INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 19 and 20, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Diakon Lutheran Social Ministries was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on a review of personnel records and the facility's policy and procedures, the facility failed to document feedback on completed training in three of nine records.
The findings include:
Nine personnel records were reviewed on November 19, 2012. Of the nine, seven were reviewed for training and documentation of feedback forms after the completion of training, #1, 2, 3, 4, 5, 6 and 8. The following records failed to show documentation of feedback forms in records, #1, 5 and 6. The training year reviewed was January 1, 2011 through December 31, 2011.
The facility director and clinical supervisor was interviewed on November 20, 2012 and confirmed the findings.
|
Plan of Correction
Preparation and submission of this plan of correction is required by State and Federal Law. The Plan of Correction does not constititute admission for purposes of general liability, professional malpractice or any other court proceeding.
The Clinical Director/designee will retrain staff on the completion of training feedback forms.
Training certificates will not be accepted without a completed Feedback Form.
The Clinical Director/Designee will audit personnel records to ensure the training and documentation of feedback forms are in place. Any issue noted will be addressed as appropriate. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in two of six personnel records.
The findings include:
Nine personnel records were reviewed on November 19, 2012. Six personnel records pertained to counselors, #4, 5, 6, 7, 8 and 9. Four of the six personnel records required the completion of 25 clock hours of annual training, #4, 5, 6 and 8. The facility failed to document 25 clock hours of annual training in personnel records, #5 and 8.
Employee # 5 was hired on January 18, 2010. The facility training year is from January through December. Employee # 5 only completed 9 clock hours of annual training from January 1, 2011 through December 31, 2011.
Employee # 8 was hired on May 17, 2010. The facility training year is from January through December. Employee # 8 only completed 24 clock hours of annual training from January 1, 2011 through December 31, 2011.
An interview with the facility director and clinical supervisor on November 20, 2012 confirmed the findings.
|
Plan of Correction
The Clinical Director/designee will conduct monthly audits of staff training hours to insure required hours are being met.
Staff will be updated monthly on the status of training hours.
Any issues identified will be addressed as appropriate. |
709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document case consultations in four of eight client records.
The findings include:
Eleven client records were reviewed on November 20, 2012. Eight of the eleven were required to show documentation of a case consultation in client records, #1, 2, 3, 5, 6, 7, 8 and 9. Per the facility's policy, case consultations are to be completed within 90 days of the client's admission date.
Client # 2 was admitted on May 22, 2012. The case consultation was to be documented by August 22, 2012. Client # 2's case consultation was documented September 26, 2012.
Client # 6 was admitted on August 16, 2012. The case consultation was to be documented by November 16, 2012. As of the date of the licensing inspection, there was no documentation of client # 6's case consultation.
Client # 7 was admitted on June 29, 2012. The case consultation was to be documented by September 29, 2012. Client # 2's case consultation was documented October 9, 2012.
Client # 8 was admitted on June 5, 2012 and discharged October 22, 2012. The case consultation was to be documented by September 5, 2012. Client # 8's case consultation was documented September 12, 2012.
An interview with the facility director and clinical supervisor on November 20, 2012 confirmed the findings
|
Plan of Correction
The Clinical Records of clients #2, #6, #7 and #8 cannot be corrected retroactively.
The Clinical Director/designee will retrain staff on the proper completion of the case consultation form at a staff meeting.
The Clinical Director/designee will conduct weekly random chart audits to insure compliance.
Any issues identified will be addressed as appropriate. |
709.93(a)(10) LICENSURE Client records
709.93. 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:
(10) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to include components in the discharge summary.
The findings include:
Eleven client records were reviewed on November 20, 2012. Four discharge client records were required to have documentation of a discharge summary, #8, 9, 10 and 11. The following components are required to be documented on the discharge summary; reason for treatment, services offered, respond to treatment and client status. The facility failed to include documentation that included the reason for treatment on the discharge summary for clients # 8, 9 and 11. Also, the documentation failed to include the client's response to treatment on the discharge summary in client # 8's record.
An interview with the facility director and clinical supervisor on November 20, 2012 confirmed the findings.
|
Plan of Correction
The clinical records of clients #8, #9, #11 cannot be corrected retroactively.
The Clinical Director/designee will retrain staff on the proper completion of the Discharge Summary.
The Clinical Director/designee will condut audits on all discharged charts to insure proper completion.
Any issues identified will be addressed appropriately. |
709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
|
Observations
Based on client record review, the facility failed to document a follow up attempt in two of four discharge client records.
The findings include:
Eleven client records were reviewed on November 20, 2012. A follow up attempt is required in four of the client records. The facility did not document a follow up in two client records, #10 and 11. The facility policy states that follow up will be attempted within 7 days for referrals, 30 days all others. An interview with the facility director and clinical supervisor on November 20, 2012 confirmed the findings.
Client #10 was admitted on October 3, 2012 and discharged on October 19, 2012. The follow-up attempt was to be documented by November 19, 2012. There was no follow-up attempt documented in client record #10.
Client #11 was admitted on December 13, 2011 and discharged on August 17, 2012. The follow-up attempt was to be documented by September 17, 2012. There was no follow-up attempt documented in client record #11.
|
Plan of Correction
The clinical records of clients #10 and #11 cannot be corrected retroactively.
The Clinical Director/designee will retrain staff on the proper procedure for post discharge follow-up attempts.
Random audits will be conducted by the Clinical Director/designee to insure documentation compliance.
Any issues identified will be addressed as appropriate. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
|
Observations
Based on a physical plant inspection, the facility failed to display the facility's hours of operation that can be accessed by the general public in case of an emergency.
The findings include:
A physical plant inspection was conducted on November 20, 2012. The facility's hours of operation that is conspicuously displayed to the general public is required at all outpatient treatment programs. The facility did not display their hours of operation. An interview with the facility director and clinical supervisor on November 20, 2012 confirmed the findings.
|
Plan of Correction
The hours of operation will be displayed to the general public in a conspicuous location.
Random inspections of the hours of operation posting will be conducted by the Clinical Director/designee and/or Facility Director.
Any issues identified will be addressed as appropriate. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
|
Observations
Based on a physical plant inspection, the facility failed to display a telephone number that can be accessed by the general public in case of an emergency.
The findings include:
A physical plant inspection was conducted on November 20, 2012. A telephone number that is conspicuously displayed to the general public is required at all outpatient treatment programs. The facility did not display an emergency telephone number. An interview with the facility director and clinical supervisor on November 20, 2012 confirmed the findings.
|
Plan of Correction
The Clinical Director/designee will post the emergency telephone number in an area easily viewed by the general public.
Random inspections for the emergency number will be conducted by the Clinical Director/designee and/or Facility Director.
Any issues identified will be addressed as appropriate. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
|
Observations
Based on a review of the facility's policy and procedure manuals, the facility failed to have in place a signed provider agreement with the Department of Public Welfare.
The findings include:
The policy and procedure manuals were reviewed on November 19 and 20, 2012. The facility currently receives reimbursement under the medical assistance program and the facility is to have a current signed provider agreement with the Department of Public Welfare. At the time of the inspection the facility failed to show documentation of a signed provider agreement with the Department of Public Welfare. An interview with the facility director and clinical supervisor on November 20, 2012 confirmed the findings.
|
Plan of Correction
Proof of provider agreement with the Department of Public Welfare authorizing Medicaid reimbursement will be on file.
Random inspections for the proof of provider agreement with the Department of Public Welfare authorizing Medicaid reimbursement will be conducted by the Clinical Director/designee and/or the Facility Director.
Any issues identified will be addressed as appropriate. |