INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 22, 23 and 24, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Addiction Medicine and Health Advocates, Inc. 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 August 15, 2008.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel and training records on July 22, 2008, the facility failed to document that the clinical supervisor completed a core curriculum in clinical supervision. The clinical supervisor, hired for that position in 2/02, did not have documentation of two years of prior experience as a supervisor in the provision of clinical services.
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Plan of Correction
We have contacted BDAP and were informed that the next clinical supervision training is tentatively scheduled for November 2008. We will register our clinical coordinator for this training once registration opens. The Executive Director will be responsible for making sure the clinical coordinator meets this requirement. |
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 training records on 7/22/08, the facility failed to document an individual training plan for the employee in nine of nine personnel records reviewed, #1, 2, 3, 4, 5, 6, 7, 8 and 9. The training plans were identical for each employee and did not include any subject areas from the training needs assessments.
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Plan of Correction
We will revise our training plans to include an individualized section for each staff person. This section wil identify trainings scheduled for each staff person related to training needs identified on thier needs assessment form. The training coordinator will be responsible for completing and implementing this revision. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel and training records on 7/22/08, the facility failed to document 25 clock hours of training for the 2007 training year for two of four counselors reviewed, #3 and 5.
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Plan of Correction
The training coordinator will be responsible for scheduling each counselor for a minimum of 25 hours annually. These hours will include trainings consistent with the required areas listed in the regulations. The clinical coordinator will monitor each counselor's adherence to their training plan. |
704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of administrative documents on 7/22/08, the facility failed to document that the caseload for each counselor did not exceed 35 active clients. Five of nine counselor caseloads exceeded 35 active clients.
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Plan of Correction
AMHA is currently in the process of recruiting new counselors. Recruiting is done via the Philadelphia Inquirerer and Monster.com. With the hiring of additional counselors, we will be able to reduce caseload size to under 35. The Clinical Coordinator and Executive Director will be responsible for the recruitment and hiring of new counselors.
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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 for the disclosure of information in eight of eight client records reviewed. Information was released without consent to Technow and/or Atlantic Lab in client records #1, 2, 3, 4, 5, 6, 7 and 8. The clients signed a general consent form which did not meet the criteria for an informed and voluntary consent. Additionally the facility did not have a Qualified Service Organization Agreement for TechNow, Inc. or Atlantic Lab.
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Plan of Correction
AMHA has been in contact with TechNow, now known as Atlantic Diagnostic Laboratories, to secure a QSOA. This will be completed by the Executive Director by 8/30/08. |
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 on 7/23 and 7/24/08, the facility failed to document a complete treatment plan update in seven of eight client records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8. Treatment plan updates did not include an assessment of the client's progress in relationship to all of the stated goals of the prior treatment plan in client records # 2, 4, 5 and 8. Treatment plan updates did not include the disposition of all goals from the prior treatment plan in client records # 3, 5, 6 and 7. Additionally the treatment plan update for client record # 1 was due on 3/8/08 but was not completed until 4/4/08.
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Plan of Correction
AMHA will conduct a treatment planning review during a staff meeting to discuss the deficiencies noted during the licensing review. Ongoing training will be provided to all counselors to assure compliance. The clinical coordinator will be responsible for monitoring compliance and providing training. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records on 7/23 and 7/24/08, the facility failed to document follow-up information in five of six client records reviewed, #7, 8, 10, 11 and 12.
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Plan of Correction
AMHA will complete follow-up with each discharged patient by having the counselor attempt post-discharge contact via telephone or letter. This will be documented on the Follow-up form located in the discharge section of the patient record. In addition, a post-discharge survery is completed with each discharged patient to assess their current needs. This information is kept by the receptionist in the computer on an excel spreadsheet. The clinical coordinator will be responsible for compliance with this process. |