INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21 and 22, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A. R. S. Of Lancaster, LP, 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 February 26, 2009.
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Plan of Correction
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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 employee records, the facility hired an individual for a counselor position when she did not have the required experience.
The findings include:
Eight employee records were reviewed on January 21, 2009. Three employee records pertained to counselor positions. Employee # 3, a counselor, was hired on June 2, 2008 when she had only ten months of clinical experience, two months short of the 1 year of experience required.
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Plan of Correction
Prior to hiring an employee covered by the staffing regulation The Executive Director will submit a counselor review to the state. A copy of the individual's transcript and resume will be submitted for any individual who's degree is not listed in the regulations or who's experience is questionable. The Executive Director is responsible for compliance |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility fire drill log, the facility failed to maintain a fire drill record that contained documentation of all of the required elements of a fire drill record.
The findings include:
The facility fire drill log was reviewed on January 21, 2009. The entries in the log for the fire drill conducted on 8/14/08, 8/20/08, 10/31/08, 11/26/08, 12/15/08 and 1/16/09 did not include documentation of the exit route used for each drill; the number of persons in the facility at the time of the drill; and whether or not the fire alarm or smoke detector was operative at the time of the fire drill.
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Plan of Correction
The Executive Director has updated the fire drill log to include documentation of the exit route used for each fire drill, the number of persons in the facility at the time of the drill, and whether or not the fire alarm or smoke detector was operative at the time of the fire drill.
The Safety Officer will be responsible for completion of the monthly fire drill log each month. The Executive Director will monitor the fire drill log each month and ensure all requirements of 705.28 are met. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility fire drill log and an interview with the facility director, the facility failed to document the preparation of alternate exit routes to be used during fire drills.
The findings include:
The facility fire drill log was reviewed on January 21, 2009. The entries in the log for the fire drills conducted on 8/14/08, 8/20/08, 10/31/08, 11/26/08, 12/15/08 and 1/16/09 did not include documentation of the preparation of alternate exit routes to be used during fire drills. An interview with the facility director on January 22, 2009 confirmed that documentation of the preparation of alternate exit routes to be used during fire drills was not available.
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Plan of Correction
The Executive Director has updated the fire drill log to include documentation of the preparation of alternate exit routes to be used during monthly fire drills.
Effective immediately, the Safety Officer will be responsible for completion of the monthly fire drill log and The Executive Director will monitor the fire drill log monthly to ensure compiance with all requirements of 705.28 have been met. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the facility's annual report, the facility failed to include a financial statement of income and expenses as a part of the annual report.
The findings include:
The annual report for the fiscal year ending December 31, 2007 was reviewed on January 21, 2009. There was no documentation of a financial statement of income and expenses in the annual report.
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Plan of Correction
ARS being publicly funded, so the governing body shall make available to the public an annual report which includes, but is not limited to: A financial statement of income and expenses this will be done in pie chart form and will graph in percentages of income versus percentages of expenses. The ARS Governing Body is responsible to ensure the completion of this. The 2009 Annual Report for ARS Lancaster is expected to be completed by March 1, 2009. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on a physical plant inspection, a review of facility policies and procedures and an interview with the facility director, the facility failed to post a service fee schedule in a prominent place.
The findings include:
A physical plant inspection and an interview with the facility director was conducted on January 22, 2009. There was no service fee schedule posted at the time of the inspection.
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Plan of Correction
The Executive Director has posted and framed the service fee schedule in the patient lobby area wall.
The Executive Director is responsible for continued compliance and will monitor each month to ensure the service fee schedule remains posted in a prominent place in the facility. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on a review of the facility's policy and procedure manual, the employee handbook and a physical plant inspection which included observation of the employee bulletin board, the facility failed to demonstrate the facility's efforts to inform employees of their rights.
The findings include:
Personnel records, the employee handbook and the facility policy and procedure were reviewed on January 21, 2009. A physical plant inspection was conducted on January 22, 2009 and an interview with the Facility Director also occurred on January 22, 2009. The facility was not able to demonstrate efforts to inform employees of their rights.
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Plan of Correction
The employee orientation procedure was revised to include informing employees of his/her rights. The ARS Personnel Policies Manual was corrected to reflect actual practice.
The Executive Director is responsible to ensure compliance is met. |
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 a review of client records, the facility failed to document individualized treatment plans in three of seven client records.
The findings include:
Thirteen client records were reviewed on January 22, 2009. Seven client records were reviewed for individualized treatment plans. The facility failed to document an individualized treatment plan in client records # 2, 6 and 8. The goals and objectives in those client records were standardized and were not consistent with the conclusions documented in the psychosocial evaluations.
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Plan of Correction
ARS of Lancaster's Clinical Supervisor will conduct a training on Treatment Planning for all of the clinicans by 3-16-09. The training will focus on individualized treatment plans in which the goals and objectives are consistent with conclusions documented in the psychosocial evaluation.
In addition, ARS's Clinical supervisor will audit 25% of patient charts for the next 3 months to ensure treatment plans are individualized and they are consistent with conclusions from the psychosocial evaluation. |
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 a review of client records, the facility failed to document the proposed type of support services on the treatment plans in six of nine client records.
The findings include:
Thirteen client records were reviewed on January 21, 2009. Nine client records were reviewed for treatment plans. Proposed support services are required to a part of the treatment plan. The facility failed to document proposed support services on the treatment plans in client records # 1, 2, 3, 4, 7 and 8.
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Plan of Correction
ARS of Lancaster's Clinical supervisor will conduct a training for all clinicians on Treatment Planning by 3-16-09. The training will focus on specific types of support services available to patients and the use of Lancaster County's community resource guide.
In addition, ARS's Clinical Supervisor will audit 25% of all charts in the next 3 months for compliance. |
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 a review of client records, the facility failed to document complete aftercare plans in one of one client record.
The findings include:
Thirteen client records were reviewed on January 22, 2009. One client record was required to include documentation of an aftercare plan. The aftercare plan documented in client record #12 was incomplete in that it did not include documentation of the client's future goals with time frames, support services, a contact person at the facility and the criteria for reentry into the facility.
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Plan of Correction
ARS's Clinical Supervisor will conduct a training for all clinicians on Aftercare planning by 3-16-09. The training will focus on documentation of the client's future goals and time frames, support services, a contact person at our facility, and criteria for re-admission.
In addition, ARS's Clinical Supervisor will audit 100% of aftercare plans for compliance over the next 6 months. |
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.
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Observations
Based on a review of client records, the facility failed to document complete discharge summaries in two of three client records.
The findings include:
Thirteen client records were reviewed on January 22, 2009. Three client records were required to include documentation of discharge summaries. The discharge summaries in client records # 12 and 13 did not include documentation of the reasons the client sought treatment.
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Plan of Correction
ARS's Clinical Supervisor will conduct a training for all clinicians on Discharge Summaries by 3-16-09. The training will focus on including documentation for the reasons the patient sought treatment.
In addition, ARS's Clinical Supervisor will conduct chart audits on all Discharge Summaries for the next 3 months. |