INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25 and 31, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System - IOP/CAP 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 and a plan of correction is due on November 26, 2007.
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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 a review of employee records, the facility failed to document that one employee met the required experience for the position of counselor, #3.
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Plan of Correction
Beginning 11-22-07 before a counselor is hire will be require to present evidence of his/her past clinical experience by providing an in detail letter of reference or updated resume. The facility director will review the information provided to ensure that the person has a minimum of one year of clinical experience before been hired as a counselor. In the event that the facility director is unable to determine whether the person meets the criteria to be a counselor, the information collected including copies of the persons transcripts will be sent to the Department of Health to be reviewed to determine if the person is qualified to be a counselor. Regarding the person that was hire as a counselor without the necessary experience, her position will be changed to a counselor's assistant in accordance with the guidelines found in "704.9. Supervision of counselor assistant." The facility director will be in charge making and recording these changes and of supervising the counselor assistant. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of administrative documents on 10/25/07, the facility failed to document the use of alternate exit routes in nine of the last nine fire drills.
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Plan of Correction
On 12-13-07 the IOP/CAP staff will be trained on how to properly complete the evacuation log. Beginning 12-14-07 the staff will begin to record the usage of the alternate fire exit. The Facility Director will ensure that this process takes place by reviewing the evacuation log on a monthly basis. Any staff person that does not complete the evacuation log according to the regulation will be retrained and if needed progressively disciplined. |
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
Based on a review of client records on 10/31/07, the facility failed to document a complete drug and alcohol history in six of six records reviewed. Lengths and patterns of use were missing in six of six records reviewed, #1, 2, 3, 4, 5 and 6. The client's perception was missing in four of six client records reviewed, #3, 4, 5 and 6.
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Plan of Correction
A form will be created by the Facility Director before 12-13-08 that will be used and eventually added to the psychosocial to better capture the information requested in 711.91(b)(3(ii) (patterns of use). The IOP/CAP counselors will be trained by the facility director on how to use the form and on 12-14-08 the counselors will start using it. The Facility director will be in charged of conducting monthly chart reviews to ensuring that the counselors capture the information required beginning. Any Biopsychosocial that does not complies with this regulation will be returned to the counselor for correction. This will begin 12-14-08. |
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
Based on a review of client records on 10/31/07, the facility failed to document a complete psychosocial evaluation in six of six client records reviewed, #1, 2, 3, 4, 5 and 6. A clinical assessment of the clients's assets/strengths and support systems were missing in #1, 2, 3, 4, 5 and 6. Negative factors which may inhibit the potential for treatment and counselor conclusions and impressions were missing in five of six records reviewed, #1, 2, 3, 5 and 6. The clients's attitude toward treatment was missing in four of six records reviewed, #1, 4, 5 and 6. Coping mechanisms were not documented in two of six client records reviewed, #1 and 5.
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Plan of Correction
On 12-13-07 the IOP/CAP counselors will be trained by the facility director on how to complete the Psychosocial Evaluation. Beginning 12-14-07 any psychosocial evaluation that does not meet the requirements found in 711.91(6) will be returned to the counselor for correction. This process will be enforced by the facility director. There will be monthly chart reviews by the Facility Director to ensure that this regulation is followed. |
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
Based on a review of client records on 10/31/07, the facility failed to document goals stated in terms of measurable criteria in six of six client records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
On 12-13-07 the IOP/CAP counselors will be trained by the facility director on how to develop measurable long and short term goals. Beginning 12-14-07 any treatment plan that does not include measurable long and short term goals will be returned to the counselor to be corrected. The facility director will be in charged of ensuring that this process takes place by conducting chart reviews on a monthly basis. |