INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 7-9, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cornell Abraxas I 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 March 18, 2011.
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, an interview with the facility director and a Division supervisory review, the facility failed to ensure that each counselor met the qualifications for the position in one of six personnel records.
The findings include:
On February 7-8 2011, sixteen personnel records were reviewed. Six personnel records were required to have documentation of the qualifications for the position of counselor. The facility failed to ensure documentation of counselor qualifications in personnel records # 8.
Employee # 8 was hired as a drug and alcohol counselor assistant on October 9, 2009 and promoted to a drug and alcohol counselor on November 14, 2010. Employee # 8 has a Bachelor of Arts in Administration of Justice. A supervisory review by the Division was held on February 9, 2001 and employee # 8 was found not to meet the educational requirements for the position of counselor. The degree was found to be more law enforcement / investigation focused rather than behavioral/ rehabilitation focused.
The facility director was interviewed on February 9, 2011. No additional information was available for review. It was reported that facility staff was under the impression that this degree would qualify for the position of counselor.
|
Plan of Correction
The counselor successfully completed 12 weeks of direct observation and 36 weeks of close supervision. She received a positive assessment to carry full caseload on December 2, 2009. She continues to have monthly supervisory conference with a clinical supervisor. In order to fulfill counselor qualifications, she is pursuing Certified Alcohol and Drug Counselor certification through the Pennsylvania Certification Board (PCB). She will complete the application process no later than March 8, 2011. Once the application is accepted, PCB will provide her with a list of test dates & locations. The counselor will then schedule a date/time to complete the test. Once the counselor obtains the certification, a verified copy of the certification will be maintained in the counselor's personnel file.
To ensure future candidates meet counselor qualifications, the quality & compliance specialist and/or program manager will review the candidate's transcripts. Prior to the candidate being offered a counselor position, the specialist or program manager will determine if the degree is related. Particular emphasis will be placed upon college courses in the behavioral/rehabilitative/social sciences.
|
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the fire drill logs and an interview with the facility director, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on February 8, 2011. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility did not document any alternate exits used during fire drills for the months of March - December 2010 and January 2011. The front door was the exit route used during every fire drill.
An interview with the facility director took place on February 9, 2011 at approximately 1:30 PM. It was reported that the facility is alternating exits during drills, however; it is not being properly documented. No additional documentation was presented for review.
|
Plan of Correction
The quality & compliance specialist met with the Safety Officer on February 24, 2011. They revised current documentation relative to fire drills, to accurately reflect if primary or secondary exits were being used. The quality & compliance specialist provided the revised documentation to the Maintenance Department and Supervisory Teams. She explained the need to alternate exit routes each month. In addition, the quality & compliance specialist explained the exit route used should be clearly documented on the Fire Drill Log. She emphasized the importance of documenting if the primary or secondary exit was used.
The revised documentation will be implemented for all drills beginning in March. The safety officer and quality & compliance specialist will monitor fire drill logs to ensure compliance with the standard. Findings will be discussed in the monthly Safety/Infection Control Committee meetings.
|
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. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on a review of client records, qualified service organization agreements and an interview with the facility director, the facility failed to document an informed and voluntary consent or a qualified service organization agreement when releasing blood/urine samples to an outside agency for testing in three out of three client records.
The findings include:
Thirteen client records were reviewed on February 7-9, 2011. Blood/urine samples were sent to an outside agency in three client records. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Client records # 1, 4 and 8 did not include a signed consent to release information from nor was a qualified service organization agreement in place for the outside agency.
Client # 1 was admitted on November 12, 2010. On November 13, 2010, a blood/urine sample was sent to an outside agency for laboratory analysis without an informed and voluntary consent from the client.
Client # 4 was admitted on September 10, 2010. On October 20, November 16 and November 18, 2010, blood/urine samples were sent to an outside agency for laboratory analysis without an informed and voluntary consent from the client.
Client # 8 was admitted on October 22, 2010. On November 25, 2010, a blood/urine sample was sent to an outside agency for laboratory analysis without an informed and voluntary consent from the client.
The facility director was interviewed on February 9, 2011 at approximately 1:30 PM and confirmed the facility did not have a qualified service organization agreement with the agency that conducts blood/urine testing. The facility director also confirmed that informed and voluntary consents had not been completed for clients who were participating in blood/urine testing.
|
Plan of Correction
On February 18, 2011, the quality & compliance specialist spoke with representatives from Quest Diagnostics. The representative agreed to complete a qualified service organization agreement with Abraxas I. This agreement would specify the services Quest would provide, while addressing requirements surrounding client confidentiality. Quest Diagnostics completed the agreement on February 21, 2011. Two copies were completed. One is on file with the quality & compliance specialist; the other is with Quest Diagnostics. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
|
Observations
Based on a review of policy and procedure, monthly medication storage area inspection logs and an interview with the facility director, the facility failed to document monthly inspections of the medication storage areas as required by agency policy.
The findings include:
The monthly medication storage area inspection logs were reviewed on February 8, 2011. Per agency policy, inspections of the medication storage areas are to be conducted monthly. There were no medication storage area inspections for the months of April, July, October, November and December 2010. There was also no inspection of the medication storage area for the month of January 2011.
An interview with the facility director took place on February 9, 2011 at approximately 1:30 PM, at which time the aforementioned information was confirmed. No additional documentation was provided for review.
|
Plan of Correction
On February 2, 2011, the quality & compliance specialist met with each of the nurses. We discussed medication storage inspections. We also reviewed how to document the inspection. Each nurse was assigned an area to inspect. Inspections are to be completed on a monthly basis. Each nurse is to submit his/her documentation to the quality & compliance specialist by the 5th of the following month. The quality & compliance specialist will monitor inspection documentation to ensure compliance. Findings will be discussed in the monthly Safety/Infection Control Committee meetings. |