INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 16 through 17, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of one record reviewed.
Findings:
Nine personnel records were reviewed on May 16, 2012. In personnel record #4, the counselor did not meet the qualifications for the position of counselor based on the fact that he had not obtained his Master's degree when hired and his Bachelor degree did not meet for the qualification for a counselor. An interview with the project director on May 17, 2012 confirmed the findings.
|
Plan of Correction
The Executive Assistant was provided the bulletin, distributed by the Department of Health on March, 2010, that lists which degrees are acceptable. The Executive Assistant screens all resumes prior to forwarding to Executive Director for decision to schedule an interview. The Executive Assistant was given a copy of this bulletin by the Executive Director on 5/17/2012 for future reference. The counselor involved in this citation received the actual degree document on May 12, 2012 (See attached) |
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.
|
Observations
Based on a review of the facilities staff schedule work hours and the Fist Aid and CPR certification cards, the facility failed to provide a sufficient number of staff persons trained in CPR and First Aid during the project's hours of operation.
The findings include:
The CPR certification cards and First Aid certification cards were reviewed on May 16, 2012. The facility's hours of operation are; Monday through Thursday 9 am - 9 pm, Friday 9 am - 5 pm and Saturday 9 am - 1 pm. There were only one staff documented having a current CPR certification on varied shifts, show insufficient coverage.
Monday - Lack of sufficient coverage 7:30 pm to 9 pm
Wednesday - Lack of sufficient coverage 5 pm to 5:30 pm
Saturday - Lack of sufficient coverage 9 am to 1:30 pm
An interview with project director on May 16, 2012 confirmed the findings.
|
Plan of Correction
The Executive Director has scheduled a plan to review the First Aid/CPR coverage grid on a quarterly basis. This quarterly monitoring of the coverage grid will allow for a timely adjustment when there is a change or projected change in staff working hours or personnel. This grid of staff coverage for First Aid/CPR will be reviewed and staff scheduling adjustments will be made to assure that a minimum of two (2) staff members are scheduled during our hours of operation. This adjustment by the Executive Director will occur by June 30, 2012. |
704.12(a)(5) LICENSURE Partial Hosp Ratio
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on May 16, 2012, the facility failed to ensure that the staff to client ratios remained at or below 10:1.
The findings include:
On May 16, 2012 the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed the project director/facility director, clinical supervisor and three counselors for the clinical staff. However, one of the counselors did not meet the educational qualification for the position and had to be demoted to counselor assistant and could not include his hours into the ration equation, and the counselor assistant is currently in the direct observation supervision period.
The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40), and the total number of current clients as of May 16, 2012 exceeded the allowable maximum of 10:1.
The actual client ratio is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients treatment by the facility's standard work week.
The number of hours per week for the facility director, clinical supervisor and counselors was 48 hours. 48 divided by the facility work week of 40 hours equals 1.2 FTE. The number of current clients is 13 divided by the 1.2 FTE is 10.8333333333. This results in a ratio of 11:1 which exceeds the maximum of 10:1.
|
Plan of Correction
The Executive Director will make the necessary adjustments to the clinical workforce to assure adequate, required time is devoted to each partial hospitalization client. The Executive Director will check that these adjustments do not exceed the 10:1 maximum ratio by applying the standard formula. This will be achieved by June 29, 2012. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
|
Observations
Based on the physical plant tour, the facility failed to ensure that all exits were unobstructed.
The findings include:
The physical plant tour took place on May 17, 2012. At around 3:35 pm, it was observed that the exit on the 2nd floor, the second exit to the deck was stuck and was difficult to open. This licensing inspector informed the project director and he also struggled to open the exit, confirming the findings of the licensing specialist.
|
Plan of Correction
On June 29th the Executive Director contacted the maintenance group that services and makes repairs to all the Lemoyne properties. They will repair or replace sticking door if necessary on Saturday June 30, 2012. The Executive Director will observe this work to confirm that the doors open properly. |
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.
|
Observations
Based on a review of the fire drill record, the facility failed to document four of twelve monthly fire drills.
The findings include:
The fire drill record was reviewed on May 16, 2012. The fire drill record was reviewed from June 2012 to May 2012. Four of those twelve months did not document that a fire drill was conducted. Documented fire drills were not recorded for April 2011, June 2011, February 2012 and April 2012. This was confirmed with the director on May 16, 2012.
|
Plan of Correction
The Executive Assistant is ultimately responsible to make sure that a fire drill takes place on a monthly basis at both the Lemoyne and York locations. This activity is documented on the fire drill log with a copy forwarded to the Executive Assistant. Any gaps in these monthly drills should be reported to the Executive Director. The Executive Assistant will remind the support person conducting the fire drill on monthly basis and will point out any required variances with exit routes (blocked route) and times of day. The Executive Director will inform the Executive Assistant to regularly monitor this activity by June 30, 2012. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in eight of eight client records.
The findings include:
Sixteen client records were reviewed on May 17, 2012. Eight of the sixteen was reviewed from the partial hospitalization activity, #9, 10, 11, 12, 13, 14, 15 and 16. A psychosocial evaluation was required in eight client records, #9, 10, 11, 12, 13, 14, 15 and 16. An interview with facility staff on May 17, 2012 confirmed the findings.
The psychosocial evaluations in client records #9, 10, 11, 12, 13, 14, 15 and 16 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #9, 10, 11, 12, 13, 14 and 15 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #9, 10, 11, 12, 13, 14, 15 and 16 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #9, 10, 12, 13 and 15 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluation in client records #11 and 15 did not include an evaluation of the client's attitude toward treatment and how it would impact treatment.
The psychosocial evaluation in client records #11, 12 and 15 did not include an evaluation of the counselor conclusions/impressions of the client.
|
Plan of Correction
The Clinical Coordinator will review with the clinical staff in the staff meeting on 7/18/12 that all composite pictures/psychosocial evaluation of the client must include the clients problems/needs, assets/strengths and how they would impact treatment, support systems and how they would relate to treatment, coping mechanisms and how they would relate to or impact treatment, negative factors and how they would impact treatment and the counselor's conclusions and impressions of the client including the client's attitude toward treatment and how it would impact treatment. Examples will be provided. The Clinical Coordinator will randomly audit charts for compliance by random audits of one clinical chart at each clinical supervision for 6 months. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
|
Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, showing that it is for 24-hour emergency medical and psychiatric coverage.
The findings include:
The letters of agreements were reviewed on May 17, 2012. The only letter of agreement regarding 24- hour emergency medical and psychiatric coverage was signed with a local hospital. The agreement failed to document that it has coverage 24 hours a day 7 days a week for medical and psychiatric coverage.
An interview with the project director on may 16, 2012 confirmed the findings.
|
Plan of Correction
The Emergency Medical/Psychiatric coverage at Holy Spirit Hospital did not indicate that their coverage was for (24) hours and (7) days a week. The Executive Director will request an addendum to our current agreement that will clearly state when that coverage is available. This request will occur on June 27, 2012 with a target date of compliance set for July 15, 2012. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
|
Observations
Based on a review of administrative policies and procedures, the facility failed to complete the 2010-2011 audit by the end of the project's fiscal year, as required by regulation.
The findings include:
The administrative policies and procedures were reviewed on May 16, 2012. Per regulation, the project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The project's fiscal year is from July through June. The project's audit for July 1, 2010 through June 30, 2011 was due to be completed no later than December 31, 2011. The project failed to document the completion of an annual audit for the 2010-2011 fiscal year.
An interview with the project director on May 16, 2012 confirmed the findings.
|
Plan of Correction
The Bookkeeper will be responsible to arrange for the annual audit that will allow for adequate time to have it completed by the accounting firm before December 31st of each year. Therefore, an initiative will take place to schedule the audit in August (or) September to assure completion prior to that deadline. The accounting firm will be contacted to schedule the audit by June 29, 2012. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in eight of eight client records.
The findings include:
Sixteen client records were reviewed on May 17, 2012. Eight of the sixteen was reviewed from the outpatient activity, #1, 2, 3, 4, 5, 6, 7 and 8. A psychosocial evaluation was required in eight client records, #1, 2, 3, 4, 5, 6, 7 and 8. An interview with facility staff on May 17, 2012 confirmed the findings.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluation in client records #3 and 4 did not include an evaluation of the client's attitude toward treatment and how it would impact treatment.
The psychosocial evaluation in client records #2, 3, 4, 5, 6 and 7 did not include an evaluation of the counselor conclusions/impressions of the client.
|
Plan of Correction
The Clinical Coordinator will review with the clinical staff in the staff meeting on 7/18/12 that all composite pictures/psychosocial evaluation of the client must include the clients problems/needs, assets/strengths and how they would impact treatment, support systems and how they would relate to treatment, coping mechanisms and how they would relate to or impact treatment, negative factors and how they would impact treatment and the counselor's conclusions and impressions of the client including the client's attitude toward treatment and how it would impact treatment. Examples will be provided. The Clinical Coordinator will randomly audit charts for compliance by random audits of one clinical chart at each clinical supervision for 6 months. |
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.
|
Observations
Based on a review of client records, the facility failed to document in the treatment plan update the client's progress as it relates to the goals identified in the individualized treatment and rehabilitation plan.
The findings were:
Sixteen client records were reviewed on May 17, 2012. Of the sixteen, eight were from the outpatient activity, #1, 2, 3, 4, 5, 6, 7 and 8. Of the eight six were required to show documentation of a treatment plan update, #1, 2, 3, 4, 5 and 6. It was determined that the therapist failed to document in the treatment plan update the client's progress as it related to the the goals identified in the individualized treatment and rehabilitation plan, #2, 3 and 4. Additionally, per the facility's policy, treatment plan updates are to be completed within 60 days of the comprehensive treatment plan.
Client #7's comprehensive treatment plan was completed on January 27, 2012 and their update completed on April 3, 2012, 7 days from the required 60 day update of March 27, 2012.
An interview with facility staff on May 17, 2012 confirmed the findings.
|
Plan of Correction
The Clinical Coordinator will review with the clinical staff in the staff meeting on 7/18/12 that all treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. It will also be reviewed that it is to be documented in the treatment plan update the progress as it relates to the goals identified in the individualized treatment plan. Examples will be provided. The Clinical Coordinator will monitor for compliance by reviewing treatment plan reviews when they are submitted for supervisor signature for 6 months. Each counselor is to submit their active client list at each bi-weekly supervision session. At that time a review of deadline dates for treatment plans, updates and case reviews will take place. |
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.
|
Observations
Based on a review of client records, the facility failed to document a case consultation within the 90 day time frame in two of six client records.
The findings include:
Sixteen client records were reviewed on May 17, 2012. Eight of the sixteen was reviewed from the outpatient activity, #1, 2, 3, 4, 5, 6, 7 and 8. A case consultation was required in six client records, #1, 2, 3, 4, 5 and 7. Per the facility's policy, case consultations will take place every 90 days for the 1st year of treatment. An interview with facility staff on May 17, 2012 confirmed the findings.
Client # 2 was admitted on January 3, 2012 and their case consultation was due by April 5, 2012. The case consultation was completed on May 9, 2012, 34 days past the required 90 day time frame.
Client # 7 was admitted on January 6, 2012 and discharged on April 19, 2012. Their case consultation was due by April 6, 2012. As of the date of client #7's discharge date April 19, 2012 there was no documentation of their case consultation.
|
Plan of Correction
The Clinical Coordinator will review with the clinical staff in the staff meeting on 7/18/12 that all client records require a case consultation at minimum every 90 days. Examples will be provided. The Clinical Coordinator will randomly audit charts for compliance by random audits of one clinical chart at each clinical supervision for 6 months. Each counselor is to submit their active client list at each bi-weekly supervision session. At that time a review of deadline dates for treatment plans, updates and case reviews will take place. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to document goals with timeframes in the aftercare plan in two of three client records.
The findings include:
Sixteen client records were reviewed on May 17, 2012. Of the sixteen, eight were from the outpatient activity, # 1, 2, 3, 4, 5, 6, 7 and 8. Aftercare plans were required in three client records, #6, 7 and 8. The facility did not document goals with timeframes in the aftercare plans in client records #7 and 8.
|
Plan of Correction
The Clinical Coordinator will review with the clinical staff in the staff meeting on 7/18/12 that all client records require a complete aftercare plan, including time frames, for all positively discharged clients. Examples will be provided. The Clinical Coordinator will randomly audit charts for compliance by random audits of one clinical chart that has been discharged at each clinical supervision for 6 months |