INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 21, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northwestern Human Services of PA., Susquehanna Center was found to be not 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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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of the facility's Staffing Requirements Facility Summary Form, one counselor assistant supervision notes and a conversation with facility staff, the facility failed to have a full-time clinical supervisor or counselor provide the required supervision for two counselor assistants. This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Regulation 704.5(b) states that "If the facility does not have a clinical supervisor on staff, clinical responsibilities shall be addressed in one of the following ways: (b)(1) A facility director who has direct responsibility for clinical services shall meet the qualifications in at least one of the paragraphs of 704.7(b) (relating to qualifications for the position of counselor) Where the director provides clinical supervision or counseling, he/she must meet the qualifications for the position of counselor.
Our facility does not have a Clinical Supervisor position. The Program Director has always held a dual role of Program Director and Clinical Supervisor. The Program Director/Clinical Supervisor has been responsible for the direct and indirect supervision of counselor assistants. The facility will submit an exception letter request to DDAP by 1/1/17. If the exception request is not granted the facility will make sure there is a Lead Counselor who meets the qualifications defined in "704.6. Qualifications for the position of clinical supervisor" assigned to any future Counselor Assistant. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and an interview with the project/facility director, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in employee record #17. Employee #17 was was hired August 16, 2016. This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to have the training completed within 7 days of the staff's hire date. Currently, all staff attend Fire Safety Training on day one of New Hire Training. In addition, fire extinguisher training occurs on site of the facility. This is facilitated by the Program Director within 7 days of their start date. Staff #17 did not have the new hire training line up with her start date for her internship semester. Moving forward, when there is an intern, the facility will ensure that their fire safety training is completed during new hire within the 7 days of hire. If the start date for their internship does not line up with new hire training, the program director will facilitate Fire Safety Training to meet the regulation. Records of this training will be kept in their personnel and training records so it is available during licensure inspection. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and an interview with the project/facility director, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in personnel records #6, 7, 15, 16 and 17.Employee #6 was hired on as a counselor on 12/3/15. Employee #7 was hired as a counselor on 10/3/16. Employee #13 was hired as an intern on 10/12/15 and as a counselor assistant on 5/9/16. Employee #15 was hired as an intake coordinator on 10/20/15. Employee #16 was hired as an administrative assistant on 4/4/16. Employee #17 was hired as an intern/counselor on 8/16/16. This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff will be trained/re-trained by the Program Director on emergency procedures for our facility location during our staff meeting on 11/29/16. Then staff #'s 6,7,15, and 16 will have training through a site specfic emergency procedure. Staff #17 is no longer with the facility. Moving forward all new staff will be trained by the Program Director on their first day of new hire that is onsite. |
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
Based on a review of fire drill records submitted by the facility director, for the period from 10/23/15 through 9/22/16, the facility failed to indicate the time of day during which the fire drills were conducted.This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director will create a fire drill log by 11/23/16 that will include time of day of the fire drill. Starting with November's Fire Drills the Program Director will conduct all fire drills and document all necessary information including time of day to ensure that we are completing drills during different hours of operation. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records conducted on October 21, 2016, the facility failed to document an annual performance evaluation for employee #1. Employee #1 was hired as the Project Director on 7/1/2015. This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Currently all clinical and administrative staff have employee evaluations completed by the Program Director. The Program Director's performance evaluation is completed by the Project Director. NHS will ensure that moving forward the Project Director will have their performance evaluation completed annually by their supervisor. This will be monitored through the use of calendar alert that will alert the Program Director and Project Director about the evaluation approximately 2 months prior to the due date. This evaluation will then be forwarded to the personnel records so that the evaluation is available upon licensure inspection. The current Project Director will have his performance evaluation completed and reviewed with him by 12/31/16. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records and a conversation with facility staff on October 21, 2016, the facility failed to utilize an informed and voluntary consent to release form in client records, #1 through 9. The facilty failed to include on the consent to release form that the client has the right to revoke in writing or verbally. The facility only gave the client the option to revoke, on the consent to release form, in writing to the Project Director. Additionally, client record #7 contained a release to a government agency dated 1/26/16 that did not indicate the purpose of the information to be release.This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
NHS updated all Drug and Alcohol releases as of September 2016. The Language was changed from: "I may revoke this Authorization at any time, in writing to the Director of the program from which I received treatment, except to the extent that action has been taken in reliance thereon." to: "I may revoke this Authorization at any time except to the extent that NHS has acted in reliance on this Authorization." On 10/24/16 all non-compliant blank releases were shredded to avoid the incorrect release being used. On 10/24/16 all staff were instructed via email that all new clients need to have the updated current releases, which were attached to the email. Also, all staff were instructed to replace the non-compliant releases for all current drug and alcohol clients' by completing new releases with the compliant language at the consumer's next individual counseling session. For all current clients this will be tracked through each counselor's D&A client spreadsheet. This spread sheet is already submitted to the Program Director at the end of each week. Upon receipt of the spreadsheet each week the Program Director will send reminders to each counselor of who is still in need of an updated release. All current consumers will have the non-compliant release replaced by the compliant release by 1/30/17. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's policy and procedure regarding the reporting of unusual incidents, the facility failed to include adequate verbiage pertaining to the reporting of events at the facility requiring the presence of police, fire or ambulance personnel.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
We have updated the verbiage for the department in our current policy. The policy reflects the language change from DOH to DDAP. This policy was updated by our Quality department on 11/17/16. As of 11/17.2016 the policy now includes the correct language. |
709.34 (c) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on a review of facility's policy and procedure regarding the reporting of unusual incidents, the facility failed to include adequate verbiage pertaining to the reporting of events at the facility regarding outbreak of a contagious disease requiring CDC notification.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
We have updated the verbiage for the department in our current policy. The policy reflects the language change from DOH to DDAP. This policy was updated by our Quality department on 11/17/16. As of 11/17.2016 the policy now includes the correct language. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation that included the counselor's documented evaluative statement and recommendations based on information gathered in client histories in records #4 & 9. Client #4 was admitted on 4/20/15 and was an active client at the time of the licensing inspection. Client #9 was admitted on 8/6/15 and was discharged on 12/29/15.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
All newly completed psychosocial evaluations will be reviewed by the Program Director. While auditing the chart the Program Director will review each counselor's overall psychosocial evaluation and recommendations to ensure the full picture of the client is being captured. If there is an evaluation in which it appears the evaluation has limited content in those identified sections the Program Director will work directly with the counselor in supervision to improve the overall evaluation and recommendation for the client. |