INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 1-2, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penn Presbyterian Medical Center 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 August 1, 2008.
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Plan of Correction
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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on a review of administrative records and staff interviews, the facility failed to provide documentation that the project's governing body has approved a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Plan of Correction
The governing body of Penn Presbyterian Medical Center will approve by resolution the Intensive Outpatient Program's compliance plan for Chapter 704 related to the drug and alcohol staff educational and experiential qualificatons at the next Executive Board Committe meeting to be held on July 21st, 2008 |
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 six personnel records, the facility failed to provide documentation that all counselors met the qualifications for their position. Employee #6 did not meet the qualifications for the position of counselor based on the educational qualifications presented for review.
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Plan of Correction
A letter was submitted by the Facilty Director on July 22, 2008 to the Division of Drug and Alcohol Program Licensure requesting a Staffing Qualifications Review for Employee #6.
In addition the Facility Director will review all resumes prior to their employment at PPMC to ensure that the counselor meets the qualifications for the position of counselor. A counselor will not be hired unless they meet all the qualifications. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of six personnel records, the facility failed to document complete individual training plans for five of six records reviewed, #2, 3, 4, 5, and 6. The individual plans failed to document the time frames within which the training would be obtained and the resources that would be utilized. Additionally, there was no documented training plan for personnel record #1.
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Plan of Correction
Individual training plan form was revised by the Facility Director on July 23, 2008 to reflect the time frames within which the training would be obtained and the resources that would be utilized.
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on the physical plant inspection on 7/1/08, the facility failed to ventilate bathrooms by exhaust fan or window in three of seven bathrooms. Three bathrooms did not have operable exhaust fans or windows.
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Plan of Correction
The Director of Maintanence at Penn Presbyterian Medical Center will ensure that all three bathrooms have operable exhaust fans by 8/31/2008. Two fans have already been fixed and a part has been ordered for the third. |
705.27 (4) (ii) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(ii) Assignments of staff during emergencies.
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Observations
Based on a review of administrative documents on 7/1/08, the facility failed to document written procedures for assignments of staff during emergencies.
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Plan of Correction
The facility director will be responsible for documenting written procedures for assignments of staff during emergencies. This will be completed by August 31, 2008. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill record and a conversation with the facility director on 7/1/08, the facility failed to document that a fire alarm or smoke detector was set off during each fire drill. The fire drills are announced verbally.
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Plan of Correction
The Director of Safety Management will submit a letter to the Division of Drug and Alchohol Licensure requesting permission to announce fire drills verbally. Fire Alarm Inspections will continue as required. Completion date will be 8/15/2008. |
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 seven client records on July 2, 2008, six client records were due for -psychosocial evaluations. The facility failed to document complete psychosocial evaluations in four of six client records reviewed, #1, 2, 5 and 6. Psychosocial evaluations were a repeat of historical data and did not include a clinical assessment of the client's assets/strengths, support systems and negative factors that may inhibit treatment.
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Plan of Correction
Facilty Director will provide education for the counselors on completing psychosocials to include a clinical assessment of the client's assets/strengths, support systems and negative factors that my inhibit treatment. This education will completed by August 31st, 2008. For follow-up, the Facility Director will audit 2 charts a month for 6 months by each counselor for a total of 10 charts/month. |
711.92(a) LICENSURE Coordination of Client Treatment
711.92. Treatment and rehabilitation services.
(a) The project shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
Based on a review of administrative documents and a conversation with the facility director, the facility failed to document, with a sign off by the governing body, a written plan for the coordination of client treatment and rehabilitation services.
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Plan of Correction
The governing body of Penn Presbyterian Medical Center will approve by resolution the Intensive Outpatient Program's plan for the coordination of client treatment and rehabilitation services at the next Executive Board Meeting on July 31, 2008. |
711.92(c) LICENSURE Individual TX Plan
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:
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Observations
Based on a review of seven client records on July 2, 2008, six client records were due for individualized treatment plans. The facility failed to complete individualized treatment plans in the timeframe required per program policy in six of six client records where required, #1, 2, 3, 4, 5 and 6. The timeframe for completion was 21 days from admission and treatment plans were completed within one to three months from admission. Additionally, treatment plans for two of six client records reviewed, #2 and 3, had identical goals and action steps.
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Plan of Correction
The Facilty Director will clarify policy on timeframe required for completing treatment plans to ensure compliance. Completion Date 8/15/2008. Facilty Director will devise an audit tool for the clinical supervisor to use to ensure the individual treatment plans are completed on time. As follow-up to ensure goals and action steps are individualized, the Facility Director will audit 10 charts each month for 6 months; 2 from each of the 5 counselors. Completion date Jan 2009. |
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 seven client records on July 2, 2008, the facility failed to document treatment plan goals stated in terms of measurable criteria in four of seven client records where required, #1, 2, 3 and 7.
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Plan of Correction
The Facility Director will provide education to the counselors on documenting treatment plan goals in terms of measurable criteria. This training will be completed by August 21st. To ensure compliance the Facility Director will audit 10 charts a month, 2 from each of the 5 counselors for 6 months and then the clinical supervisor will audit the counselors treatment plans on an ongoing basis. |
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of seven client records on July 2, 2008, four of the client records were required to demonstrate the provision of treatment services in accordance with the individualized treatment plan. The facility failed to document that counseling services were provided according to the individual treatment plan in two of four client records where required, #2 and 6. The treatment plans prescribed one individual session per week and neither the record of service nor the progress notes documented that individual sessions were scheduled or provided once per week.
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Plan of Correction
The record of service form was revised 7/3/2008 by the Facility Director. Education was given to the counselors by the Facility Director on 7/10/2008 on need to document in progress notes when the individual sessions were scheduled and/or provided. Facility director will audit 2 charts from each counselor each month for 6 months to ensure compliance. The clinical supervisor will audit all record of services each month on an ongoing basis. |
711.94 (g) LICENSURE Medical Assistance Provider Agreement
711.94. 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).
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Observations
Based on a review of seven client records on 7/2/08, six client record were funded through medical assistance. The facility failed to provide documentation of the physician's signature on treatment plans in six of six client records reviewed, #1, 2, 3, 4, 5 and 6. Outpatient treatment for the six clients reviewed was funded by the Department of Public Welfare.
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Plan of Correction
Facility Director will put process in place to have all treatment plans signed by physician. Completion Date July 28th, 2008. Facility Director will audit 10 charts per month for compliance, 2 from each counselor for 6 months and then the clinical supervisor will be responsible for completing ongoing chart audits. |