INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 29 - 30, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on May 9, 2007.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
The plan documenting the qualifications and training of staff failed to include student interns as part of the support staff.
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Plan of Correction
The facility director/clinical supervisor will ensure that the facility summary report includes the names of active student interns as well as the title of the role they are functioning in while at the program. The necessity of inclusion of the above mentioned information will be conveyed to staff by the Program Director at a staff meeting on May 16, 2007.The reviews and supervision will begin immediately. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
The project failed to provide documentation of clinical supervision for the student intern conducting clinical treatment.
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Plan of Correction
The facility director will ensure that a clinical supervisor assigned to mentor a student intern will meet with the student on a weekly basis for supervision purposes. The clinical supervisor will document each supervision encounter and keep a record of the weekly interactions. The necessity of inclusion of the above mentioned information will be conveyed to staff by the Program Director at a staff meeting on May 16, 2007. The reviews and supervision will begin immediately. |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
One staff bathroom on the second floor was missing the sink, mirror, soap and mechanical dryer.
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Plan of Correction
This area, previously designated as a staff bathroom, was not being used as a functioning bathroom during the time of review. The sink, mirror and soap dispenser had been removed as part of the renovation from the area being used as a bathroom to the area being used as a storage room. The only remaining fixture in the room was the toilet bowl, which has subsequently been removed, and the room has been converted to a storage room. |
705.24 (4) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(4) Provide privacy in toilets by doors.
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Observations
The staff bathroom on the second floor was missing a full door for privacy.
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Plan of Correction
This area, previously designated as a staff bathroom, was not being used as a functioning bathroom during the time of review. The sink, mirror and soap dispenser had been removed as part of the renovation from the area being used as a bathroom to the area being used as a storage room. The only remaining fixture in the room was the toilet bowl, which has subsequently been removed, and the room has been converted to a storage room. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
The staff bathroom on the second floor was missing an exhaust fan.
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Plan of Correction
This area, previously designated as a staff bathroom, was not being used as a functioning bathroom during the time of review. The sink, mirror and soap dispenser had been removed as part of the renovation from the area being used as a bathroom to the area being used as a storage room. The only remaining fixture in the room was the toilet bowl, which has subsequently been removed, and the room has been converted to a storage room. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to provide documentation of evacuation times on the fire drill logs.
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Plan of Correction
The facility director will meet with the WPIC Corporate Safety Officer and review the current form used to document fire drills, emergency preparedness, and hazard surveillance. The form will be modified to include documentation of the amount of time that each evacuation requires. The modified form will be implemented by 7/1/07.
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711.91(b)(3)(i) LICENSURE Medical History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Medical histories were late in 8 out 10 client records. Two client records were missing a list of the symptoms and illnesses. One client record was not updated during a six month period of time. All histories need to contain the required areas, need to be documented in accordance with agency policy, and be updated within department time frames.
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Plan of Correction
The facility director/clinical supervisor will ensure through supervision and quality assurance chart review, that the aspect of medical history documentation comprises a consistent history documenting the client's historical and pertinent personal data including symptoms and illnesses as they relate to medical problems. In addition the director/clinical supervisor will ensure that the documentation of medical histories is completed on time and contains required information as to be in accordance with agency policy. Furthermore the facility director/clinical supervisor will ensure that the medical history documentation is updated within specified time frames. The necessity of inclusion of the above mentioned information will be conveyed to staff by the Program Director at a staff meeting on May 16, 2007. The reviews and supervision will begin immediately.
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711.91(b)(3(ii) LICENSURE D & A History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Nine out of ten client records were late according to facility policy. One client record did not contain an updated drug and alcohol history within Department time frames.
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Plan of Correction
The facility director/clinical supervisor will ensure through supervision and quality assurance chart review, that the aspect of personal history comprises a complete history. In addition the director/clinical supervisor will ensure that the documentation of personal histories is completed on time and contains required information as to be in accordance with agency policy. Furthermore the facility director/clinical supervisor will ensure that the personal history documentation is updated within specified time frames. The necessity of inclusion of the above mentioned information will be conveyed to staff by the Program Director at a staff meeting on May 16, 2007 The reviews and supervision. |
711.91(b)(3)(iii) LICENSURE Personal History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Nine out of ten personal histories were late according to facility policy. One client record had not been updated since an intake from a previous treatment experience. The histories were incomplete on a consistent basis. Personal histories should contain all required areas and be documented in accordance with facility policy, and be updated in accordance with Department time frames.
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Plan of Correction
The facility director/clinical supervisor will ensure through supervision and quality assurance chart review, that the aspect of psychosocial histories comprises a complete history. In addition the director/clinical supervisor will ensure that the documentation of psychosocial histories is completed for each client, completed on time and contains required information as to be in accordance with agency policy. Furthermore the facility director/clinical supervisor will ensure that the psychosocial history documentation is updated within specified time frames. The necessity of inclusion of the above mentioned information will be conveyed to staff by the Program Director at a staff meeting on May 16, 2007. The reviews and supervision will begin immediately. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Seven out of ten psychosocial evaluations were late in accordance with facility policy. One evaluation was not documented. The majority of the psychosocial evaluations failed to contain all required information. In order for evaluations be complete and properly documented they must include, on a consistent basis, all required information and be completed in accordance with the facility time frame.
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Plan of Correction
The facility director/clinical supervisor will ensure through supervision and quality assurance chart review, that the aspect of psychosocial evaluations contain perspective analysis and recommendations of clinician based upon intake presentation as well as collateral data. In addition the director/clinical supervisor will ensure that the documentation of psychosocial evaluations are completed for each client, completed on time and contain required information as to be in accordance with agency policy. Furthermore the facility director/clinical supervisor will ensure that the psychosocial evaluation documentation is updated within specified time frames. The necessity of inclusion of the above mentioned information will be conveyed to staff by the Program Director at a staff meeting on May 16, 2007. The reviews and supervision will begin immediately.
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711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) 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
Treatment plans were not individualized in all client records reviewed.
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Plan of Correction
The facility director/clinical supervisor will ensure through supervision and quality assurance chart review that the aspects of treatment plans will be developed according the needs of each individual receiving services and shall personalized according to the problems gleaned from the bio-psychosocial assessment process. The necessity of inclusion of the above mentioned information will be conveyed to staff by Program Director at a staff meeting on May 16, 2007. The reviews and supervision will begin immediately. |
711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) 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
Treatment plan goals were not realistic and measurable in the client records reviewed.
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Plan of Correction
The facility director/clinical supervisor will ensure through supervision and quality assurance chart review that the aspects of treatment plans will include goals for each client that are realistic, attainable and measurable. The necessity of inclusion of the above mentioned information will be conveyed to staff by Program Director at a staff meeting on (May 16, 2007. The reviews and supervision will begin immediately. |
711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The type and frequency of treatment to be provided was not consistently documented in the treatment plans of the clinical records reviewed.
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Plan of Correction
The facility director/clinical supervisor will ensure through supervision and quality assurance chart review that there is consistent documentation in each client treatment plan that details the type and frequency of treatment to be provided to the individual client. The necessity of inclusion of the above mentioned information will be conveyed to staff by Program Director at a staff meeting on May 16, 2007. The reviews and supervision lwill begin immediately.
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711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
The facility failed to document support services in the comprehensive treatment plans.
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Plan of Correction
The facility director/clinical supervisor will ensure through supervision and quality assurance chart review that there is consistent documentation in each client treatment plan that details a comprehensive list of support services available to the client. The necessity of inclusion of the above mentioned information will be conveyed to staff by Program Director at a staff meeting on May 16, 2007. The reviews and supervision will begin immediately.
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
In client records #5 ,6, 7, 8, 9, 10 and 12 the treatment plan updates failed to document the client's progress relative to the stated goals and objectives. The treatment plan updates also failed to address the client's completion of goals and objectives.
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Plan of Correction
The facility director/clinical supervisor will ensure through supervision and quality assurance chart review that the treatment plan updates include documentation of the client's progress/and or lack of progress in relation to each goal addressed during the previous 60 days. Furthermore the facility director/clinical supervisor will ensure that the documentation includes the client's completion of goals and objectives. The necessity of inclusion of the above mentioned information will be conveyed to staff by Program Director at a staff meeting on May 16, 2007. The reviews and supervision will begin immediately. |
711.93(a) LICENSURE Complete Client Record
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
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Observations
The facility failed to ensure that complete client records were available for review during the inspection process. This was particularly true for progress note availability in closed client records.
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Plan of Correction
The facility director/clinical supervisor will ensure through supervision and quality assurance chart review that all charts have a complete client record as defined by the agency.The Clinical Administrator, in conjunction with the Vice President of Ambulatory Operations for WPIC; the Director of Health Information Services for WPIC; and the WPIC Information Services department will arrange for access to the electronic record-keeping system during licensing reviews. The Clinical Administrator will also ensure the presence of representatives from all these aspects of the record system during the review to provide assistance and information regarding the system. This arrangement is available immediately pending appropriate notification to those departments of a minimum of 4 weeks in time. |
711.93(a)(2) LICENSURE Record of Services Provided
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes all information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(2) Record of services provided.
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Observations
The facility failed to provide for accurate records of service in client records # 1, 5 and 11. In client record #5, progress notes did not match the record of service. In client record #1 an individual treatment session and a group treatment session were documented as having taken place at the same time. In client record #11 no record of service was available.
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Plan of Correction
The facility director/clinical supervisor will ensure through supervision and quality assurance chart review, that accurate records of services are kept for each client and there is no duplication of services rendered. Furthermore the facility director/clinical supervisor will ensure that progress notes match the record of services and the documentation reflects this appropriately. The necessity of inclusion of the above mentioned information will be conveyed to staff by the Program Director at a staff meeting on May 16, 2007 The reviews and supervision will begin immediately.
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711.93(a)(4) LICENSURE Progress Notes
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(4) Progress notes.
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Observations
The facility failed to ensure that group notes consistently documented an assessment of the client's participation in group in all of the client records reviewed. The assessment piece should be the clinical interpretation of the client's participation and progress by the counselor. In client record #12 numerous individual notes were missing.
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Plan of Correction
The facility director/clinical supervisor will ensure through supervision and quality assurance chart review, that there is documentation of an assessment of each client's participation during each group attended. The assessment will consist of the counselor's clinical interpretation of the client's participation and progress. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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
The UPMC/University of Pittsburgh Medical Center Consent to Treatment and Payment form contains general consents to release information which are not permitted by drug and alcohol confidentiality regulations. Although a separate, restricted drug and alcohol specific consent (#6 on the form) has been added, this does not supercede or replace the general consent contained in #1C and #3.
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Plan of Correction
The Clinical Administrator shall meet with members of WPIC Corporate Administration in regard to developing an appropriate consent to release protected drug and alcohol regulation. The consent form shall be in compliance with 4 PA 255.5 as well as directly in 42 CFR Part 2, Subpart C, subsection 2.32 and indirectly at subsection 2.31 as regards confidentiality of drug and alcohol treatment records, and shall demonstrate the patient's intent to release information voluntarily. This form shall contain the following information: The name of the person, agency, or organization to whom disclosure is made; the specific information disclosed; the purpose of disclosure and, the dated signature of the client or guardian. This form shall be implemented by 10/1/07. |
711.95(b) LICENSURE Efficient Retrieval of Data
711.95. Uniform Data Collection System.
(b) A data collection system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
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Observations
Information requested during the licensing inspection was not easily retrieved and in some cases could not be retrieved.
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Plan of Correction
The Clinical Administrator, in conjunction with the Vice President of Ambulatory Operations for WPIC; the Director of Health Information Services for WPIC; and the WPIC Information Services department will arrange for access to the electronic record-keeping system during licensing reviews. The Clinical Administrator will also ensure the presence of representatives from all these aspects of the record system during the review to provide assistance and information regarding the system. This arrangement is available immediately pending appropriate notification to those departments of a minimum of 4 weeks in time.
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