INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 9, 2009 and November 10, 2009 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. The following deficiencies were identified during this inspection and a plan of correction is due on December 10, 2009.
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Plan of Correction
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, facility failed to ensure and document that the project director and facility director completed at least 12 hours of training for the training year 2008 in two of two personnel records.
Findings:
The project director and facility director's personnel records were reviewed on November 9, 2009, both records were required to provide documentation of twelve hours on annual training. The facility failed to provide documentation of training hours for both the project director and facility director for the training year January 1, 2008 through December 31, 2008
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Plan of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
The Project Director and the Facility Director will complete and provide documentation of completion of a minimum of 12 approved traning hours annually in areas inclusive but not limited to those identified under 704.11(d)(2) Licensure Annual Traning Requirements. Certificates of completion will be maintained in each respective HR file. Facility Director will complete 7 hours of managerial training through Diakon's training division as well as a minimum of 5hrs additional training through external conferences/trainings. Project Director will attend conferences/training relative to the scope of his responsibility. Trainings will occur between January - December 2010 |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on the review of personnel records, the facility failed to have documentation of reference investigations in three of eight records reviewed.
The findings include:
Eight personnel records were reviewed on November 9, 2009. Reference investigations were required in eight personnel records. Reference investigations were not documented in personnel records #6, 7 and 8. Employee record #6 was hired 4/27/09 and as of the review date no reference investigations completed. Employee 7 was hired 8/6/09 and as of the review date no reference investigations completed. Employee record #8 was hired 7/10/09 and as of the review date no reference investigations completed.
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Plan of Correction
Employee/contractor #6,7, and 8 will have reference investigations completed and placed in the staff personnel files. New hire personnel files will be audited by the Facility Director on any new staff hired in the past 30 days to assure compliance with reference investigations. Any new hire files found without reference investigations will have them completed. The Clinical Director will complete a minimum of 2 reference investigations on all new staff/contractors. The Clinical Director will document the reference checks in the staff/contractors personnel files. Audits will be completed on new hire personnel files by the Facility Director. |
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:
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Observations
Based on the review of client records, the facility failed to document a comprehensive treatment plan in four of seven client records.
The findings include:
Eight client records were reviewed on November 10, 2009. Treatment plans were required in seven client records. Client records #3, 4, 5 and 8 had treatment plans completed before the psychosocial evaluations were completed. Comprehensive treatment plans can not be documented until the client's psychosocial history and psychosocial evaluations are completed. Client record #3's comprehensive treatment plan was completed on 5/19/09 and their psychosocial evaluation was completed on 6/16/09. Client record #4's comprehensive treatment plan was completed on 8/4/09 and their psychosocial evaluation was completed on 9/4/09. Client record #5 comprehensive treatment plan was completed on 1/26/09 and their psychosocial evaluation was completed on 2/2/09. Client record #8 comprehensive treatment plan was completed on 6/9/09 and their psychosocial evaluation was completed on 6/15/09.
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Plan of Correction
Client's #5 and 8 have been discharged from the program. Client's #3 and #4 treatment plans will be reviewed to assure inclusion of information from the psychosocial history and evaluations, as indicated. Current treatment plans will be randomly audited for proper and timely completion. Clinical staff will be re-educated by the Clinical Director on the proper and timely completion of the psychosocial evaluations and treatment plans. To ensure ongoing compliance the Compliance Officer/designee will randomly audit 6 charts a week and provide the Clinical Director with a report of these findings. Any identified issues will then be addressed with the specific clinician. |
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.
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Observations
Based on the review of client records, the facility failed to individualize short term goals with action steps in three of seven client records reviewed.
Findings:
Eight client records were reviewed on November 10, 2009. Short and long-term goals were required in seven client records. Short term goals with action steps were identical in client records, #1, 5 and 6. The short term goal was to remain clean and sober with action steps that stated; "1. attend treatment, 2. use 3 positive coping skills and 3. document two triggers."
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Plan of Correction
Client #5 has been discharged from the program. Client's #1 and 6 short term goals will be reviewed and updated as apppropriate. Current short term goal documentation will be randomly audited on current clients to assure individuality. Clinical staff will be re-educated by the Clinical Director on the proper completion of the treatment plans with appropriate short and long term goals with action steps. To ensure ongoing compliance the Compliance Officer/designee will randomly audit 6 charts a week and provide the Clinical Director with a report of these findings. Any identified issues will then be addressed with the specific clinician. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services in three of seven client records reviewed.
Findings:
Eight client records were reviewed on November 10, 2009. Documentation of support services was required in seven client records. Support services were not documented in client records, #1, 5 and 6.
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Plan of Correction
Client #5 has been discharged from the program. Client's #1 and 6 will have their support services documentation reviewed and updated as appropriate. Current support services documentation will be randomly audited on current clients. The Clinical Director will educate the clinician responsible for charts #1,5 and 6 to review the proper documentation of supportive services in the clients' charts. Ongoing compliance will be monitored by the Compliance Officer/designee through weekly random chart audits and provide the Clinical Director with a report of these findings. Any identified issues will then be addressed with the specific clinician. |
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.
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Observations
Based on a review of client records, the facility failed to document a complete treatment plan update in six of seven client records.
Findings:
Eight client records were reviewed on November 10, 2009. Treatment plans updates were required in seven client records. In client records #1, 2, 3, 4, 5 and 6 treatment plan updates did not include the client's progress in relationship to the stated goals of the treatment plan, but rather stated generalized comments that were not specific to the client's progress in treatment.
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Plan of Correction
Client #5 has been discharged from the program. Client's #1,2,3,4, and 6 will have treatment plans reviewed and updates completed as appropriate. Current client records will be randomly audited to assure treatment plan updates were completed. Any identified issues will be corrected,as appropriate. Clinical staff will be re-educated by the Clinical Director on the proper and complete documentation of the individualized treatment plans and treatment plan updates. To ensure ongoing compliance the Compliance Officer/designee will randomly audit 6 charts a week and provide the Clinical Director with a report of these findings. Any identified issues will then be addressed with the specific clinician. |
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.
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Observations
Based on the review of client records, the facility failed to document treatment plans in two of four discharged client records reviewed.
The findings include:
Eight client records were reviewed on November 11, 2009. Aftercare plans were required in two discharged client records. In accordance with the facility's policy and procedure manual, the facility will start working on the aftercare plans by the second to the last session prior to discharge. Client record #5, discharged on 5/29/09, did not have goals with time frames documented in the aftercare plan. Client record #8 did not contain documentation of an aftercare plan, the client was successfully discharged on 9/16/09.
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Plan of Correction
Audits will be completed on client records prior to being discharged. Issues identified on aftercare plans through these audits will be addressed prior to discharge. Clinical staff will be re-educated by the Clinical Director on the proper and complete documentation of Aftercare Plans. The Diakon Family Life Services policy and procedure for completing Aftercare Plans will also be reviewed. Ongoing compliance will be monitored weekly by the Compliance Officer/designee and provide the Clinical Director with a report of these findings. Any identified issues will be addressed with the specific clinician. |