurrently with the overall department needs assessment during the month of May. This will allow for planning for budget concerns if they arise.The training plan will be the responsibility of the supervisor and the therapist.
Due to the the brief period remaining in this fiscal year, this will go into effect May 1,2010 for the 2010/2011 fiscal year. |
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 records, the facility failed to document the instruction of staff in the use of the fire extinguisher within seven days of staff employment, in one of one personnel records.
The findings include:
Five personnel records were reviewed. One personnel record required documentation of fire extinguisher training. The facility failed to document the completion of fire extinguisher training within seven days of employment in personnel record # 2.
Employee # 2 was hired on November 2, 2009. The training was due within seven days, by November 11, 2009. The training was documented on November 16, 2009, which is later than the seven days required.
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Plan of Correction
Due to the variety of programs housed under CCC, a monthly training is held for new employees. Since it is held monthly, the HR Director and the Supervisor will make every effort to co-ordinate the first date of hire with the the scheduled training for the month, assuring the training will occur within the time frame required. In the event that this is not possible, an individual training will be provided on the first day of hire to assure comliance.
These changes will be efective immediately, February 22,2010. |
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 records, the facility failed to ensure that all personnel on all shifts are trained upon employment to perform assigned tasks during emergencies, in one of one personnel records.
The findings include:
Five personnel records were reviewed. One personnel record required documentation of the emergency training. The facility failed to document the completion of emergency training within seven days of staff employment in personnel record # 2.
Employee # 2 was hired on November 2, 2009. The training was due within seven days, by November 11, 2009. The training was documented on November 16, 2009, which is later than the seven days required.
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Plan of Correction
Due to the variety of programs housed under CCC, a monthly training is held for new employees which includes emergency protocols. Since it is held monthly, the HR Director and the Supervisor will make every effort to co-ordinate the first date of hire with the the scheduled training for the month, assuring the training will occur within the time frame required.
In the event that this is not possible, an individual training will be provided on the first day of hire to assure comliance.
These changes will be efective immediately, February 22,2010. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative polices and procedures and an interview with the Quality Assurance/Compliance Coordinator, the facility failed to document that the project director affixed his/her signature documenting an annual update of the written manual delineating project polices and procedures.
The findings include:
The administrative policies and procedures were reviewed on January 20, 2010. The project director failed to document the annual update of the written project policies and procedures, as required by regulation.
The Quality Assurance/Compliance Coordinator was interviewed on January 20, 2010. The Quality Assurance/Compliance Coordinator reports the policy and procedure manual was prepared and annually updated, but could not find documentation that this had occurred.
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Plan of Correction
Administrative update of policies and procedures occur through out the year, and are signed by the Project director before becoming effective.
However, the overall manual was not documented as being reviewed for the year. The Compliance Co-Ordinator will be responsible to prompt the Project Director to review the manual and to document the review with a signature and the date of review. This review shall occur at the beginning of the fiscal year, to be completed by July 31.
The manual has been reviewed for this fiscal year.
Correction is effective immediately. |
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 a review of client records and an interview with the facility director, the facility failed to document treatment plan updates within the sixty day time frame in two of two client records.
The findings include:
Eight client records were reviewed on January 21, 2010. Two of the eight client records were required to have treatment plan updates. Per the facility policy, treatment plan review and updates are required to be completed every sixty days. The facility failed to document treatment plan review and updates within sixty days, in client records # 1 and 6.
In client record # 1, the client was admitted on July 10, 2009. The comprehensive treatment plan was completed on August 7, 2009. The first treatment plan update was due no later than October 7, 2009 and was completed on October 8, 2009. The second treatment plan update was due by December 7, 2009 and was completed December 15, 2009. Both of the treatment plan updates were completed late.
In client record # 6, the client was admitted on March 12, 2009 and the client was discharged September 3, 2009. The comprehensive treatment plan was completed on April 2, 2009. The first treatment plan update was due no later than June 2, 2009. It was completed June 3, 2009. The second treatment plan update was due August 2, 2009. The facility failed to document the completion of the second treatment plan update.
The director confirmed the treatment plan updates were not completed within the 60 day timeframe.
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Plan of Correction
CCC uses an electronic medical record for all documentation. A feature of the software is an ability to prompt the therapist when an update is due prior to that date.
In this case, the update notification was not set at the correct time frame for the treatment plan to be completed on time. We have since changed the prompting date to an earlier time frame and informed the staff of the changes. This should eliminate this problem.
Additionally, a chart audit will be initiated in the next quarter. This will provide an ongoing review of charts to determine compliance.
Th EMR changes were put into effect immediately following the licensing visit in January 2010.The audits will begin in April,2010. |
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 on a review of client records and an interview with the facility director, the facility failed to document case consultations within the sixty day time frame in two of two client records.
The findings include:
Eight client records were reviewed on January 21, 2010. Two of the eight client records were required to have treatment plan updates. Per the facility policy, case consultations are required to be completed every sixty days. The facility failed to document case consultations within sixty days, in client records # 1 and 6.
In client record # 1, the client was admitted on July 10, 2009. The first case consultation was due no later than October 7, 2009. The facility failed to document the first case consultation. The second case consultation was due no later than December 7, 2009, and it was done late on December 15, 2009.
In client record # 6, the client was admitted on March 12, 2009 and the client was discharged September 3, 2009. The first case consultation was due no later than June 2, 2009. It was completed June 3, 2009. The second case consultation was due August 2, 2009. The facility failed to document the completion of the second case consultation.
The director confirmed the case consultations were not completed within the 60 day timeframe.
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Plan of Correction
CCC uses an electronic medical record for all documentation. A feature of the software is an ability to prompt the therapist when an update is due prior to that date. Case Consultations are done in conjunction with the treatment plan updates.In this case, the update notification was not set at the correct time frame for the treatment plan to be completed on time therefore making the case consult late also. We have since changed the prompting date to an earlier time frame and informed the staff of the changes. This should eliminate this problem.
Additionally, a chart audit will be initiated in the next quarter by the Quality Assurance Co-ordinator and his committee. This will provide an ongoing review of charts to determine compliance with all required documentation.
The EMR changes were put into effect immediately following the licensing visit in January 2010.The audits will begin in April,2010.
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