INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10 - 12, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System At Williamsburg 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report forms for all of the facilities within the drug and alcohol treatment project, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Report forms for the drug and alcohol treatment project's seventeen facilities were reviewed on March 2, 2015. The project employs a total of 106 full-time counselors and counselor assistants. This number of full-time counselors and counselor assistants would require a minimum of 13 full-time clinical supervisors. The project currently employs 8 full-time clinical supervisors, as of March 2, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Management, along with the Executive Director, will ensure there is one full-time clinical supervisor for every eight full-time counselors and counselor assistants. Caseloads will be redistributed by July 1, 2015 so that clinical supervisors who carry a caseload fall within the guidelines of chapter 704.6. Facility directors and clinical supervisors will be re-educated by the Quality Management Department on permissible case load sizes for each level of care.
Compliance will be accomplished by the facility director, along with the clinical supervisor(s), monitoring the number of full-time counselors vs. clinical supervisors on a quarterly basis.
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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
Based on a review of personnel records, the facility failed to document the required period of close supervision for one counselor assistant.
The findings include:
Five personnel records pertaining to newly hired counselor assistants were reviewed on March 10, 2015. These five personnel records were reviewed for documentation of close supervision. The facility failed to document the required period of close supervision for employee # 9.
Employee # 9 is a counselor assistant and was hired on August 18, 2014. Employee # 9 has a Bachelor's degree in a related field but does not have the one year of clinical experience required for the position of counselor. Employee # 9 is required to have six months of close supervision. The facility failed to document the required period of close supervision for employee # 9.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will document weekly supervisions for Employee #9 until August 18th, 2015.
Employee #9 will then meet the requirements for "counselor".
Weekly supervision documentation will be monitored by the system's quality management department.
Quality management staff will review all new hire resumes and qualifications to ensure that the new hire meets the qualifications required to be a counselor/counselor assistant. Quality Management will also ensure that required supervision for the position is completed.
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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 the facility's Staffing Requirements Summary Report form, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training and other health related topics using a Department approved curriculum.
The findings include:
The facility's Staffing Requirements Summary Report form was reviewed on March 10, 2015. Eight employees listed on the Staffing Requirements Summary Report form did not have the required HIV/AIDS and TB/STD training.
Employee # 11 was hired as a counselor assistant on December 30, 2013. HIV/AIDS and TB/STD training was due to be completed no later than December 30, 2014. There was no documentation of HIV/AIDS and TB/STD training for employee # 11, as of March 10, 2015.
Employee # 12 was hired as support staff on February 11, 2013. HIV/AIDS and TB/STD training was due to be completed no later than February 13, 2015. There was no documentation of HIV/AIDS and TB/STD training for employee # 12, as of March 10, 2015.
Employee # 13 was hired as support staff on November 26, 2012. HIV/AIDS and TB/STD training was due to be completed no later than November 26, 2014. There was no documentation of HIV/AIDS and TB/STD training for employee # 13, as of March 10, 2015.
Employee # 14 was hired as support staff on May 11, 2011. HIV/AIDS and TB/STD training was due to be completed no later than May 11, 2013. There was no documentation of HIV/AIDS and TB/STD training for employee # 14, as of March 10, 2015.
Employee # 15 was hired as support staff on June 2, 2010. TB/STD training was due to be completed no later than June 2, 2012. There was no documentation of TB/STD training for employee # 15, as of March 10, 2015.
Employee # 16 was hired as support staff on September 11, 2012. HIV/AIDS and TB/STD training was due to be completed no later than September 11, 2014. There was no documentation of HIV/AIDS and TB/STD training for employee # 16, as of March 10, 2015.
Employee # 17 was hired as support staff on January 3, 2012. HIV/AIDS training was due to be completed no later than January 3, 2014. There was no documentation of HIV/AIDS training for employee # 17, as of March 10, 2015.
Employee # 18 was hired as support staff on June 3, 2011. HIV/AIDS training was due to be completed no later than June 3, 2013. There was no documentation of HIV/AIDS training for employee # 18, as of March 10, 2015.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 17 - 19, 2014 licensing inspection.
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Plan of Correction
Staff persons will receive a minimum of 6 hours HIV/AIDs and at least 4 hours of TB/STD using a State Department approved curriculum. Counselors and counselor assistants will receive training within the first year of employment and all other staff shall complete the training within the first 2 years of employment.
Cove Forge has identified a trainer who will utilize the Department of Drug & Alcohol's curriculum to prepare education and training in these topics. The trainer will provide training for staff at Cove Forge BHS on a quarterly basis and/or as needed based on the number of new staff needing training.
Cove Forge will strive to have the trainer prepared to begin educating staff by June 30th 2015.
The Nursing Director will be responsible for working with the identified staff to prepare the training materials and assist in finalizing the training plans.
Based on the surveyor's review of the current staff training requirements, eight employees did not have the required HIV/AIDS and TB/STD training.
HIV/AIDS training is being offered at Cove Forge on 4/21/15 and TB/STD training is being offered at Cove Forge on 4/27/15. The eight employees #'s11 through #18 have been registered for these trainings. Staff supervisors will be responsible for ensuring that these employees attend the training.
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709.83(a) LICENSURE Client records
709.83. 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual which included information relative to the client's involvement with the project in four of five partial hospitalization client records.
The findings include:
Five partial hospitalization client records were reviewed on March 10 - 12, 2015. Five client records required documentation of a record of services provided. Three client records were closed and required documentation of a discharge summary. The facility failed to document a record of services provided in client records # 5, 8 and 9. The facility failed to document a discharge summary within one week after discharge in client records # 7, 8 and 9.
Client # 5 was admitted into treatment on January 12, 2015. Per review of the client's treatment plan and progress notes, the client was receiving individual and group counseling weekly. There was no documentation of a record of services provided in client record # 5.
Client # 7 was admitted into treatment on September 23, 2014 and discharged on October 16, 2014. A discharge summary was due to be completed no later than October 23, 2014. The discharge summary for client # 7 was not completed until December 1, 2014.
Client # 8 was admitted into treatment on October 11, 2014 and discharged on October 25, 2014. Per review of the client's treatment plan and progress notes, the client was receiving individual and group counseling weekly. There was no documentation of a record of services provided in client record # 8. A discharge summary was due to be completed no later than November 1, 2014. The discharge summary for client # 8 was not completed until March 10, 2015.
Client # 9 was admitted into treatment on December 18, 2014 and discharged on January 8, 2015. Per review of the client's treatment plan and progress notes, the client was receiving individual and group counseling weekly. There was no documentation of a record of services provided in client record # 9. A discharge summary was due to be completed no later than January 15, 2015. The discharge summary for client # 9 was not completed until March 10, 2015.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 17 - 19, 2014 licensing inspection.
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Plan of Correction
The Clinical Director and Assistant Director met with the clinical counseling department on March 13, 2015 and reviewed the findings of the review.
Clinical staff were re-educated on the need for every client to have a complete record of service and discharge summary in every chart.
A minimum of 10 charts will be reviewed by the Clinical Director and Assistant Director monthly for the next 6 months to ensure there is a Record of Service and it is completed thoroughly and accurately.
Counselor together with patient #5 completed the Record of Service.
The duration section of the Record of Service has been added to the EMR (electronic medical record).
The Clinical Director and Assistant Director will be responsible for monitoring patient records and counseling staff for delinquent discharge documentation
Since the implementation of the EMR, (electronic medical record) daily alerts will be sent to the counselors who do not have their discharge summaries completed within 7 days post discharge.
These alerts will be monitored by the Clinical Director as well as the Assistant Director on a daily basis for six months. They will prompt and counsel counselors who are not timely in completing the discharge summary.
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