INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16-18, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on August 17, 2007.
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
The facility failed to comply with this standard because the caseload for staff #2 exceeded the permitted 35:1 ratio. The exception letter addressing the issue of extended caseloads dated 2/28/05 requires that a counselor be acting in the status of a fully qualified counselor for one year before they are eligible for an extended caseload. The counselor in question was recently promoted from counselor assistant and has not functioned in the counselor position for a one year period.
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Plan of Correction
The clinical supervisor will monitor caseloads to ensure the ratio is being met according to regulation and the counselor met the eligibility for the extended caseload. The program director will monitor to ensure compliance |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to meet this requirement because the hot water temperature was measured at 140 degrees Fahrenheit and should not exceed 120 degrees Fahrenheit.
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Plan of Correction
The hot water tank temperature has been adjusted to meet the 120 degree Fahrenheit requirement. The program director will monitor sporadic to make sure the temperature is within requirement. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
The facility failed to meet the requirements of this regulation because the agency manual was not organized in a manner which allowed staff to efficiently reference policies and procedures pertinent to the discharge of their assigned duties. Language in the manual tends to be generic in nature and does not consistently meet regulatory requirements, thus failing to delineate project policies and procedures.
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Plan of Correction
Policies will be reviewed and amended/changed/purged as needed. The program director and policy advisor from DH Home Office will be responsible. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The facility did not meet the requirements of this standard because the policy did not address 4 Pa. Code subsection 255.5 in its entirety. The policy focused only on 4 Pa. Code subsection 255.5(b). Language in the policy failed to clearly distinguish between HIPAA requirements and regulations and the federal regulations on client confidentiality in substance abuse treatment centers at 42 CFR Part 2, ( revision 13 modified 11/2006). Forms were observed in client files which still contained language inconsistent with the intent of 42 CFR Part 2, Subparts C, D and E relating to the release of information without client consent. Language in the forms stated that the client could ask for releases of information to be restricted but that the agency need not honor such requests. The referral policy stated that "..In as many instances as possible, a release of information shall be signed in order to coordinate treatment for each patient". The intent of applicable laws is that the client must consent to any releases of personal information which identifies them as a consumer of Drug and Alcohol treatment services unless excepted by 42 CFR Part II subparts D & E and as are also permitted by state law and regulation.
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Plan of Correction
The policy will be reviewed/amended as needed. The director and policy advisor from DH Home Office will be responsible in ensuring consents meet 4 Pa. Code Subsection 255.5 and 42 CFR Part 2. |
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.
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Observations
The facility failed to meet the requirements of this regulation because family medical histories were not consistently documented in the client records reviewed. They were missing or incomplete in client records # 2, 8, 9, 11 and 12.
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Plan of Correction
Program Director will inform responsible medical staff on the proper documentation of family medical histories. The program director will monitor chart to ensure compliance. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The facility failed to meet the requirements of this standard because personal histories lacked sufficient detail in 12 of 12 records reviewed, specifically education history, employment history and recreational history. Personal histories should collect as much personal information about a client as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated.
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Plan of Correction
The clinical supervisor will train clinical staff on proper documentaion upon admission of the detail needed specifically education history, employment history, and recreational history. This will be monitored by the clinical supervisor through the chart audits. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to meet the requirements of this regulation because type and frequency of services was missing or incomplete on the comprehensive treatment plans in client records #4, 8 and 9. Several other records which were not fully reviewed were also spot checked to review this issue and were found to have missing or incomplete information.
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Plan of Correction
The Clinical Supervisor will train clinical staff to ensure all type and frequency of services are complete in the client records. The clinical supervisor will be responsible to monitor compliance through chart audits. |
709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
The facility failed to meet the requirements of this regulation because copies of all client related correspondence were not maintained in the client record. 4 Pa. Code subsection 255.5 (a)(10) states that "Project shall keep and maintain a written record of all information which are disclosed under this section." Information released to entities addressed under 4 Pa. Code was not on file in client records on a consistent basis. (Client records # 3, 4, 5, 6, 7, 8, 10 and 11.)
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Plan of Correction
The clinical supervisor will train clinical staff on filling out the PCPC forms so they only release informaion contained in the release. This will be monitored by the clinical supervisor. |
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
The facility failed to meet the requirements of this regulation because after care plans did not address each of the required components specified. Specifically, contact person and reentry process were not documented as part of the aftercare planning process. (client records # 1, 2, 5, 6, 7, 8 and 11).
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Plan of Correction
The clinical supervisor will train clinical staff to ensuse after care plans address each of the required components, specifically, contact person and reentry process. This will be monitored by the clinical supervisor. |