INITIAL COMMENTS
|
This report is the result of an on-site licensure renewal inspection conducted on May 15, 2007 through May 16, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on June 15, 2007.
|
Plan of Correction
|
709.28(c)(2) 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:
(2) Specific information disclosed.
|
Observations
The facility failed to document the specific information to be disclosed on consent to release information forms in five of eleven client records reviewed, #2, 3, 6, 16 and 17.
|
Plan of Correction
Clinical Supervisor and Deputy Director have begun a weekly mandatory training on clinical documentation for all clinical staff. This will include a review of how to complete client consent to release information forms and client confidentiality by no later than 6/14/07 .
CQI Committee met on 5/31/07 and developed an indicator related to compliance with this standard. This indicator will be monitored monthly over the course of the next 6 months and at random thereafter.
|
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.
|
Observations
The facility failed to provide documentation of fire extinguisher training within seven days from the date of employment in four of ten personnel records reviewed, #4, 6, 9 and 10.
|
Plan of Correction
Facilities Manager, responsible for fire extinguisher training, will (1) confirm if these training forms were misfiled somewhere or (2) complete fire extinguisher training on these staff by 6/11/07.
Fire extinguisher training within 7 days has been added to the New Employee Orientation Checklist. This should assist the Facilities Manager in assuring this occurs within that 7 day period.
All staff hired for the program since 5/07 will have verified fire extinguisher training within 7 days of hire on file.
Deputy Director will monitor ongoing compliance with regard to this standard. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
The facility failed to conduct unannounced fire drills at least once a month. Fire drills were missing for the months of November 2006, December 2006 and January 2007.
|
Plan of Correction
Clinical Supervisor will assume responsiblity for fire drills effective immediately.
A fire drill schedule will be developed in advance for the year, to be be known only to the clinical supervisor, who will implement drills as per the schedule. This has been completed. They will remain " unannounced and random" to the rest of the staff.
Deputy Director will assure ongoing compliance with regard to this standard. |
705.28 (d) (8) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(8) Prohibit the use of elevators during a fire drill or a fire.
|
Observations
The facility failed to prohibit the use of elevators during a fire drill or fire. The elevator was documented as the exit route used on the 3/14/07 and the 4/18/07 fire drill.
|
Plan of Correction
Effective immediately,it has been reviewed with all staff that elevators may NOT be used during a fire drill or actual fire event. Signs are posted at the elevators and this issue will be reinforced at annual staff fire safety training.
The Clinical Supervisor, supervising the drills, will assure ongoing compliance with regard to this standard. |
709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
The facility failed to include a history of illness and symptoms in three of three client records reviewed, #15, 16 and 17. The facility failed to document a complete family medical history in two of three client records reviewed, #15 and 17.
|
Plan of Correction
Deputy Director and Clinical Supervisor will revise the current family medical history section to a checklist format-- by 7/1/07.
Clinical Supervisor and CQI committee will assure that all items are completed as comprehensively as possible via random record reviews to be completed monthly and ongoing.
|
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
The facility failed to complete a psychosocial evaluation in one of three client records reviewed, #15. The facility failed to include potential or available client support systems in two of two client records reviewed, #16 and 17. The facility failed to include the client's preferred coping mechanisms in one of two client records reviewed, #16.
|
Plan of Correction
Deputy Director and Clinical Supervisor will conduct weekly clinical documentation training for all clinical staff which will include the need to complete a comprehensive biopsychosocial evaluation that meets all BDAP requirements. Completed 5/31/07.
CQI Committee developed an indicator specific to this on 5/31/07 and will be monitoring ongoing compliance with regard to this standard monthly for six months and at random thereafter. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
|
Observations
The facility failed to document individual counseling twice weekly in two of three client records reviewed, #15 and 16.
|
Plan of Correction
Clinical Supervisor reviewed with the partial hospitalization staff the requirement that individual counseling occur twice weekly for all partial clients throughout the course of treatment-- 6/7/07.
CQI Committee will monitor ongoing compliance with regard to this standard. |
709.82(d)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(2) Group counseling, at least twice weekly.
|
Observations
The facility failed to document group counseling twice weekly in two of three client records reviewed, #15 and 16.
|
Plan of Correction
A CQI process is in place to monitor the completion of group notes.
Deputy Director will assist CQI Committee in developing an indicator to assure this includes group counseling, three times per week, for clients in our partial hospitalization program-- by 6/28/07. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
|
Observations
The facility failed to document case consultation notes in two of three client records reviewed, #15 and 16.
|
Plan of Correction
Deputy Director and Clinical supervisor will conduct weekly clinical documentation training to cover frequency of case consultations. Completed 5/31/07.
CQI Committee developed an indicator with regard to this standard-- 5/31/07--and will review this indicator monthly for six months and at random thereafter. |
709.83(a)(11) LICENSURE Client records
709.83. 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
The facility failed to document follow-up information in one of one client records reviewed, #17.
|
Plan of Correction
Effective 6/1/07, BCC implemented a new procedure for tracking follow up that is centralized-- instead of counselor by counselor.
The Clinical Supervisor will monitor the new procedure and assure ongoing compliance with regard to this standard. |
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
|
Observations
The facility failed to display the hours of operation conspicuously to the general public.
|
Plan of Correction
Berks Counseling Center recently moved into a new building.
The Executive Director will inform the building owner of this standard and the need to post BCC's hours of operation on the front of the building.
Building owner will approve and facilities coordinator will assure hours are posted by 7/1/07. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
|
Observations
The facility failed to display an emergency telephone number conspicuously to the general public.
|
Plan of Correction
BCC recently moved into a new facility.
Executive Director will inform building owner of this standard and request approval to post emergency phone number in front of building by 7/1/07.
Once approval is secured, Facilities Director will post number in a conspicuous place noticeable to the public. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
The facility failed to include a history of illness and symptoms within medical history in eight of eight client records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8. The facility failed to document a complete family medical history in eight of eight client records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8.
|
Plan of Correction
Deputy Director and Clinical Supervisor will revise the current family medical history section to a checklist format-- by 7/1/07. Clinical Supervisor and CQI committee will assure that all items are completed as comprehensively as possible via random record reviews to be completed monthly and ongoing.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
The facility failed to complete psychosocial evaluations, within the time frame identified by the facility, in two of eight client records reviewed, #7 and 8. The facility failed to include client assets/strengths in three of eight client records reviewed, #4, 7 and 8. The facility failed to include the client's preferred coping mechanisms in seven of eight client records reviewed, #1, 2, 4, 5, 6, 7 and 8.
|
Plan of Correction
Deputy Director and Clinical Supervisor will conduct weekly clinical documentation training for all clinical staff which will include the need to complete a comprehensive biopsychosocial evaluation that meets all BDAP requirements. Completed 5/31/07. CQI Committee developed an indicator specific to this on 5/31/07 and will be monitoring ongoing compliance with regard to this standard monthly for six months and at random thereafter. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
The facility failed to complete an individual treatment plan in two of eight client records reviewed, #2 and 7. The facility failed to complete an individual treatment plan, within the time frame identified by the facility, in three of six client records reviewed, #3, 6 and 8.
|
Plan of Correction
It is the agency policy to complete a comprehensive individualized treatment plan by the client's second session.
The Deputy Director and Clinical Supervisor will conduct weekly training on clinical documentation including the time frames and standards related to the individual treatment plan.Completed 5/31/07.
The CQI Committee has developed an indicator with regard to this standard and will assure compliance with this standard by monitoring monthly for 6 months and at random thereafter. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) 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.
|
Observations
The facility failed to formulate individualized, realistic and measurable goals in three of six client records reviewed, #3, 4 and 5.
|
Plan of Correction
Deputy Director and Clinical Supervisor will, as part of weekly clinical documentation training, reinforce the need to identify individualized, realistic and measurable goals. To be completed 6/28/07.
CQI Committee will monitor ongoing compliance with regard to this standard. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
The facility failed to complete treatment plan updates in two of six client records reviewed, #2 and 5. The facility failed to review and update treatment plans within the required time frame (60 days) in one of six client records reviewed, #4. The facility failed to include an assessment of the client's progress in relationship to the stated goals in one of six client records reviewed, #3.
|
Plan of Correction
Deputy Director and Clinical Supervisor will conduct weekly clinical documentation training to reinforce the need to complete treatment updates that adequately reflect client progress and the time frames for doing so. Completed 5/31/07.
The CQI Committee developed an indicator to review this standard -- Completed 5/31/07--and will monitor this indicator monthly for the next six months and at random thereafter. |
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
The facility failed to document case consultations in three of seven client records reviewed, #3, 5 and 6.
|
Plan of Correction
Deputy Director and Clinical Supervisor will conduct weekly clinical documentation training to include time frames for completion of case consultations by 6/15/07.
CQI Committee developed an indicator with regard to this standard-- completed 5/31/07--and will monitor ongoing compliance with regard to this standard monthly for the next six months and at random thereafter. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
The facility failed to develop an aftercare plan with measurable goals and time frames and support services in four of four client records reviewed, #8, 9, 13 and 14.
|
Plan of Correction
Deputy Director and Clinical Supervisor will conduct weekly clinical documentation training to cover how to more effectively complete aftercare plans by 6/15/07.
CQI Committee has already developed an indicator with regard to this standard--- completed 5/31/07-- and monitor compliance with regard to this standard monthly for the next 6 months and at random thereafter. |
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
The facility failed to document follow-up information in three of eight client records reviewed, #11, 13 and 14. The facility failed to document follow-up information, within the time frame identified by the facility, in four of five client records reviewed, #7, 8, 9 and 12.
|
Plan of Correction
Effective immediately, Clinical Supervisor at BCC implemented a new policy for tracking and monitoring follow up activities.
Deputy Director and Clinical Supervisor will review new process, which includes a tracking system to monitor when follow up is due and verify that it was completed, at weekling clinical documentation training on 6/14/07.
Clinical Supervisor will monitor that follow up is occurring at per agency policy and BDAP standards.
CQI Committee will also monitor ongoing compliance with regard to this standard. |
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
The facility failed to display the hours of operation conspicuously to the general public.
|
Plan of Correction
Berks Counseling Center recently moved into a new building. The Executive Director will inform the building owner of this standard and the need to post BCC's hours of operation on the front of the building. Building owner will approve and facilities coordinator will assure hours are posted by 7/1/07. |
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
The facility failed to display an emergency telephone number conspicuously to the general public.
|
Plan of Correction
BCC recently moved into a new facility. Executive Director will inform building owner of this standard and request approval to post emergency phone number in front of building by 7/1/07. Once approval is secured, Facilities Director will post number in a conspicuous place noticeable to the public. |
704.11(a) LICENSURE Staff Development Procedure
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:
|
Observations
The facility failed to develop a comprehensive staff development program that included time frames for completion of the overall assessment of staff training needs, the overall plan addressing those needs, and the mechanism to collect feedback.
|
Plan of Correction
Deputy Director did revise Policy on Training to be clear about time frames in which feedback forms must be returned and how those feedback forms will be utilized in program planning-- completed 6/4/07. Deputy Director will assure both training plan and staff feedback forms are readily available upon next site visit. Deputy Director will be responsible for ongoing compliance with regard to this standard. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
The facility failed to provide documentation of the required HIV/AIDS training in three of ten personnel records reviewed, #2, 9 and 10. The facility failed to provide documentation of the required TB/STD training in five of ten personnel records reviewed, #2, 3, 8, 9 and 10.
|
Plan of Correction
Nurse will provide both HIV and TB training this month-- HIV June 6 and 13 and TB June 20. All staff who have not yet had this training will complete it at this time, including the clinical supervisor who needs TB training.
Deputy Director will assure ongoing compliance with regard to this standard.
|