INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on January 17 to 19, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, ARS of Lancaster, LP, 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.
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Plan of Correction
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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.
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Observations
Based on the review of personnel records, the facility failed to document that each counselor met the qualifications for the position in two of seven personnel records reviewed.
Findings:
Eleven personnel records were reviewed on January 17, 2012. Two of seven personnel records reviewed of counselors did not have documentation of qualifications required, # 4 and 5.
Employee # 4 was hired on June 27, 2011 as a counselor. The documented degree for this employee was a bachelor's degree that did not meet a qualified field of study.
Employee # 5 was hired on November 28, 2011 as a counselor. The facility failed to document verification of the degree. Without degree verification there was not way to determine if the employee met the qualifications for the position of counselor.
The findings were reviewed with the Project Director, Facility Director and Clinical Supervisor.
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Plan of Correction
The facility director will ensure that all new clinical staff provide a copy of their degree from an accredited college along with transcripts to ensure that completion of the degree occurred, in addition to a confirmation that the major meets qualifications for the position hired. This will be done prior to the commencement of employment. Compliance will be monitored through on going personnel record audits by the facility director.
Additionally, employee #4 was reclassified as a counseling assistant as of 1/18/12 and is currently incompliance with all requirements of a counselor assistant.
Employee #5's degree has been verified as of 1/18/12 sociology and has been determined to be qualified as a counselor.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log, the facility failed to document a fire drill at least once a month as required by this regulation.
The findings include:
The fire drill record log was reviewed on January 17, 2012. The fire drill log was reviewed from January 2011 to December 2011. The facility failed to document a fire drill in April 2011.
The findings were confirmed by the facility director and clinical supervisor.
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Plan of Correction
The Health and Safety officer will meet with the Facility Director once a month to ensure the yearly plan for monthly unannounced fire drills is implemented and completed. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on the review of the agency policy and procedures and administrative reports, the facility failed to document collaboration between the project director and governing body in formulating annual goals and objectives for the 2011 fiscal year.
The findings included:
The agency policy and procedures and administrative reports were reviewed on January 17, 2012. No documentation was presented to support the Project Director and the governing body collaborated on the formulation of goals and objectives for the fiscal year of January 1, 2011 through December 31, 2011.
The Project Director was informed of the findings and reported the collaboration was not documented.
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Plan of Correction
From this date, the Project Director will document the collaboration between the governing body and the project director in formulation of the annual goals and objectives for the fiscal year within the governing body minutes on an annual basis. The governing body is scheduled to meet on February 6, 2012. While the 2012 fiscal year goals and objectives have been formulated previously, the governing body and project director will be re-reviewing in collaboration to approve the goals and objectives for the 2012 fiscal year. The project director will ensure that this review will be fully documented within the governing body minutes to ensure this issue does not recur. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on the review of the agency policy and procedures and administrative reports, the facility failed to document annual goals and objectives for the 2011 fiscal year.
The findings included:
The agency policy and procedures and administrative reports were reviewed on January 17, 2012. The documentation that was presented for the goals and objectives for the January 1, 2011 through December 31, 2011 fiscal year, failed to include time frames with available resources.
The Project Director confirmed these findings.
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Plan of Correction
The goals and objectives for 2011, previously reviewed by the Governing Body on January 17, 2012, will be modified by Project Director the Governing Body to include time frames and available resources. Once modified, they will be reviewed again with the Governing Body. This review will occur prior to February 17, 2012. This review will be fully documented within the governing body minutes. In the future, project goals and objectives will always include time frames and available resources. Project and Facility Director will ensure that this procedure remains in place for 2012 and future years. |
709.23(b)(2) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(2) Written reports of project operations.
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Observations
Based on a review of the policy and procedures, the facility failed to document board meeting minutes for fiscal year 2011.
The finding include:
The agency policy and procedures and administrative reports were reviewed on January 17, 2012. According to the facility's by-laws, board meeting minutes will be documented and contain the date of meeting, names of members present, topics discussed, decisions made, actions taken, reports from committees and will be signed Board members. The CEO and Facility Director were not able to produce Board Meeting minutes for fiscal year January 1 to December 30, 2011, as required by facility by-laws.
The Project Director was informed of the findings and reported meeting minutes had not been documented.
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Plan of Correction
Governing Body meetings taking place in 2012 and in the future will follow the facility's by-laws, ensuring that the meetings will be fully documented with meeting minutes that include the date of meeting, names of members present, topics discussed, decisions made, actions taken, reports from committees and will be signed Board members.
The project and facility director will perform a quarterly review of meeting minutes to ensure all of the required information is contained in the minutes. If items are missing from minutes, the minutes will be sent back to the governing body for revision.
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709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on a review of facility documentation, the facility failed to complete a performance report to summarize progress towards meeting goals and objectives for the fiscal year January 1 to December 31, 2011.
The findings included:
During an administrative review on January 17, 2012, the performance report for the summary of goals and objectives for fiscal year January 1 to December 31, 2011, was requested for review. The facility was unable to produce documentation of a report that was complete during the January 1 to December 31, 2011 fiscal year. The facility provided a year end draft of a summary of a review of the goals and objectives; however, this did not meet the requirement
The Project Director was informed of the findings.
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Plan of Correction
The Project Director will ensure the review of the performance report that summarizes the progress report towards meeting the goals and objectives is fully documented within the governing body meeting minutes. This report is reviewed with the governing body at least semi-annually. The performance report summarizing progress of the 2011 goals and objectives will be reviewed with the governing body on February 6, 2012. This will also be documented within the governing body minutes. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician for 24-hour emergency psychiatric coverage.
The findings include:
The letters of agreement were reviewed on January 17, 2012. The facility failed to document a letter of agreement regarding 24- hour emergency psychiatric coverage.
The Project Director was informed of the findings and confirmed the lack of documentation.
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Plan of Correction
The Executive Director obtained a transfer agreement with a licensed hospital that provides psychiatric services to allow for 24-hour emergency coverage. The initial term of the agreement is one year. Thereafter, the agreement will automoatically renew for an indefinite number of additional one-year terms. The Executive Director will ensure that the contract remains active. This was completed on 1/30/12. |
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 the review of administrative documentation the facility failed to provide an audit of financial activities for the January 1 to December 31, 2010, fiscal year.
The findings include:
The annual audit was requested on January 17, 2012. The financial report presented was noted to be a review, not an audit within the document. This documentation did not meet the requirements for the completion of an audit by an independent public accountant.
The findings were reviewed with the Project Director who confirmed the document was an annual review and not an audit.
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Plan of Correction
The project director has submitted an exception request to regulation 709.25. If this exception request is accepted, the facility will continue to engage an independent public accountant to review the financial statements of the facility. If this exception request is not approved, the Project Director will be responsible for ensuring the Governing Body engages an independent accountant to perform an audit of the financial statements annually starting with the 2011 fiscal year financial statements. The Project Director will ensure that the financial audit is completed within 6 months of the end of the fiscal year. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records during the annual licensing inspection, the facility failed to provide results of reference checks in five of six personnel records.
The findings included:
Eleven personnel records were reviewed on January 17, 2012. Six personnel records were new hires and required documented reference checks. The facility failed to document the results of reference checks in personnel records, # 4, 5, 8, 10 and 11.
Personnel record # 4 had a hire date of June 27, 2011. There was no documentation of reference results.
Personnel record # 5 had a hire date of November 28, 2011. There was no documentation of reference results.
Personnel record # 8 had a hire date of June 6, 2011. There was no documentation of reference results.
Personnel record # 10 had a hire date of June 12, 2011. There was no documentation of reference results.
Personnel record # 11 had a hire date of May 21, 2011. There was no documentation of reference results.
The Project Director was informed of the absence of the reference check results and confirmed that they were not documented.
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Plan of Correction
Human Resource Director will complete reference checks on all new employees before they are hired and communicate with the Facility Director that the reference was completed. The reference checks results will be documented in writing and placed in employee's personnel record. All active personnel records will be reviewed by human resource to ensure that reference checks are included within the record. For any active employee record past the probation period that does not contain documentation of the reference checks, a memo will be placed in their record explaining that reference checks were not documented. All employees hired within the last 90 days of this date that does not contain documentation of the reference checks, the reference check will be reperformed by the human resources director and included within the employee record by March 15, 2012.
The facility director will perform an audit of the reference checks on March 16, 2012 to ensure all reference checks are completed.
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709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
Based on the review of personnel records, the facility failed to document verification of training experience in one of six personnel records reviewed.
Findings:
Eleven personnel records were reviewed on January 17, 2012. Six records reviewed were for newly hired employees and required verification of training and experience. The facility failed to document the verification of training experience in personnel record # 5.
Personnel record # 5 was hired November 28, 2011. The personnel record failed to document verification of the degree. A copy of the degree was in the record; however, it failed to include the area of study/major. Transcripts were requested to verify the degree concentration; the facility was unable to provide the documentation.
The findings were confirmed by the Project Director, Facility Director and Clinical Supervisor.
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Plan of Correction
From this date, the executive director will require that all new employees provide a copy of their degree and transcripts on the first day of hire. The new employee will not be able to begin employment until these documents are provided. Human Resource will monitor compliance through yearly employee record audits.
The employee for Personnel record #5 did provide a copy of her transcript on 1/18/12 that verified that she majored in sociology, which is a related field of study for the counselor position. This documentation was placed in the employee record. This was corrected on 1/18/12.
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709.28(a)(2) 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:
(2) Staff access to client records.
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Observations
Based on the review of the agency policy and procedures, the facility failed to document what staff had access to confidential patient information by name or position.
The findings included:
The agency policy and procedures were reviewed on January 17, 2012. The facility's policy failed to include who had access to patient records by name or position.
The Project Director was informed of the findings and confirmed the lack of limitations were not clearly defined in the facility's policy and procedure manual.
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Plan of Correction
The facility director and project director updated the facility policy procedures on 1/18/2012 to amend the policies and procedures concerning confidentiality to specifically include the titles/positions of staff members authorized to access confidential patient information. A review of this amended policy concluded that no staff member in a position that is not approved to access confidential patient information has had access to confidential information. |
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 patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in five of ten records. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in four of ten records reviewed.
The findings included:
Fifteen patient records were reviewed January 18 and 19, 2012. Ten records were reviewed regarding documentation for release of information . The facility failed to ensure that an informed and voluntary consent to release information was obtained in five of ten records reviewed, # 8, 9, 12 and 14. The facility also failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in four of ten records, # 1, 2 and 8.
A review of patient record # 1 revealed a letter to the probation officer dated 12/8/2011 that released treatment plan information of patient requirements to attend monthly individual counseling and one group a month. The information disclosed exceeded the limitations imposed by Pa Code 255.5 (b).
A review of patient record # 2 revealed a consent to release information to the employer that permitted the nature of the services provided, short statement of relapse and the patient's prognosis. The information permitted exceeded the limitations imposed by Pa Code 255.5 (b).
Patient # 8 was admitted on April 27, 2011. A review of patient record # 8 revealed information was released to a funding source on April 20, 2011. The patient did not sign a release prior to releasing information for the funding entity. The release was signed on April 26, 2011. This record also documented a letter to the probation officer dated 6/22/2011 that released treatment plan information of patient requirement to attend 1.0 hour of individual counseling per month, as well as, attend 1.5 hours of group per month. The information disclosed exceeded the limitations imposed by Pa Code 255.5 (b).
Patient # 9 was admitted on December 7, 2011. Patient record # 9 revealed information was released to a funding source on 12/5/2011. The patient did not sign a release prior to releasing information for the funding entity. The release was signed on 12/6/2011.
A review of patient record # 10 revealed a letter dated November 8, 2011, addressed to "To Whom it May Concern" and signed by the physician assistant. There was no way to determine if an informed consent to release information was signed for the information in this letter due to the fact it was not addressed to a specific person.
Patient # 12 was admitted on July 28, 2011. A review of patient record # 12 revealed information was released to a funding source on 7/25/2011. The patient did not sign a release prior to releasing information for the funding entity. The release was signed on 7/27/2011.
Patient # 14 was admitted on September 1, 2011. A review of patient record # 14 revealed information was released to a funding source on 8/23/2011. The patient did not sign a release prior to releasing information for the funding entity. The release was signed on 8/30/2011.
The findings were reviewed with the facility director and clinical supervisor.
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Plan of Correction
A training regarding Confidentiality was presented to the clinical team by the Facility Director and Clinical Supervisor on 2/3/12. Clinical Supervisor will complete a random audit of 10% of clinical records for patients in treatment to ensure compliance with the consents to release information. Continued compliance will be monitored through regular random chart audits by Clinical Supervisor, Lead Counselor and Peer Reviews. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility failed to give the client an opportunity to request reconsideration of a decision to terminate treatment in three of six patient records.
The findings included:
Fifteen patient records were reviewed on January 18 and 19, 2012. The project was required to give the patient an opportunity to request reconsideration of a decision to terminate patient treatment in six patient records. The project did not document that the patient was given an opportunity to request reconsideration in patient records # 2, 4 and 5.
Patient # 2 was discharged on 10/20/2011. A termination letter dated 10/20/2011 did not inform the patient an opportunity to request reconsideration of a decision terminating treatment.
Patient # 4 was discharged on 1/10/2012. A termination letter dated 1/10/2012 did not give the patient an opportunity to request reconsideration of a decision terminating treatment.
Patient # 5 was discharged on 11/9/2011. A termination letter dated 11/9/2011 did not inform the patient an opportunity to request reconsideration of a decision terminating treatment.
The findings were reviewed with the Facility Director and Clinical Supervisor.
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Plan of Correction
The policy regarding Discharges will be reviewed by Clinical Supervisor in Clinical Team Meeting on 2/6/12. Specifically, the Clinical Supervisor will review the importance of communicating to the patient, his/her right to appeal the decision to terminate treatment. Patients are informed of their discharges through a written letter. Going forward from 2/7/12 discharge letters will now contain a statement informing the patient of his/her right to appeal the discharge. Continued compliance will be monitored through discharge audits to ensure all termination letters have an appeal opportunity and are used appropriately by Clinical Supervisor or Lead Counselor |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of patient records, the facility failed to document a treatment plan with long and short term treatment goals in seven of nine patient records.
The findings include:
Fifteen patient records were reviewed on January 18 and 19, 2012. Nine patient records required treatment plans. Seven of nine patient records failed to document long and short term goals, # 7, 8, 9, 12, 13, and 14. Patient record # 15 did not have a treatment plan completed.
Patient # 7 was admitted on December 13, 2011. A treatment plan was completed on December 21, 2011. The treatment plan failed to identify short-term goals.
Patient # 8 was admitted on April 27, 2011. A treatment plan was completed on June 3, 2011. The treatment plan failed to identify short term goals.
Patient # 9 was admitted on December 7, 2011. A treatment plan was completed on January 6, 2012. The treatment plan failed to include short-term goals.
Patient # 12 was admitted on July 28, 2011. A treatment plan was completed on August 9, 2011. The treatment plan failed to include short-term goals.
Patient # 13 was admitted on October 25, 2011. A treatment plan was completed on November 22, 2011. The treatment plan failed to include short-term goals.
Patient # 14 was admitted on September 1, 2011. A treatment plan was completed on September 10, 2011. The treatment plan failed to include short-term goals.
Patient # 15 was admitted on December 15, 2011. A treatment plan was not completed as of the time of the inspection. The treatment plan was due by January 15, 2012.
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Plan of Correction
The Clinical Supervisor will provide a training on treatment plan goals by 2/15/12. The training will focus on identifying and creating short and long term goals on treatment plans for all patients. As patient treatment plans are due for modification or required updating, counselors will ensure both long term and short term goals are formulated by the patient and counselor in session. These treatment plans will be reviewed for compliance by Clinical Supervisor and/ or Lead Counselor to ensure compliance in this area. |