INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on July 18, 2007 through July 19, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on August 13, 2007.
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Plan of Correction
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709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
The facility failed to demonstrate that employees were informed of their rights in two of two personnel records reviewed, #1 and 2.
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Plan of Correction
Action: Upon hire, staff will be verbally informed of rights and will be given an employee handbook.
Means: Staff will sign a form that they have been informed both verbally and through the handbook, of their rights. The form will be filed in their personnel binder
Person responsible: The employee's immediate supervisor will be responsible for ensuring that the described procedure occurs.
Project will be in full compliance by 9/4/07
Staff training Clinical Coordinator will train clinical supervisor in employee rights.
Supervisory follow up Clinical Coordinator will receive a copy of notification of employee rights form.
Staff person responsible Clinical Supervisor
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709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Job descriptions were not signed by the employee's supervisor in two of two records reviewed, #1 and 2.
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Plan of Correction
Action: Upon hire, staff will be provided a copy of their job description that is signed by their immediate supervisor. A copy of the description will be signed by supervisor and employee and will be filed in the personnel binder.
Means: The immediate supervisor will sign two (2) copies of the job description. One will be given to the employee. The other will be signed by the employee and filed in the personnel file.
Person Responsible: The employee's immediate supervisor will be responsible for ensuring that the described procedure occurs.
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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
Information was released to a clients's parents without client consent in one of three client records reviewed, #3. Parental signature lines were included on consents to release information, treatment plans and treatment plan updates in three of three records reviewed, #1, 2 and 3. Parental consent for disclosure of information and treatment planning is not mandated by state law and cannot be required. Consents to release contained "release to" and "received from" language in three of three records reviewed, #1, 2 and 3. The "receive from" language must be removed from the consent form since the law and regulation does not address or regulate entities wanting to obtain information. Entities may obtain information without any procedures or requirements.The consent to treatment form included a statement that allowed information to be disclosed without client consent in three of three records reviewed, #1, 2 and 3. This language must be removed from the consent to treatment form.
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Plan of Correction
Action: Clinical Supervisor will conduct supervision with all of the program's employees on confidentiality laws related to substance abuse.
Means: Satff will participate in a training presentation complete with handouts including C.F.R. 42, HIPAA regulations, and ACT 255.5 Regulations.
Project will be in full compliance by 9/17/07.Time is needed in order to have teaching staff return from summer vacation.
Supervisory follow up Clinical Coordinator will review training objectives and receive a copy of the training sign in sheet.
Staff person responsible Clinical Supervisor.
Staff Training will occur on confidentiality laws and guidelines with all staff.
Action: Releases have been revised. Parental signature lines have been removed. The "received from" has been removed.
Treatment plans have been revised. Parental signature lines have been removed.
Consent for treatment has been revised. The statement that allowed disclosure without client consent has been removed
Means: All forms are now in compliance accurate language.
Person Responsible: Clinical Supervisor
Project will be in full compliance by 7/30/07
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to ensure visual privacy for clients in one large group room and counselor's offices. Windows allowed for clients to be seen during counseling sessions.
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Plan of Correction
Action: Window coverings will be installed all windows within the program.
Means: Blinds will be ordered and installed to all windows
Person Responsible: Facilities Director will ensure that the blinds are ordered and installed
Project will be in compliance by 9/15/07
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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
The facility failed to provide documentation of fire extinguisher training in one of two personnel records reviewed, #1.
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Plan of Correction
Action: All staff will be trained and the training will be documented in the personnel file. Arrangements have been made with local fire department to facilitate this training.
Means: Staff will be trained upon hire and the training will be documented in the personnel file
Person Responsible: Facilities Director will be responsible to ensure that all staff are trained and it is documented in the file.
Project will be in full compliance by 10/1/07
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct monthly fire drills.
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Plan of Correction
Action: Program will conduct monthly unannounced fire drills
Means: Clinical Supervisor will coordinated the drills with the other on-site programs to ensure monthly drills are conducted
Person Responsible: Clinical Supervisor will ensure that unannounced fire drills occur monthly
Project will be in full compliance by 9/15/07
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705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
The facility failed to conduct monthly fire drills.
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Plan of Correction
Action: Program will conduct monthly, unannounced fire drills that occur during normal staffing conditions and are coordinated with other on site programs.
Person responsible: Clinical Supervisor will ensure that monthly unannounced drills are conducted during normal staffing conditions.
Project will be in full compliance by 9/15/07
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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
The facility failed to provide documentation of emergency training in two of two personnel records reviewed, #1 and 2.
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Plan of Correction
Action: Staff will be trained on the emergency procedures upon hire and that training will be documented in the personnel record by the Clinical Supervsior.
Person Responsible: Clinical Supervisor willl ensure that staff are trained upon hire and will ensure that the training is documented in the personnel record.
Project will be in full compliance by 10/1/07
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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
The facility failed to conduct monthly fire drills.
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Plan of Correction
Action: Program will conduct monthly, unannounced fire drills that occur during normal staffing conditions and are coordinated with other on site programs.
Person responsible: Clinical Supervisor will ensure that monthly unannounced drills are conducted during normal staffing conditions.
Project will be in full compliance by 9/15/07
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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
The facility failed to conduct monthly fire drills.
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Plan of Correction
Explanation for noncompliance: Program failed to conduct drill during normal staffing conditions.
Action: Program will conduct monthly, unannounced fire drills that occur during normal staffing conditions and are coordinated with other on site programs.
Person responsible: Clinical Supervisor will ensure that monthly unannounced drills are conducted during normal staffing conditions.
Project will be in full compliance by 9/15/07
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
The facility failed to conduct monthly fire drills.
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Plan of Correction
Action: Program will conduct monthly, unannounced fire drills that occur during normal staffing conditions and are coordinated with other on site programs.
Person responsible: Clinical Supervisor will ensure that monthly unannounced drills are conducted during normal staffing conditions.
Project will be in full compliance by 9/15/07
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
The facility failed to conduct monthly fire drills.
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Plan of Correction
Action: Program will conduct monthly, unannounced fire drills that occur during normal staffing conditions and are coordinated with other on site programs.
Person responsible: Clinical Supervisor will ensure that monthly unannounced drills are conducted during normal staffing conditions.
Project will be in full compliance by 9/15/07
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709.82(e)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
The facility failed to present documentation that dental services were available to clients if necessary.
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Plan of Correction
Action: Changes Program will enter into a Quality Service Agreement with a local dentist so that the program can refer clients when necessary.
Means: The Clinical Supervisor will develop a QSA and approach a local dentist practioner for the purposes of establishing a referral process.
Person responsible: Clinical Supervisor
Project will be in full compliance by 9/4/07. |
709.82(e)(3) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
The facility failed to present documentation that legal services were available to clients if necessary.
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Plan of Correction
Action: Changes Program will enter into a Quality Service Agreement with the counties Legal Aid Southeastern Pa., Chester County Office for referral services should a client require or desire legal assistance.
Means: The Clinical Supervisor will develop a QSA and approach the Legal Aid of Southeastern Pa.
Person Responsible: Clinical Supervisor
Project will be completed by 9/4/07. |
709.83(a)(9) LICENSURE Client records
709.83. 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:
(9) Progress notes.
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Observations
The facility failed to ensure that group progress notes included a plan for the next session in three of three client records reviewed, #1, 2 and 3.
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Plan of Correction
Action: Cinical Supervisor will provide instruction during indiviual supervision with clinical staff on proper documentation of group notes including " plan."
Means: Clinical supervisor will faciltate educating clinical staff on proper group documentation and review subsequent group notes as follow up.
Person Responsible: Clinical Supervisor
Project will be in full compliance by 7/30/07. |
709.84(e) LICENSURE Project management services
709.84. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
The facility failed to document follow-up information in two of two client records reviewed, #2 and 3.
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Plan of Correction
Action: Clinical Supervisor will provide instruction during individual supervision with clinical staff on follow up requirements, and the importance of having follow up contacts.
Means: Clinical Supervisor will develop a follow up contact form that is to be completed during regular time intervals by the client's primary therapist.
Staff Training: Clinical staff will be trained on the timeline guidelines for such follow-up and instructed on how to complete the follow up form.
Supervisory follow up : Clinical Supervisory will verify that follow up contacts and forms have been completed in the mandated time frame.
Staff Person Responsible: Client's primary therapist will complete follow up contacts. |
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
The facility failed to provide documentation of credentials for employee #3.
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Plan of Correction
Action: Upon hire, staff will provide all appropriate documentation regarding his/her credentials including degrees held, relevant certifications, relevant licenses, and relevant training attendance certificates including but not limited to CPR/First Aid, Safe Physical Restraint, Ethics, Confidentiality, Fire Safety Training, and Crisis Management.
Means: Human Resource Department will be advised of filed requirements, complete a checklist of all possible/necessary supping documentation, and maintain a copy of such documentation in the employees file.
Person Responsible: Clinical Supervisor will develop supporting documentation checklist.
Supervisory follow up: The Clinical Supervisor will review each checklist upon completion along with supporting documentation.
Staff training: Clinical Supervisor will train human resource department on required documentation.
Staff Person responsible human resource personnel as designated.
Project will be in full compliance by 9/10/07.
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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
The facility failed to identify time frames for completion of the assessment of staff training needs, the overall training plan and the annual evaluation of training needs in the policy and procedures for staff development.
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Plan of Correction
Action: The Chester County intermediate Units policy regarding training and staff assessment will be followed. Plans for staff training are developed on a yearly basis before August 1st.
Means: The plan is developed with staff input, and to comply with drug and alcohol treatment requirements, federal and state law, and Pennsylvania Department of Education initiatives. All staff at Changes will be provided with mandatory training as well as having opportunities to attend trainings on a voluntary basis. The Clinical Supervisor will provide the Assistant Director of Chester County Intermediate a list of training requirements for Changes Staff.
Person Responsible: The Assistant Director of Chester County Intermediate Unit Human resources is responsible for developing a staff development plan for employees however the Clinical Supervisor at Changes will provide a list of training requirements for staff at Changes by June 1 of each year.
Project will be in full compliance by 9/10/07.
The trainings will be provided throughout the year.
Supervisory follow up: The Clinical Supervisor is responsible for ensuring staff participation in required training, providing documentation of staff participation in required training on a yearly basis by June 30 to the Clinical Coordinator.
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility failed to provide documentation that any staff were certified in CPR and trained in first aid.
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Plan of Correction
Action: All staff will be enrolled in CPR Training.
Means: Contact will be made with local Red Cross to arrange CPR Training.
Person Responsible: Clinical Supervisor will monitor that all newly hired and current staff members receive and maintain current CPR Training.
Project will be completed by 9/20/07.
Staff Training: Each and every staff member will attend CPR Training and receive appropriate certification.
Supervisory follow up: Clinical Supervisor will monitor personnel files to ensure all staff members maintain CPR Certification.
Staff Person Responsible: Clinical Supervisor
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