INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 17-18, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Consortium 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 December 22, 2009.
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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 records, the facility failed to document a core curriculum in clinical supervision in two of three records.
The findings include:
Ten personnel records were reviewed on November 17-18, 2009. Of those ten records, three were clinical supervisors requiring documentation of a core curriculum in clinical supervision or at least two years of prior clinical supervisory experience. The facility did not document a core curriculum or prior supervisory experience in two of three clinical supervisors' personnel records, # 3 and 4.
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Plan of Correction
0031
704.6(c) Core Curriculum Supervisor Training
Responsible: Facility Director will be responsible to ensure that Clinical Supervisors attend and complete the core curriculum in clinical supervision.
Time Frame: Clinical Supervisors completed the DOH approved core curriculum in clinical supervision from December 7, 2009 through /December 11, 2009.
Monitoring: Facility Director will monitor that certificates of completion for core curriculum in clinical supervision is filed in staff personnel files in Human Resource
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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, the facility failed to document a minimum of 6 hours of HIV/AIDS and/or 4 hours of TB/STD training in two of five personnel records.
The findings include:
Ten personnel records were reviewed on November 17-18, 2009. Of those ten records, five required documentation of 6 hours of HIV/AIDS and 4 hours of TB/STD training. The facility did not document 6 hours of HIV/AIDS and/or 4 hours of TB/STD training in personnel records # 9 and 10.
Staff persons # 9 and 10 are counselors, requiring documentation of 6 hours of HIV/AIDS and 4 hours of TB/STD training within the first year of employment.
Staff person # 9 was hired in April 2008, but HIV/AIDS training was not documented at the time of inspection.
Staff person # 10 was hired in August 2008 but HIV/AIDS and TB/STD training was not documented at the time of inspection.
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Plan of Correction
0067
704.11(c)(1) Mandatory Communicable Disease Training
Responsible: The Facility Director will be responsible to ensure staff to receives a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training using DOH approved curriculum.
Time Frame All counselors and counselor assistants shall complete the training within the first year of training or by April 30, 2009. All other staff shall complete the training within the first 2 years of employment.
Monitoring: The Facility Director/Program Manager will monitor the staff completion of HIV/AIDS and TB/STD training along with completion of evaluation forms and submission of training certificates to e submitted and entered into Human Resource staff files.
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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 records, the facility failed to document at least 25 clock hours of training annually in one of two personnel records.
The findings include:
Ten personnel records were reviewed on November 17-18, 2009. Of those ten records, two were counselors requiring documentation of 25 clock hours of training annually. The facility did not document 25 hours of training for the 2008-2009 training year in personnel record # 9.
Personnel record # 9 documented only 14 hours of training for the 2008-2009 training year.
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Plan of Correction
0833
704.11(f)(2) Training Hours Req. Counselor
Responsible: Each counselor will be responsible to complete at least 25 clock hours of training annually. Clinical Supervisors in conjunction with Human Resource Department will monitor completion of training hours through submission of certificates of completion of approved training.
Time Frame: Documentation of 25 hours of approved annual training will be subnmitted to Facility Director and filed in staff Human Resource personnel file. Training evaluations will be submitted for all trainings.
Monitoring: Facility Director and/or Supervisor will monitor the completion of staff annual training hours and ensure submission of certificates of completion of training hours to Human Resource Department. |
705.21 (2) LICENSURE General req. for nonresidential facilities.
705.21. General requirements for nonresidential facilities.
The nonresidential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
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Observations
Based upon a tour of the facility ' s physical plant and an interview with the facility director, the facility failed lacked documentation to show that they had a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
The findings include:
A tour of the facility ' s physical plant and an interview with the facility director was conducted on November 18, 2009 at approximately 10:00 AM. The facility did not have a certificate of occupancy posted. The facility director confirmed that they did not have documentation of their occupancy permit.
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Plan of Correction
P173
705.21(2) General req. for nonresidential facilities:
Responsible: The Facility Director in conjunction with the Director of Facilities will be responsible to ensure a certificate of occupancy is obtained.
Time Frame: A certificate of occupancy and/or an exemption of such if required will be obtained by March 31, 2010.
Monitoring: The Facility Director will monitor the obtaining of the certificate of occupancy. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a tour of the facility ' s physical plant, the facility failed to maintain the hot water temperature at or below 120 degrees Fahrenheit.
The findings include:
A tour of the facility ' s physical plant was conducted on November 18, 2009 at approximately 10:00 AM. The hot water temperature in the men ' s restroom on the second floor measured 129 degrees Fahrenheit.
The water temperature was measured again at approximately 2:00 PM, but the temperature remained at 129 degrees.
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Plan of Correction
P197
705.24 (3) Bathrooms
Responsible: The Facilities Director will ensure the custodial staff is responsible to lower and maintain a water temperature in the men's restroom to below 120 degrees Fahrenheit.
Time Frame: The water temperature was lowered to at least 120 degrees Fahrenheit or below in the men's restroom on December 7, 2009.
Monitoring: The custodial staff will monitor the water temperature and maintain at a temperature at or below 120 degrees Fahrenheit.
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705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a tour of the facility ' s physical plant, the facility failed to light interior exits and stairs at all times.
The findings include:
A tour of the physical plant was conducted on November 18, 2009 at approximately 10:00 AM. The facility was required to light interior exits and stairs at all times. The interior emergency exit stairway on the west side of the facility was not lighted at the time of the inspection. Based on an interview with the facility director and a maintenance personnel, it was determined that the light fixture was outdated and needed to be replaced.
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Plan of Correction
P247
705.28 (a) (1) Fire Safety
Responsible: The Facilities Director will be responsible to replace the light fixtures to ensure all interior emergency exits and stairs are lighted at all times.
Time Frame: All interior emergency exits and stairs will be lighted by January 15, 2009.
Monitoring ; The Facilities Director will ensure the maintenance staff monitors all interior emergency exits and stairs are lighted at all times
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705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a tour of the facility ' s physical plant, the facility failed to maintain protective caps over each electrical outlet in play areas designated for children.
The findings include:
A tour of the physical plant was conducted on November 18, 2009 at approximately 10:00 AM. The facility was required to maintain protective caps over each electrical outlet in areas designated for children. One of the two interior play areas had four electrical outlets without protective caps.
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Plan of Correction
P297
705.29 (2) (iii) Child care
Responsible: The Facility Director/Program Manager will be responsible to ensure all electrical outlets in play areas designated for children maintain protective caps over each electrical outlet.
Time Frame: As of November 27, 2009 all electrical outlets in play areas designated for children have protective caps over each electrical outlet.
Monitoring: The maintenance staff will monitor the electrical outlets to maintain protective caps over all electrical outlets in play areas designated for children.
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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.
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Observations
Based on a review of administrative documentation, the facility failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The Findings include:
The facility ' s administrative documentation was reviewed on November 17-18, 2009. The facility was required to document a financial audit within six months following the end of their fiscal year. The facility ' s 2007-2008 fiscal year ended on June 30, 2008, but the financial audit for this period was dated February 27, 2009.
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Plan of Correction
0169
709.25(a) Fiscal Management
Responsible: The Controller will be responsible to ensure an independent certified public accounting firm is engaged to perform an audit of the organization's financial statements for the fiscal year ending June 30 of each year. In addition the Controller will request for a waiver of the industry standard to the Department of Health for the components of the audited financial statements related the organization's drug and alcohol programs
Time Frame: Request for waiver will be submitted by March 31, 2010.
Monitoring: The Controller will monitor the organizations obtaining the services of an independent certified public accounting firm to perform an audit of the organizations financial statements for the fiscal year ending June 30 of each year.
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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 the review of client records, the facility failed to document informed and voluntary consent from the client for the disclosure of information contained in five of nine client records.
The Findings include:
Thirteen client records were reviewed on November 17-18, 2009. Documentation of informed and voluntary consent was reviewed in nine records. The facility did not document informed and voluntary consent for the release of information in client records # 1, 3, 7, 8 and 9.
Client records # 1, 3, 7, 8 and 9 did not document the client ' s right to verbally revoke signed consents for the release of information to the clients ' primary care physician. The facility documented the clients must revoke these consents in writing.
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Plan of Correction
0277
709.28 (c) Confidentiality
Responsible: The Clinical Supervisor will be responsible to ensure all counseling staff utilize an informed and voluntary consent for the release of information of client information that documents the client may revoke the consent verbally and in writing.
Time Frame: All clinical staff will receive training on appropriate completion of consent forms at least twice during the year including during initial orientation of new staff.
Monitoring: The Facility Director/ Supervisor will monitor all client records for the use of correct and completed consent forms.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in eight of nine client records.
The findings include:
Thirteen client records were reviewed on November 17-18, 2009. Of those thirteen records, psychosocial evaluations were reviewed in nine. The facility did not document a psychosocial evaluation in client records # 1, 2, 3, 4, 5, 7, 8 and 9.
The facility did not document a psychosocial evaluation to include the client ' s assets/strengths that can contribute to the resolution of identified problems in records # 1, 2, 3, 4, 5, 7, 8 and 9.
The facility did not document a psychosocial evaluation to include the client ' s preferred coping mechanisms in client records # 1, 2, 3, 4, 7, 8 and 9.
The facility did not document a psychosocial evaluation to include the client ' s negative factors that might affect treatment in client records # 1, 2, 3, 4, 5, 7, 8 and 9.
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Plan of Correction
1871
709.91(b)(6) Intake and admission:
Responsible: The Clinical Staff will be responsible to document completion of psychosocial evaluations within thirty days from date of admission.
Time Frame: As of December 16, 2009 the Facility Director will provide bi-weekly supervision and/or training to staff on documentation of psychosocial evaluations to be completed within thirty days from date of admission.
Monitoring: Facility Director/Supervisor wll monitor all monthly admissions to ensure psychosocial evaluations are completed within thirty days from date of admission
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