INITIAL COMMENTS
|
This report is a result of an on-site licensing inspection conducted on March 5-7, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, NET Treatment Services, Inc. - NET Steps 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:
|
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 outpatient personnel records, the facility failed to document the qualifications for the position of counselor in one of twelve records.
The findings include:
Twelve outpatient personnel records identified as counselors were reviewed on March 5, 2012. Documentation of the qualifications for the position of counselor was not included in personnel record # 10A.
Personnel record # 10A contained documentation of a degree from an accredited college, but the degree was not is in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field.
Personnel record # 10A contained documentation of a Master of Divinity degree.
An interview with the facility director on March 5, 2012 confirmed the findings.
|
Plan of Correction
While the identified staff has 2 masters degrees and a doctorate degree from accreditiated colleges, his major of Divinity was found to be ineligible.
POC: This employee has since been terminated. To prevent future reoccurrances, NET Human Resources will review any new therapist hires and insure that the educational background of the candidate complies with the Chapter 704 requirements.
Effective date: March 9, 2012
Responsible Person(s) Facility Director & NET Human Resources Representative |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
|
Observations
Based on an inspection of the facility's physical plant, the facility failed to limit smoking to designated smoking areas.
The findings include:
A physical plant inspection was conducted on March 7, 2012 at approximately 3:20 PM. At the time of inspection a noticeable odor of cigarette smoke was detected in the two communal bathrooms of the men's residential program.
The Program Director of the men's residential program confirmed the presence of a cigarette smoke odor the men's bathrooms.
|
Plan of Correction
The following is written in response for the Wharton residential program:
On March 7th, the Residential Program Director reviewed the Wharton Center's existing policies regarding smoking with all residents at the Wharton Center, reminding them that the only area where smoking is permitted is outside of the facility and that there is signage clearly indicating that smoking is not permitted in the bathrooms or facility.
In addition, on March 7th, the Residential Program Director reviewed the program's enforcement plan with all program staff to ensure that all staff meet the expected requirements of the program's ongoing procedures for monitoring and enforcement of the program's smoking policies.
To ensure ongoing compliance the Residential Program Director will continue to implement and ensure regular enforcement of the smoking policies of the facility, which will include the ongoing and frequent daily monitoring of the communal bathrooms to prevent residents from smoking in these areas.
COMPLETION DATE = 3/7/12
|
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:
|
Observations
Based on the review of inpatient client records, the facility failed to comply with 4 Pa. Code relating to projects and coordinating bodies: disclosure of client-oriented information.
The findings include:
On March 7, 2012, four inpatient client records were reviewed for documentation of informed and voluntary consent, specifically records # 1, 2, 3 and 4. The facility documented the release of client information which exceeded the limitations of 4 Pa. Code in client records # 1, 2, 3 and 4.
Client records # 1, 2, 3 and 4 contained a signed consent to release information form that released "Urinalysis" to the courts.
Client # 1 was admitted on 1/26/12. Client # 1's record contained a signed consent form releasing the client's "Urinalysis" to the courts on 1/26/12.
Client # 2 was admitted on 1/23/12. Client # 2's record contained a signed consent form releasing the client's "Urinalysis" to the courts on 1/23/12.
Client # 3 was admitted on 1/30/12. Client # 3's record contained a signed consent form releasing the client's "Urinalysis" to the courts on 1/30/12.
Client # 4 was admitted on 1/18/12. Client # 4's record contained a signed consent form releasing the client's "Urinalysis" to the courts on 1/18/12.
An interview with the Program Director of the men's residential program on March 7, 2012 confirmed the findings.
|
Plan of Correction
The following is written in response for the Wharton residential program:
In February, 2012, NET's Residential Facility Director did twice contact the Director of Philadelphia's Office of Addiction Services, the Director of the Philadelphia Health Management Corporation's CEU, as well as the Director of Philadelphia Treatment Court, and did request a court order, signed and submitted by a judge of the courts, to order Urinalysis results for each client stipulated to Drug and Alcohol treatment be released to the court. The requested orders remained pending at the time of the licensing inspection conducted at this facility.
By April 2, 2012, the Residential Facility Director will contact for a third time the Directors (as noted above) to again request a court order, signed and submitted by a judge of the courts, to order Urinalysis results for each client stipulated to Drug and Alcohol treatment be released to the court.
COMPLETION DATE = 5/31/2012 |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on the review of inpatient client records, the facility failed to document a personal history that included historical and pertinent legal and employment data in five out of five records.
The findings include:
On March 7, 2012 five inpatient client records were reviewed for personal histories, specifically records # 1, 2, 3, 4 and 5. The facility did not document a personal history to included historical and pertinent legal and employment data in client records # 1, 2, 3, 4 and 5.
Client # 1 was admitted on 1/26/12. The personal history in client # 1 ' s record did not include historical and pertinent legal and employment data.
Client # 2 was admitted on 1/23/12. The personal history in client # 2 ' s record did not include historical and pertinent legal and employment data.
Client # 3 was admitted on 1/30/12. The personal history in client # 3 ' s record did not include historical and pertinent legal and employment data.
Client # 4 was admitted on 1/18/12. The personal history in client # 4 ' s record did not include historical and pertinent legal and employment data.
Client # 5 was admitted on 8/30/11. The personal history in client # 5 ' s record did not include historical and pertinent legal and employment data.
An interview with the Program Director of the men ' s residential program on March 7, 2012 confirmed the findings.
|
Plan of Correction
The following is written in response for the Wharton residential program:
As of March 12th, 2012, NET clinical supervisor has been reviewing active client records to ensure that a personal history is documented in each record which includes all pertinent legal and employment data.
NET clinical supervisor met with clinical staff on March 22, 2012, instructing the clinical staff to ensure that the collection of a personal history for each client does include all pertinent legal and employment data.
To ensure ongoing compliance NET Program Director and NET Clinical Supervisor will review weekly all newly collected personal histories to ensure that histories are complete and include all pertinent legal and employment data.
COMPLETION DATE = 5/31/2012 |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on the review of inpatient client records, the facility failed to document treatment plan updates to include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan in four out of four records.
The findings include:
On March 7, 2012 four client records requiring treatment plan updates were reviewed, specifically records # 1, 2, 3 and 4. The facility did not document a treatment plan update to include an assessment of the client ' s progress in client records # 1, 2, 3 and 4.
Client # 1 was admitted on 1/26/12. The treatment plan update in client # 1 ' s record dated 2/17/12 did not include an assessment of progress.
Client # 2 was admitted on 1/23/12. The treatment plan update in client # 2 ' s record dated 2/17/12 did not include an assessment of progress.
Client # 3 was admitted on 1/30/12. The treatment plan update in client # 3 ' s record dated 2/22/12 did not include an assessment of progress.
Client # 4 was admitted on 1/18/12. The treatment plan updates in client # 4 ' s record dated
2/10/12 and 2/28/12 did not include an assessment of progress.
An interview with the Program Director of the men ' s residential program on March 7, 2012 confirmed the findings.
|
Plan of Correction
The following is written in response for the Wharton residential program:
NET Program Director and Clinical Supervisor met with counseling staff on March 22, 2012 and educated the counseling staff on the need to ensure that all treatment plan updates include a clear assessment of the client's progress since entering treatment. NET Program Director and Clinical Supervisor discussed the need for the counseling staff to include a clear prognosis of the client's progress on each update as well as include an overall assessment of the progress noted. Additionally, NET Program Director and Clinical Supervisor educated the counseling staff on the need to ensure that each goal is addressed, and, should the client not make progress on any particular goal, an assessment of why a lack of progress will be noted for that goal as well as a modification to therapeutic interventions as a means of further supporting the client in making progress on such goal.
To ensure ongoing compliance, NET Program Director and Clinical Supervisor will review weekly all newly developed treatment plan updates to ensure the above is completed. The clinical supervisor's signature on the treatment plan update will signify compliance with above.
COMPLETION DATE = 5/31/2012 |