INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 18, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, 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:
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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 a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form completed on April 15, 2013, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff in one of three personnel records reviewed. Also, the facility failed to ensure that staff persons and volunteers received at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff in one of five personnel records reviewed.
The findings include:
On April 16, 2013, three personnel records and the SRFSR form were reviewed to verify that employees had HIV/AIDS training and five personnel records and the SRFSR form were reviewed to verify that employees had STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff. The facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS in one of three personnel records reviewed, specifically, personnel record # 4. The facility also failed to ensure that staff persons received at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff in one of five personnel records reviewed, specifically, personnel record # 4.
Employee # 4 is a counselor and was hired August 10, 2011. Employee # 4 was due to complete a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training by August 10, 2012. However, personnel record # 4 did not include documentation of HIV/AIDS and TB/STD training as of April 16, 2013.
The findings were confirmed during an interview with the clinical supervisor on April 16, 2013 at approximately 11:30 A.M.
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Plan of Correction
It is Holcomb behavioral Health Systems Policy that all staff and volunteers of the D&A Project recieve 6 hours of HIV/AIDS and other health related topics within the first year of employment for clinical staff, or two years for non clinical staff.
The staff member cited in the Personnel Records review has resigned. The Program Supervisor will be responsible to ensure all new staff recieve the appropriate trainings in the appropriate time frames |
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 ensure that each counselor completed 25 clock hours of required training in one of two personnel records reviewed.
The findings include:
On April 16, 2013, two personnel records requiring documentation of 25 clock hours of training were reviewed. The facility failed to provide documentation of 25 clock hours of training in one of two personnel records reviewed, specifically, personnel record # 4.
Employee # 4 is a counselor and was hired on August 10, 2011. The facility's training year was from January 1, 2012 to December 31, 2012. Employee # 4 was required to complete 25 clock hours of annual training hours by December 31, 2012. However, personnel record # 4 only had documentation of 18.25 clock hours of annul training hours for the January 1, 2012 to December 31, 2012 training year as of April 16, 2013.
The findings were confirmed during an interview with the clinical supervisor on April 16, 2013 at approximately 11:30 A.M.
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Plan of Correction
It is the policy of Holcomb Behavioral health Systems that each counselor involved in the D&A Project recieve 25 hours of relevant training each year. The staff member who was cited as not achieving that goal has resigned, and the Program Supervisor will be responsible for ensuring all future compliance.
She has developed an eloctronic tickler file to keep track of each employee, and their training hours to date. |
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 observations on April 17, 2013, the facility failed to light interior exits and stairs at all times.
The findings include:
A physical plant inspection was conducted on April 17, 2013. During the inspection, at approximately 10:51 A.M., there were areas of the interior emergency exit stairs from the basement leading to the first floor hallway between counseling rooms # 4 and 5 that were not lighted due to one of the light bulbs in the exit being blown out.
The findings were confirmed during an interview with the clinical supervisor on April 17, 2013 at approximately 10:51 A.M.
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Plan of Correction
HBHS has an Environment of Care Coordinator at each of it's sites to perform monthly safety and facility chacks on each facility.
Our new EOC Coordinator will add the monitoring of light fixtures to her monthly evaluation.
The stairwell in question had the light bulb replaced 5-1-13. The
Facility Director will oversee the process. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on observations on April 17, 2013, the facility failed to ensure the date of the inspection by the local fire department or fire extinguisher company for the fire extinguishers is indicated on the fire extinguisher or inspection tag. Also, the facility failed to ensure that the fire extinguisher was placed properly in the facility.
The findings include:
A physical plant inspection was conducted on April 17, 2013. It was observed during the inspection from approximately 10:51 A.M. to 11:00 A.M. that the fire extinguisher near the front entrance was removed from the fire extinguisher hanging bracket. the facility did locate the missing fire extinguisher, but, were unable to mount it at the time of the inspection.
The two fire extinguishers on the first floor did not indicate on the fire extinguishers or inspection tags the date of the annually inspection by the local fire extinguisher company. Upon the completion of the physical plant inspection, the facility presented billing documentation to the Licensing Specialist, indicating that the fire extinguishers were inspected by the local fire extinguisher company on August 8, 2012.
The findings were confirmed during an interview with the clinical supervisor on April 17, 2013 at approximately 11:15 A.M.
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Plan of Correction
It is Holcomb behavioral Health Systems written policy to have all Fire Extinguishers tested and inspected on a yearly basis.
Two of our extinquishers were not tagged as such by the inspection company, despite their paperwork indicating that the work had been done.
Holcomb will arrange for the company to come out again and re test, and properly tag the extinguishers, and continue to do so on a yearly basis.
Person responsible will be the Facility Director.
Time Frame: Immediate, and yearly.
Ther was an extinguisher on the first floor that had been removed from it's wall bracket; it has been resored, and the bracket strengthened.
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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 fire drill records, the facility failed to conduct unannounced fire drills at least once a month in one of eleven records reviewed.
The findings include:
Fire drill records were reviewed on April 17, 2013. The records were reviewed from the period covering May 2012 to March 2013. The facility did not have documentation of an unannounced fire drill in one of eleven months reviewed, specifically, September 2012.
The findings were confirmed during an interview with the clinical supervisor on April 17, 2013 at approximately 10:00 A.M.
This is a repeat citation. The facility was cited on April 3, 2012 for noncompliance with this standard.
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Plan of Correction
It is Holcomb Behavioral Health's written policy to hold monthly fire drills at our facilities.
We have replaced our previous Environment of care representative, and the new Environment of Care representative will be responsible for arranging, and documenting, the monthly, unannounced drills.
The EOC rep will perform these responsibilities under the direction of the Facility Director.
Time Frame: Immediate and Ongoing |
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 review of administrative documentation, the facility failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of the fiscal year.
The findings include:
The administrative documentation was reviewed on April 16, 2013. The facility was required to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of their fiscal year. The facility's 2011 through 2012 fiscal year ended on June 30, 2012. However, the facility's financial audit for this period was not completed until February 20, 2013.
The findings were confirmed during an interview with the Chief Compliance Officer on April 16, 2013 at approximately 11:00 A.M.
This is a repeat citation. The facility was cited on April 3, 2012 and March 24, 2011 for noncompliance with this standard.
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Plan of Correction
The Facility Director has notified the Facility's Accounting Firm that the annual audit of financial activities associated with the project's drug/alcohol abuse services for fiscal year 2012/2013 must be received by December 1, 2013. Also informed them that all future audits needed to be submitted by the deadline. The Project Director will ensure, moving forward, that the financial audit is completed on time for upcoming years. A tickler system has been put into place to notify Holcomb staff and accounting firm of impending due date. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document preliminary treatment and rehabilitation plan or preliminary treatment and rehabilitation plan in accordance with their policy and procedures in three of eight client records reviewed.
The findings include:
The facility's policy titled: "Drug & Alcohol Treatment Activities," states:
"A Preliminary treatment plan must be developed on the day of admission for both traditional outpatient services and for IOP level of care."
On April 18, 2013, eight client records requiring documentation of a preliminary treatment and rehabilitation plan were reviewed. The facility did not document a preliminary treatment and rehabilitation plan or document a preliminary treatment and rehabilitation plan in accordance with their policy and procedures in three of eight client records reviewed, specifically, client records # 1, 2, and 7.
Client # 1 was admitted October 15, 2012. The preliminary treatment and rehabilitation plan was due October 15, 2012. However, client record # 1 did not include documentation of a preliminary treatment and rehabilitation plan as of April 18, 2013.
Client # 2 was admitted September 28, 2012. The preliminary treatment and rehabilitation plan was due September 28, 2012. However, the preliminary treatment and rehabilitation plan was not completed until November 13, 2012.
Client # 7 was admitted May 21, 2012. The preliminary treatment and rehabilitation plan was due May 21, 2012. However, the preliminary treatment and rehabilitation plan was not completed until October 22, 2012.
The findings were confirmed during an interview with the clinical supervisor on April 18, 2013 at approximately 3:30 P.M.
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Plan of Correction
Preliminary Treatment Plans will be developed for all HBHS clients at the first session, which is the date of admission. The Clinical Supervisor will create a written guide which will include a timeline of documentation. The Clinical Supervisor will give guide to each staff and will address the need for a Preliminary Treatment Plan in weekly individual supervision and monitor each new admission for compliance.
The Clinical Supervisor will be responsible for this process.
There were three clients that had missing preliminary treatment and rehabilitation plans. These plans will be completed by 5-23-13 |
709.92(a) 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:
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Observations
Based on a review of client records, the facility did not document an individual treatment and rehabilitation plan or individual treatment and rehabilitation plans that included type of treatment and rehabilitation services and/or proposed type of support services in seven of eight client records reviewed.
The findings include:
The facility's policy titled: "Drug & Alcohol Treatment Activities," states:
"For IOP level of care, the master treatment plan must be developed with 30 days from the date of admission and updated every 30 days thereafter..........For the traditional Outpatient level of care, a master treatment plan must be completed minimally within 30 days from the date of admission and must be reviewed and updated minimally every 60 days thereafter."
On April 18, 2013, eight client records requiring documentation of an individual treatment and rehabilitation plan were reviewed. The facility did not document individual treatment and rehabilitation plan or individual treatment and rehabilitation plans that included type of treatment and rehabilitation services and/or proposed type of support services in seven of eight client records reviewed, specifically, client records # 1, 2, 3, 4, 5, 7, and 8.
Client # 1 was admitted October 15, 2012. The individual treatment and rehabilitation plan was completed November 26, 2012. However, the individual treatment and rehabilitation plan did not include proposed type of support services as of April 18, 2013.
Client # 2 was admitted September 28, 2012. The individual treatment and rehabilitation plan was completed December 13, 2012. However, the individual treatment and rehabilitation plan did not include type of treatment and rehabilitation services and proposed type of support services as of April 18, 2013.
Client # 3 was admitted January 18, 2013. The individual treatment and rehabilitation plan was completed February 13, 2013. However, the individual treatment and rehabilitation plan did not include type of treatment and rehabilitation services and proposed type of support services as of April 18, 2013.
Client # 4 was admitted January 17, 2013. The individual treatment and rehabilitation plan was completed February 5, 2013. However, the individual treatment and rehabilitation plan did not include type of treatment and rehabilitation services and proposed type of support services as of April 18, 2013.
Client # 5 was admitted July 2, 2012. The individual treatment and rehabilitation plan was completed July 31, 2012. However, the individual treatment and rehabilitation plan did not include type of treatment and rehabilitation services as of April 18, 2013.
Client # 7 was admitted May 21, 2012. The individual treatment and rehabilitation plan was due June 20, 2012. However, client record # 7 did not include documentation of an individual treatment and rehabilitation plan as of April 18, 2013.
Client # 8 was admitted August 28, 2012. The individual treatment and rehabilitation plan was completed November 6, 2012. . However, the individual treatment and rehabilitation plan did not include type of treatment and rehabilitation services and proposed type of support services as of April 18, 2013.
The findings were confirmed during an interview with the clinical supervisor on April 18, 2013 at approximately 3:30 P.M.
This is a repeat citation. The facility was cited on April 3, 2012 for noncompliance with this standard.
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Plan of Correction
All individual Treatment Plans will indicate the type of treatment and/or the proposed type of support services for each client. The Clinical Supervisor will include on the written timeline guide the required inclusion of type of treatment provided and external support services on all Treatment Plans. The Clinical Supervisor will create the Timeline/Document Requirement guide. The Clinical Supervisor will give and review this handout with each staff member in weekly supervision and monitor all Treatment Plans.
There were seven client charts that did not have documentation of an individual treatment and rehabilitation plan, individual treatment and rehabilitation plans that included type of treatment and rehabilitation services, and/or proposed type of support services.
These charts will be corrected by 5-24-13, and the Clinical Supervisor will be responsible for this process.
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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, the facility failed to document an individual treatment and rehabilitation plan update and/or subsequent individual treatment and rehabilitation plan update in accordance with their policy and procedures in three of five client records reviewed.
The findings include:
The facility's policy titled: "Drug & Alcohol Treatment Activities," states:
"For IOP level of care, the master treatment plan must be developed with 30 days from the date of admission and updated every 30 days thereafter ... .....For the traditional Outpatient level of care, a master treatment plan must be completed minimally within 30 days from the date of admission and must be reviewed and updated minimally every 60 days thereafter ... .......Treatment plan updates will include a formal, written review of the client's progress in relationship to the stated goals with the comprehensive treatment plan."
On April 18, 2013, five client records requiring documentation of an individual treatment and rehabilitation plan update were reviewed. The facility did not document an individual treatment and rehabilitation plan update and/or subsequent individual treatment and rehabilitation plan update in accordance with their policy and procedures in three of five client records reviewed, specifically, client records # 1, 2, and 4.
Client # 1 was admitted October 15, 2012. The individual treatment and rehabilitation plan was completed November 26, 2012. The individual treatment and rehabilitation plan update was due January 25, 2013. However, the individual treatment and rehabilitation plan update was not completed until March 20, 2013.
Client # 2 was admitted September 28, 2012. The individual treatment and rehabilitation plan was completed December 13, 2012 and the individual treatment and rehabilitation plan update was completed January 10, 2013. The subsequent individual treatment and rehabilitation plan updates were completed February 14, 2013 and March 14, 2013. However, the individual treatment plan update completed on January 10, 2013 and subsequent individual treatment and individual treatment plan update completed on March 14, 2013 did not include an assessment of the client's progress as of April 18, 2013.
Client # 4 was admitted January 7, 2013. The individual treatment and rehabilitation plan was completed February 5, 2013 and the individual treatment and rehabilitation plan update was completed April 3, 2013. However, the individual treatment and rehabilitation plan update did not include an assessment of the client's progress as of April 18, 2013.
The findings were confirmed during an interview with the clinical supervisor on April 18, 2013 at approximately 3:30 P.M.
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Plan of Correction
The Clinical Supervisor will create a written guide of all required documentation, which will include due dates and content for each required document. The Clinical Supervisor will give the guide to each staff and review it during weekly supervision. Each chart will be monitored during staff supervision to ensure Treatment Plan Updates and The Clinical Supervisor will be responsible for this process.
The subsequent treatment plan update completed on March 15, 2013 in client record # 2 will be amended to include an assessment of the client's progress. Also,the subsequent treatment plan update completed on April 3, 2013 in client record # 4 will be amended to include an assessment of the client's progress. |