INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 3 -5, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cornell Abraxas I 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the employee personnel records, the facility failed to document the required period of close supervision for one counselor assistant.
The findings include:
Five personnel records were reviewed on February 3, 2015. One of the five personnel records reviewed was for the position of counselor assistant. The counselor assistant represented in record # 4, was hired on September 28, 2014. The counselor assistant meets the educational requirements, but not the experiential requirements. The counselor assistant is required to have close supervision documented for six months. Supervision notes were not documented for the months of October 2014, November 2014, December 2014 and January 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the case of the counselor assistant represented in record #4, the Clinical Director met with the Treatment Supervisor II responsible for completing close supervision with this counselor assistant to review the close supervision requirements. The Clinical Director and the Treatment Supervisor II met with the counselor assistant to explain how close supervision will be observed. The Treatment Supervisor II began close supervision with this counselor assistant on February 11, 2015. Close supervision of this counselor assistant will continue for six consecutive months.
Moving forward, the Clinical Director will be responsible for reviewing the educational and experiential requirements for all counselor assistant candidates. The Clinical Director will consult with the Human Resources Coordinator and Quality & Compliance Specialist regarding counselor assistant candidates. The Clinical Director will complete a memo outlining the candidate's status in relation to the educational/experiential requirements and the required level of supervision. This memo will be electronically provided to the Facility Director, Quality & Compliance Specialist, Human Resources Coordinator, Program Manager, and the Treatment Supervisor II. The original, signed memo will be maintained in the candidate's personnel file.
The Clinical Director will review counselor assistant supervision requirements with all Treatment Supervisors. Treatment Supervisors will be required to document weekly conference notes indicating services that were observed for the week, as well as providing an overview of the discussion with the counselor assistant. The Clinical Director will conduct monthly chart audits of counselor assistant supervision files, to verify that the supervisory conferences are being documented consistently. The Clinical Director will present her findings to the Leadership Team during regularly scheduled meetings.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, a review of the facility summary report, and a conversation with the Quality & Compliance Specialist, the facility failed to provide documentation of HIV/AIDS training for two of six personnel.
The findings include:
Five personnel records and the facility summary report were reviewed on February 3, 2015. Six personnel were required to have documentation of HIV/AIDS training. The facility did not provide documentation of the required HIV/AIDS training for personnel #4 and 5.
Employee # 4 is a counselor and was hired on September 16, 2013. HIV/AIDS training was to be completed within one year of hire, by September 16, 2014. The facility failed to provide documentation of HIV/AIDS training.
Employee # 5 is a Clinical Supervisor and was hired August 5, 2013. HIV/AIDS training was to be completed within one year of hire, by August 5, 2014. The facility failed to provide documentation of HIV/AIDS training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 and Employee #5 will attend the scheduled 6 hour HIV/AIDS training at Abraxas I on March 5, 2015.
Also beginning March 5, 2015, the Training Department will forward a copy of all HIV/AIDS and TB/STD training rosters to the Quality & Compliance Specialist. The Quality & Compliance Specialist will then update the DDAPL Staffing Report with the training hours completed for each employee in the DDAPL licensed programs.
The Quality & Compliance Specialist will update the DDAPL Staffing Report no less than once per quarter.
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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 on a review of client records, the facility failed to document an informed and voluntary consent from the client prior to disclosure of information in four of ten client records.
The findings included:
Ten client records were reviewed on February 4-5, 2015. Ten client records were required to document an informed and voluntary consent from the client prior to the disclosure of information.
Client #1 was admitted to treatment on July 8, 2014 and was discharged on October 7, 2014. A release of information for a funding source was signed on July 8, 2014, but did not include the name of the person, agency or organization to whom disclosure is made.
Client #2 was admitted to treatment on May 28, 2014 and was discharged on August 29, 2014. Documentation included phone calls and progress notes for a parent and grandparents, but release of information forms were not signed for the family members. Documentation included a phone call on July 6, 2014, a phone call on July 15, 2014, a family session on July 19, 2014, and a family session on August 9, 2014.
Client #5 was admitted to treatment on September 11, 2014 and was discharged on December 11, 2014. A release of information for a funding source was signed on September 11, 2014, but did not include the name of the person, agency or organization to whom disclosure is made.
Client #7 was admitted to treatment on September 26, 2014. A release of information for a funding source was signed on September 26, 2014, but did not include a relevant purpose.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
During the March 2015 Team Meetings, the Program Manager and Quality & Compliance Specialist will conduct a 1 hour training with direct care employees and supervisors on how to properly complete consent to release information forms and the purposes for doing so.
During the April 2015 Counselor Meetings, the Clinical Director and Quality & Compliance Specialist will conduct a 30 minute refresher training with Counselors, Counselor Assistants and Treatment Supervisors on how to properly complete consent to release information forms and the purposes for doing so.
The Quality & Compliance Specialist will complete quarterly chart audits on a random sample of client charts to verify consent to release information forms are completely and accurately documented.
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