INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on September 30, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Alpha House Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
|
Observations
Based on a review of the personnel records on October 7, 2021, the staff person appointed as the Project Director/Facility Director on August 2, 2021 failed to have the required 2-year experience which includes supervision of others and program planning.
|
Plan of Correction
The Board representatives for the facility are responsible for ensuring that corrective action is taken to officiate the repositioning of staff #1, who as Project Director/Facility Director, did not meet standard qualifications.
The Board acted in the following way: Staff #1, who was appointed as the Project Director/Facility Director on August 2, 2021 and failed to meet the required 2-year experience of supervision of others and program planning, has been repositioned as of October 1, 2021, as Clinical Supervisor. Staff #1 meets the standard qualifications.
Staff #2 has been hired and appointed as the Project Director/Facility Director on November 4, 2021 and is a qualified person. Staff #2 has a masters degree and 17+ years of experience in the human service agency to include supervision of others, direct service, and program planning.
Project Director/Facility Director and Clinical Supervisor are currently responsible for hiring staff. To ensure that candidates have the required experience and proper qualifications for the position being applied for, the Clinical Supervisor has implemented a binder for reference, containing chapter 704 staffing regulations, to be reviewed before initiating the hiring process. Specifically, before an initial interview can be scheduled, the hiring staff (Project Director/Facility Director and Clinical Supervisor) must first consult the binder with chapter 704 staffing regulations to verify that required experience and proper qualifications are met. Once confirmed that an applicant has met the standard qualifications, then an initial interview can be scheduled.
On November 10, 2021, in response to ensuring that all current staff meets standard qualifications for their current position, the Clinical Supervisor has reviewed each current employee personnel file to confirm that each employee meets the required experience and proper qualifications, according to the reference binder containing chapter 704 staffing regulations. The conclusion of this review is that all current employees meet standard qualifications for the position in which they are employed.
This facility is in full compliance of the employee qualifications standard as of November 4, 2021.
This facility is in full compliance of implementing measures to make sure this deficiency does not recur, as of November 10, 2021, by creating the chapter 704 reference binder for future hiring purposes, and using it to conduct an immediate review of all current employees compliance. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of the client's record on September 30, 2021, the facility failed to document the reason for the client's discharge on the Notice of Termination dated 7/22/21. The reason documented was because the client violated a cardinal rule.
|
Plan of Correction
A staff person who discharges a client from this facility is responsible for notifying the client, in writing, of the decision to involuntarily terminate the client's treatment project and that needs to include the reason(s) for termination.
Stating that the "client violated a cardinal rule" is insufficient reasoning.
Staff has been trained and supervised in a mandatory staff meeting on the following dates: 10/13/21, 10/20, 2021, and 10/27/21, to teach and train staff to comply with the standard for producing, in writing, the facility decision for involuntary termination for the purpose of sufficiently notifying the client.
The facility has repurposed its discharge form to include a written summary of discharge whereby the client will receive a copy with sufficient reasoning for involuntary discharge from his or her treatment project.
Staff #1 is responsible for supervising the discharge process, following up with each discharge, and has been appointed as the oversight in reviewing and approving the repurposed discharge summary forms, to be given to the client and to be filed in the client chart. |
709.53(a) LICENSURE Complete Client Record
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
|
Observations
Based on a review of the client's record on September 30, 2021, the facility failed to provide a complete client record. Additional information that was not included in the client's record was emailed to the Program Representative Supervisor on 10/1/21 and 10/5/21 after the completion of the complaint investigation.
|
Plan of Correction
Primary Counselors and all staff that complete documentation for clients are responsible for contributing to and producing a complete client record that includes all items relative to client involvement in his or her treatment project.
As of October 13, 2021, the Clinical Supervisor conducts chart reviews once a week and is responsible for addressing missing items of documentation that constitutes a complete client record.
A form has been created and is being used to verify chart review dates by the Clinical Supervisor and is filed in the client record.
This facility is currently in compliance of ensuring that the client has a complete client record. |
709.53(a)(5) LICENSURE Progress Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
|
Observations
Based on a review of the client's record on September 30, 2021, the facility failed to include all progress notes in the record. Progress notes were emailed to the Program Representative Supervsior on 10/1/2021 and 10/5/2021 after the complaint investigation was completed.
|
Plan of Correction
The primary counselor is responsible for including all progress notes in the client's record.
The Clinical Supervisor is responsible for conducting weekly chart reviews to ensure that all progress notes are in the client's record. As of October 13, 2021, if a client record is missing progress notes, then the Primary Counselor will be advised to complete the progress note and include it in the clients record within that week. The chart review for the client is not considered completed until the client record includes all progress notes.
Clinical Supervisor will provide additional oversight by ensuring that primary counselors complete one hour of training through NAADC titled The Progress Note: Where Laws and Ethics Meets Efficiency. Primary Counselors must complete the quiz and earn the CEU by November 12, 2021. This training addresses the importance of improving documentation skills for progress notes.
As of October 13, 2021, this facility has been in compliance of including all progress notes in the client record, according to the completed chart reviews. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
|
Observations
Based on a review of the client ' s record on September 30, 2021, the facility failed to have included in the client ' s record a complete discharge summary. The form only stated that the client was discharged because of staff decision.
|
Plan of Correction
Primary Counselors and the Clinical Supervisor are responsible for completing a discharge summary in the client's record.
Previous Client #1 discharge summary stated "staff decision" and this is insufficient and does not indicate a discharge summary.
The staff person handling the discharge is responsible for immediately documenting a summary of discharge in the client record and providing it, in writing, on the discharge letter, of which the client will receive a copy.
The discharge summary needs to state the reasons for discharge. The Clinical Supervisor trained Primary Counselors on what constitutes a sufficient discharge summary for the client record and form during the mandatory staff meeting on October 20, 2021.
The summary is provided on the repurposed form that has been in effective use since October 13, 2021.
The Clinical Supervisor reviews the discharge summary in the client record and on the discharge letter form during weekly chart reviews. Discharge summary is on the check list for the chart review form that the Clinical Supervisor uses.
If during a chart review the Clinical Supervisor identifies this item is missing, it will be completed within the week by the staff who handled the discharge, to provide the reasons.
This facility has been in compliance since October 13, 2021, due to the chart reviews being conducted by the Clinical Supervisor to ensure a complete client record, including a complete discharge summary.
|