INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 17-18, 2009 licensure renewal inspection. The follow-up inspection was conducted on June 29, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 July 22, 2010.
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Plan of Correction
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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 the review of personnel records, the facility failed to document a minimum of 4 hours of TB/STD training in one of one personnel records.
The findings include:
Two personnel records were reviewed on June 29, 2010. Of the two records reviewed, one was reviewed for documentation of 4 hours of TB/STD training. The facility did not document 4 hours of TB/STD training in personnel records #2.
Personnel #2 is a counselor, requiring 4 hours of TB/STD training within the first year of employment. Personnel #2 was hired in August 2008, but TB/STD training was not documented at the time of inspection on June 29, 2010.
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Plan of Correction
0067
704.11 (c)(1)
Responsible Party(s): The clinical supervisors will be responsible for ensuring that all clinical counseling staff recieve TB/STD training within the first year of employment with the agency. The two employees identfied as not being in compliance, will be registered for the next available TB/STD training.
Timeframe for completion: TB/STD Training will be completed by clinical counseling staff who have been employed with the agency for more than one year, by September 30, 2010.
Monitoring: Supervisors will review employee annual training plans with their respective staff once per month, to ensure that all staff recieve TB/STD training within one year of employment with the agency. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on an inspection of the facility ' s physical plant, the facility failed to prohibit the use of heaters that are not permanently mounted or installed.
The findings include:
A physical plant inspection was conducted on June 29, 2010 at approximately 2:00 PM. A portable space heater was observed in the office of the administrative assistant.
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Plan of Correction
P225
705.26(2: Heating and Cooling
Responsible Party(s): The Program Director, Clinical Supervisors, and Facilities Director, are responsible for the prohibition of all heaters that are not properly installed or mounted within the clinic, as well as the prohibition of the usage of portable heaters.
Timeframe for completion: The Program Director will re-train staff on the prohibition of portable heaters by August 15, 2010.
Monitoring: The Facilities Director will provide weekly walk-throughs of clinic offices, ensuring that there are no portable heaters on the premises. |
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
At the time of follow-up review, on June 29, 2010, it was not possible for the licensing specialist to determine if the facility followed the original plan of correction and was in compliance due to the fact that the independent annual audit of financial activities associated with the project's drug/alcohol abuse services was not yet due to be completed. Facility must resubmit original plan of correction.
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Plan of Correction
0169
709.25 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 has requested 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 was submitted by March 31, 2010 no response was received. Independent audit will be performed by July, 30, 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(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a tour of the facility ' s physical plant and based on an interview with the facility director, the facility failed to maintain the confidentiality of the clients ' identity.
The findings include:
A tour of the facility ' s physical plant and an interview with the facility director was conducted on June 29, 2010 at approximately 2:00 PM. The licensing specialist observed a client sign-in book, in the reception area, with the first and last names of clients presently or previously at the facility. The facility director confirmed the practice of having all clients sign the sign-in book upon arrival.
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Plan of Correction
0271
709.28 (a(1): Confidentiality
Responsible Party(s): The Program Director, Clinical Counseling Staff and Support staff are responsible for ensuring that the confidentiality of patients enrolled in the treatment program is maintained at all times.
Timeframe for Completion: The Program Director will request authorization from the Corporate office for approval of an electronic signature pad to be used when the patients sign into the clinic each day. Request will be made by August 15, 2010. If request is approved, the electronic signature pad will be in use by September 1, 2010.
Monitoring: The Security Staff will ensure that all patients that sign in at the front desk use only the initial for their first name and full last name beginning August 9, 2010, until such time that the electronic signature pad can be approved.
The sign in sheet will also be enclosed in folder,that must be opened each time a client signs in.
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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 twelve of fourteen records.
The findings include:
Fourteen client records were reviewed on June 29, 2010. All fourteen records required documentation of informed and voluntary consent. The facility did not document informed and voluntary consent from the client for the release of information in records # 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12 and 14.
Client records # 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12 and 14 did not document the client ' s right to verbally revoke a signed consent for the release of information to the clients ' primary care physician. The facility documented that the clients must revoke this consent in writing.
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Plan of Correction
0277
709.28(c): Confidentiality
Responsible Party(s): The Clinical Supervisors, Intake Staff,Clinical Counseling Staff, Nursing Staff and Program Director are responsible for ensuring that that each record has a valid informed and voluntary consent from the patient for the disclosure of information.
Timeframe for Completion: All Clinical and Nursing staff will be trained in regards to using the appropriate release of information for the Primary Care Physician, which allows the patient to revoke consent either verbally, or in writing. Training will take place by August 15, 2010.
Monitoring: The clinical supervisors will review 2 charts during weekly supervision with their respective clinicians, and ensure that releases are completely filled out and allow the patient to revoke consent verbally or in writing. |
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 the review of client records, the facility failed to document a psychosocial evaluation in fourteen of fourteen client records.
The findings include:
Fourteen client records were reviewed on June 29, 2010. All fourteen records required documentation of a psychosocial evaluation. The facility did not document a psychosocial evaluation, as per facility policy, in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14.
The facility ' s policy titled " 715.9- INTAKE, 709.24- TREATMENT/REHABILITATION MANAGEMENT, 709.91- INTAKE " states:
" Within 30 days following admission the Counselor/Primary Clinician completes the Psychosocial History with the client. The Counselor then completes the Psychosocial Evaluation, developing a list of problems to be reported in the Comprehensive Treatment Plan. "
PROCEDURE DESCRIPTION: The procedure outlines what is needed for the completion of the Biopsychosocial Assessment.
1)The Biopsychosocial Assessment will be completed during the intake Process
2)The completed assessment will identify all presenting problems.
3)Both past and present information will be used in the assessment, including physical, psychiatric emotional, educational, maturational, spiritual, nutritional, vocational, legal, sexual and social elements of the consumer ' s life.
4) A comprehensive medical history that includes current and past medications, any medical treatments being received, current medical conditions, and food drug and environmental allergies will be included in the assessment.
5)The assessment will include a comprehensive substance abuse history.
6)The assessment will include information that indicates the consumer ' s strengths, weaknesses and barriers to treatment.
In client records # 1, 4, 6, 7, 8, 11, 12 and 13 the strengths, weaknesses and barriers to treatment were the same in each record.
The admission date for Client #2 was 4/6/10, but a psychosocial evaluation was not documented at the time of review on 6/29/10.
The admission date for Client #3 was 4/30/10, but a psychosocial evaluation was not documented at the time of review on 6/29/10.
The admission date for Client #5 was 4/9/10, but a psychosocial evaluation was not documented at the time of review on 6/29/10.
The admission date for Client #9 was 4/28/10, but a psychosocial evaluation was not documented at the time of review on 6/29/10.
The admission date for Client #10 was 2/9/10, but a psychosocial evaluation was not documented at the time of review on 6/29/10.
The admission date for Client #14 was 5/11/10, but a psychosocial evaluation was not documented at the time of review on 6/29/10.
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Plan of Correction
1871
709.91(b((6): Intake and Admission
Responsible Party(s): The Intake Worker and the Program Director are responsible for ensuring that a biopsychosocial is documented in full for each new admission into the program, in accordance with all elements in the program's policy.
Timeframe for Completion: The Intake Worker will be responsible for completing all Bio Psycho Socials within 30 days of admission of each patient. The Intake Worker will submit all completed Bio Psycho Socials to the Program Director for review to ensure that each bio is completed on time, in full, and is individualized to the patient being interviewed.
Monitoring: The Program Director will review each bio with the Intake Worker during weekly supervision to ensure that the document is fully completed and contains all required elements. |