INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 15, 2007 to March 16, 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 April 16, 2007.
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Plan of Correction
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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 employee designated as the facility director does not meet the qualification requirements.
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Plan of Correction
There was confusion about this issue. James Vernarsky , Chief Operating Officer, for Pyramid was the Interim Director and is qualified for the position. Matt Thompson, Education Director, for Ridgeview served as the onsite Director as James was there on a weekly basis. Matt did not meet qualifications for Program Director. Matt maintained daily contact with James regarding the ongoing operations during the search period for a new Program Director. A new Program Director for Ridgeview, Marnie Hall, began on March 19, 2007. Marnie meets requirements for Program Director. Effective March 19, 2007 any confusion on the issue was resolved. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Feedback forms were not consistently documented for all staff reviewed.
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Plan of Correction
Kimberly Umstead, HR Assistant, sent notice via email to all Program Directors and Supervisors in early March 2007, informing of the regulation/policy requiring the
collection of feedback on all completed trainings. The HR Department is ensuring compliance with this standard by monitoring all submitted training certificates, and not issuing credit for the training until the evaluation is completed and submitted to Human Resources. Rick Knab, HR Director, is responsible for the overall organizational compliance with this standard. Target date for completion was March 15, 2007.
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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
For the week of February 25 to March 3, 2007 overnight coverage of CPR and First Aid was not documented.
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Plan of Correction
Patty Case will provide a written weekly schedule of 24 hour staff coverage that reflects staff qualified to administer CPR and First Aid. All schedules will be maintained in a binder for one year to allow access to this information. Marnie Hall, Program Director will monitor at least monthly for compliance. Target date for completion is April 20, 2007. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The documentation of the drug and alcohol history failed to include sufficient detail relating to the patterns of usage, specifically the client's progression of substance use and abuse.
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Plan of Correction
Marnie Hall, Program Director, and Amy Shanafelt, Director of Clinical Services, will revise the current form to accurately assess and document the client's progression of substance use and abuse. Upon approval from the forms committee, Marnie Hall will train the counselors on the correct completion of the document. Compliance will be monitored by Marnie Hall and/or Clinical Supervisor during monthly chart audits. Target date for completion is May 18, 2007. |
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
Progress notes lacked consistent documentation of topic in the data part of the notes in client charts reviewed.
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Plan of Correction
Marnie Hall, Program Director, and Amy Shanafelt, Clinical Services Director, will revise the group note to reflect the topic of group. Upon approval from the forms committee, Marnie Hall will train the counselors on the correct completion of the document. Compliance will be monitored by Marnie Hall and/or Clinical Supervisor during monthly chart audits. Target date of completion is May 18, 2007. |
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
The manual at the main administrative office and the manuals at the various locations reviewed were not consistent with regard to policies and procedures. The general organization of the manual made the review difficult and increased the potential for misunderstanding the intent of various procedures.
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Plan of Correction
The Master Policy Manual will be reviewed by Jason
Hendricks, Policy Coordinator, and the Chief Operating
Officers from each division (Adult Residential, Adolescent Residential and Outpatient). The purpose of this review is to 1) ensure consistency of policies across the organization, and 2) to re-organize the Master manual, separating out Drug and Alcohol Program policies from DPW-licensed Program policies, ensuring ease of access to the policies, and diminishing the potential for misunderstanding of the intent of the policies/procedures. Jason Hendricks will be responsible for ensuring that the Table of Contents accurately reflects the content of the manual. Jonathon Wolf, CEO/Project Director, will be responsible for ensuring timely completion of this project. Target date for final completion of this project is June 1, 2007. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Drug and Alcohol histories in client records #1, 3, 4, 5 and 8 lacked sufficient detail in the client's patterns of usage, specifically relating to the client's progression of substance use and abuse.
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Plan of Correction
Marnie Hall, Program Director, and Amy Shanafelt, Director of Clinical Services, will revise the current form to accurately assess and document the client's progression of substance use and abuse. Upon approval from the forms committee, Marnie Hall will train the counselors on the correct completion of the document. Compliance will be monitored by Marnie Hall during monthly chart audits. Target date for completion is May 18, 2007. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
The record of service was missing dates where treatment was completed in client records #3, 4 and 5.
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Plan of Correction
Marnie Hall, Program Director, will be responsible for ensuring that a record of service is completed for every client record. Marnie Hall will train the counselors on the expectations of completion of the Record of Service. Marnie Hall will ensure compliance by doing monthly chart audits, as well as following up with the counselor in regularly scheduled supervision sessions. Target date for final completion of this target is April 27, 2007. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Progress notes lacked consistent documentation of topic in the data part of the notes in client records reviewed.
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Plan of Correction
Marnie Hall, Program Director, and Amy Shanafelt, Clinical Services Director, will revise the group note to reflect the topic of group. Upon approval from the forms committee, Marnie Hall will train the counselors on the correct completion of the document. Compliance will be monitored by Marnie Hall during monthly chart audits. Target date of completion is May 18, 2007. |