INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 30, 2006 through November 1, 2006 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 November 29, 2006.
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Plan of Correction
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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
This policy was missing.
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Plan of Correction
1. The Human Resourced Manager, the Project Director, the Director of Nursing and the Facility Director will develop a policy and procedure outlining the population served at the Kirkbride Center and the recruitment and hiring of staff persons who are appropriate to the population.
2. The facility will revise its cultural awareness competency test that is given to all employees during the annual training fair in May of each year.
3. The recruitment policy will identify potential sources of prospective employees that might improve the facility's ability to recruit and hire employees who are reflective of the population served. |
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
The facility director's educational qualifications were previously reviewed by the Department and determined not to meet the requirements of the regulations. The facility director does not meet the qualifications for this position.
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Plan of Correction
1. The position of Program Manager (Facility Director) had been an overhead position for the Kirkbride Center.
2. The employee previously in the position has been reassigned to other duties (Director of Performance Improvement).
3. The employee previously serving as Director of Performance Improvement, who was an interim Clinical Supervisor at the time of the on-site inspection, has been promoted to Facility Director. That individual's qualitifications were reviewed by the survey team and both his education and years of experience were found to meet standards. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Employee #4 has not completed the core curriculum training in clinical supervision as required.
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Plan of Correction
1. The facility has experienced difficulties with the scheduling of Clinical Supervisor Training due to a) the location of such trainings; and b) the cost to the facility.
2. As a result, the facility will explore with the Bureau of Drug and Alcohol the possibility of developing its own clinical supervisor training that would meet state standards.
3. In the absense of securing permission to develop its own training, the facility will explore with BDAP the schedule of clinical supervisor trainings and scheduled Employee 4 for the training. |
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
Three employees did not meet the qualifications for the position of counselor, employee #11, 19 and 21.
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Plan of Correction
1. One of the three employees has a bachelor's degree in psychology from Millersville University and a Master's Degree in Educational Psychology from Temple University. The employee's college and graduate school transcripts will be submitted to the Division of Drug and Alcohol Program Licensure for review. In the absence of a positive finding by the division, the employee will undergo the required supervision and training for a counselor's assistant.If his master's degree is approved by the Department, his status will be changed to that of counselor. The second employee underwent three months of direct supervision in 2005; however, the documentation of that supervision was not acceptable to the surveyors. As a result, the employee's status will change from counselor to counselor assistant, and one of the clinical supervisors will provide three months of direct supervision and nine months of close supervision to ensure the employee meet state requirements. The job description of the third employee lists him as a counselor's assistant. However, the documentation of his supervision did not meet state requirements. He will undergo three months of direct supervision with a new clinical supervisor, followed by nine months of close supervision. The project also will encourage him to apply for Certified Addiction Counselor certification once he has has completed three years of direct service in the facility. The Human Resources Department will be re-educated in the staffing requirements for counselor's assistants. The training will be conducted by the Project Director to govern future hires.
2. The Clinical Supervisors on a quarterly basis will review the personnel files of employees 11, 19 and 21 to ensure compliance. Results of the audits will be reported quarterly to the executive committee for oversight and monitoring for one year.
3. The Clinical Supervisors during the weekly management meeting will erprot to the Project Director and the Medical Director the status of documentation of the three employees to ensure compliance with state Staffing Standards. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
As counselor assistants, employee #11 and 19 did not receive the required supervision.
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Plan of Correction
1. The job description for employee #11 will be change to that of counselor assistant. He will undergo three months of direct supervision by his Clinical Supervisor, followed by nine months of close supervision. The supervision will be documented in his personnel file.
2. Employee #19 will undergo three months of direct supervision, following by nine months of close supervision. The supervision will be documented in his personnel file.
3. The Human Resources Department will be re-educated in the staffing requirements for counselor's assistants. The training will be conducted by the Project Director.
4. The Project Director will re-educate the Facility Director and the Clinical Supervisors about the staffing requiremetns for counselor's assistants.
5. The Project Director will meet with employees #11, 19 and 21 to review the staffing requirements.
6. The Clinical Supervisors on a quarterly basis will review the personnel files of employees 11 and 19 to ensure compliance. Results of the audits will be reported quarterly to the executive committee for oversight and monitoring for one year.
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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:
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Observations
Staff development policies and procedures were missing.
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Plan of Correction
The project director will re-create policies and procedures outlining the facility's staff training needs. The policies and procedures will include:
a. An annual employees' needs assessment, including questionnaires to appropriate staff.
b. An individual training plan for each employee, reflecting each employee's skill level and ensuring that at least half of the annual trainings are external.
c. An annual training plan for the project that includes recommendations for future trainings from both clinical supervisors and primary therapists as well as an evaluation of the previous year's training plan.
d. The facility has identified the training year to coincide with the facility's fiscal year, which is July 1 to Junbe 30.
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Feedback forms were not completed for training attended outside the project.
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Plan of Correction
1. The Human Resources Department has developed a feedback form for employees to use for both internal and external trainings.
2. On a quarterly basis, the clinical supervisors will review the personnel files of their supervisees to ensure that training evaluation and feedback forms are completed for both internal and external trainings.
3. On a quarterly basis, the results of the reviews will be submitted to the executive committee for oversight and monitoring. |
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
Individual training plans were incomplete. Training plans did not list the subject areas and the potential resources that would be utilized.
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Plan of Correction
1. The annual training plan forms will be revised to ensure that they include potential resources for trainings.
2. The annual training plan forms will be revised to ensure that they include selected topics for trainings.
3. The Facility Director and the Clinical Supervisors will be re-trained by the Project Director in the annual requirements for training plans.
4. The Facility Director and the Clinical Supervisors will audit the personnel files on a quarterly basis to ensure compliance with the requirement.
5. Results of the audits will be presented to the executive committee quarterly for oversight and monitoring for one year. |
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.
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Observations
Documentation of six hours of HIV/AIDS and four hours of TB/STD training were missing in thirteen employee records reviewed, #2, 4, 6, 8, 9, 11, 12, 17, 19, 22, 23, 24 and 25.
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Plan of Correction
1. Trainers with the AIDS Care Group of Delaware County have agreed to provide the state-required trainings in HIV/AIDS (6 hours) and in TB/STDs (4 hours).
2. The trainings will be mandatory for all employees whose personnel files were discovered to be deficient. In addition, the trainings will be required for all newer employees who cannot produce documentation that they have completed the two state-required trainings.
3. An outlne of all employees completing the trainings will be presented to the executive committee in March 2007 for oversight and monitoring and to ensure compliance. |
704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Employees received more than one-half of their training hours by persons directly employed by the project.
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Plan of Correction
1. The Facility Director will develop a memo, to be signed off by all primary therapists, indicating that they understand a) annual training hour requirements for each position; and b) that one-half of all trainings must be with external trainers.
2. Copies of the sign-off will be placed in each individual's personnel file.
3. Quarterly, the Clinical Supervisors will audit personnel files to ensure compliance with the training requirements.
4. Quarterly, results of the audits will be presented to the executive committee for oversight and monitoring. |
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
Employee #2 had only 6.5 training hours documented.
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Plan of Correction
1. Employee #2 has been reassigned to another position outside the drug-and-alcohol program. Although that employee attended an additional 10 hours of training outside the facility, it was not reflected in his personnel file.
2. Moving forward, both the Project Director and the new Facility Director will ensure that they have completed 12 hours of training, half of which are from outside sources.
3. Quarterly, the personnel files of the Project Director and the Facility Director will be audited to ensure compliance with this requirement.
4. Results of the audits will be reported quarterly to the executive committee for oversight and monitoring. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Employee #6, did not have 12 training hours documented.
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Plan of Correction
1. Employee #6 is a licensed social worker in Pennsylvania, which requires 30 hours of trainings every two years.
2. The Project Director will inform Employee #6 that she is required to complete at least 12 hours of drug-and-alcohol-specific trainings each year.
3. Quarterly, the Project Director will audit her personnel file to ensure compliance with the requirement.
4. Results of the audits will be reported quarterly to the executive committee for oversight and monitoring. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Employees #8, 9, 12, 20 did not have 25 training hours documented.
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Plan of Correction
1. Employees #8, #9, #12 and #20 will receive memos from the Project Director and/or Facility Director indicating that they must have 25 hours of documented trainings annually and that one-half of those training hours must be with outside organizations.
2. Copies of the signed memos will be placed in the employees' personnel files.
3. Quarterly, the clinical supervisors will audit the personnel files to ensure compliance withe standard.
4. Results of the audits will be reported quarterly to the executive committee for oversight and monitoring. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Employees #13, 14 and 19 did not have the required number of training hours documented for the training year reviewed.
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Plan of Correction
1. The Facility Director has created a memo outlining the number of training hours required for counselors and that at least one-half of those trainings must be from external soources. All counselors were provided with a copy of the memo and signed off on the memo. The information has been filed in their personnel files.
2. Quarterly, the clinical supervisors will audit the personnel files to ensure that counselors are on track to obtaining the required 25 hours during the training year.
3. Results of the audits will be provided quarterly to the executive committee for monitoring and oversight. |
705.10 (b) (2) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(2) On floors with resident bedrooms, maintain a smoke detector which shall be located within 15 feet of each bedroom door. On floors with no resident bedrooms, the smoke detection device shall be located in a common area or hallway. All detection devices shall be interconnected.
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Observations
The smoke detectors in the hallway outside of the client bedrooms on unit N-3 are not interconnected.
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Plan of Correction
1.The smoke detectors on the N-3 acute psychiatric unit will be installed so that they are interconnected and positioned every 15 feet from patient rooms. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
There are no hearing impaired fire alarms located within unit N-0.
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Plan of Correction
1. In the past, the facility's configuration of fire alarms for hearing-impaired patients met state standards with respect to number and gender.
2. The facility will ensure that a strobe-lighted alarm is operational on the unit N-0.
3. Installation will be completed by January 15, 2007. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Fire drills were not documented every month for each unit.
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Plan of Correction
1. The Supervisor of the Security Department has re-educated staff on each unit that unit-specific reports following fire drills must be completed. The unit-specific reports are sent to the Security Department for review.
2. Monthly, the Supervisor of the Security Department reports fire drill data to the Environment of Care Committee for oversight and monitoring.
3. A performance indicator will be added to the fire drill reports to ensure compliance with the state regulation. |
709.22(e) 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:
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Observations
The annual report was not completed for the 2004 - 2005 fiscal year.
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Plan of Correction
1. The facility's auditors have released the preliminary draft of the 2004-2005 audit.
2. However, because the facility has only drafted its 10-K response for the U.S. Securities and Exchange Commission, the auditos will not publish the 2004-2005 audit results until the 10-K has been submitted to the SEC and has been reviewed by both the in-house legal counsel and the auditors themselves.
3. The 10-K and the final audit for 2004-2005 is expected to be completed and approved by January 31, 2007.
4. The Project Director will notify the Division of Drug and Alcohol Program Licensure of the completion of the 2004-2005 audit.
5. The executive committee will document completion and review of the audit at its February 2007 meeting.
6. The facility will seek an exception to this deficiency, asking for a grace period to complete the annual report, pending completion of work by both the auditors and the SEC.
7. If the Department of Health does not approve the request for an exception in the form of an extension, the facility will produce a summary of financial activities during the period and make that summary available for public review. |
709.22(e)(1) 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:
(1) Activities and accomplishments of the preceding year.
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Observations
The annual report was not completed for the 2004 - 2005 fiscal year.
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Plan of Correction
1. Once the facility's 10-K has been submitted to the Securities and Exchange Commission and once the 10-K has been reviewed and approved by the auditors, the 2004-2005 audit will be released publicly.
2. With the release of the 2004-2005 audit, the annual report will be completed. Notification of the completion of the annual report will occur in periodicals in the Philadelphia area.
3. The annual report, together with the public notice publication, will be submitted to the executive committee for oversight and monitoring.
4. The facility will seek an exception to this deficiency, asking for a grace period to complete the annual report, pending completion of work by both the auditors and the SEC.
5. If the Department of Health does not approve the request for an exception in the form of an extension, the facility will prepare a summary of financial activities and make that summary available to the public. |
709.22(e)(3) 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:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
The annual report was not completed for the 2004 - 2005 fiscal year.
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Plan of Correction
1. The facility's auditors have released the preliminary draft of the 2004-2005 audit.
2. However, because the facility has only drafted its 10-K response for the U.S. Securities and Exchange Commission, the auditos will not publish the 2004-2005 audit results until the 10-K has been submitted to the SEC and has been reviewed by both the in-house legal counsel and the auditors themselves.
3. The 10-K and the final audit for 2004-2005 is expected to be completed and approved by January 31, 2007.
4. The Project Director will notify the Division of Drug and Alcohol Program Licensure of the completion of the 2004-2005 audit.
5. The executive committee will document completion and review of the audit at its February 2007 meeting.
6. The facility will seek an exception to this deficiency, asking for a grace period to complete the annual report, pending completion of work by both the auditors and the SEC.
7. If the Department of Health does not approve the request for an exception in the form of an extension, the facility will prepare a summary of financial activities and make that available for public review.
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709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The written procedures for the management of treatment services did not identify procedures for completing case consultations, discharge summaries and record of services.
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Plan of Correction
1. The Project Director, the Facility Director, the Director of Performance Improvement and the Clinical Supervisors will develop a revised policy and procedure outlining the completion of case consultations, discharge summaries and records of service.
2. The revised policy and procedure will be submitted to the executive committee for review and approval.
3. Once approved, the policy will be made available to primary therapists, who will be charged with its execution. |
709.24(a)(4) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(4) Written procedures for referral outlining cooperation with other service providers.
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Observations
The written procedures outlining both incoming and outgoing referrals were missing.
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Plan of Correction
1. The Project Director, the Director of Performance Improvement, the Facility Director and the Clinical Supervisors will develop a policy and procedure outlining incoming and outgoing referrals, which staff make and accept such referrals and how such referrals are to be documented.
2. Upon completion of the policy and procedure, the plan will be presented to the executive committee for approval.
3. Following approval, copies of the policy will be made available to primary therapists, who are charged with its execution. |
709.26(a)(1) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(1) Recruitment, selection, promotion and termination of staff.
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Observations
The procedures for the recruitment and selection of staff were missing.
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Plan of Correction
1. The Project Director, the Director of Performance Improvement and the Human Resources Manager will draft a policy outlining the facility's procedures for the recruitment and selection of staff. The recruitment will include a listing of potential sources of employees, such as association and other professional organizations. The policy also will outline the objective data that will be used as part of the selection process.
2. The policy will be presented to the executive committee for approval. |
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 procedures for client confidentiality include a statement that the program will release drug and alcohol client information and alert the proper authorities in cases of suspected or proven elder abuse.
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Plan of Correction
1. The facility's policy and procedure governing the release of information will be revised by the Project Director and the Director of Performance Improvement to eliminate references to cases of suspected elder abuse.
2. The revised policy and procedure will be presented to the executive committee for approval.
3. Following approval, primary therapists will be educated in the policy revision. |
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.
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Observations
The consent to release information forms to funding sources, such as CBH or MBH, allow for more information to be released than is permissible by 4 Pa. Code 255.5. Additionally, the PCPC included the names and doses of client medications.
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Plan of Correction
1. The Project Director, the Director of Performance Improvement and the Director of Admissions will review the consent forms for Managed-Care Companies and make revisions as required by 709.28(c)(2).
2. The primary therapy staff were re-trained in appropriate responses on the PCPC, notably names and doses of client medications, by the Project Director on December 4, 2006.
3. Revisions to the policy will be presented to the executive committee for approval.
4. Primary and utilization management staff will be trained in the confidentiality requirements. |
709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
The policy and procedure was missing.
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Plan of Correction
1. The Project Director and the Director of Performance Improvement will develop a policy and procedure outlining the steps a patient may take to appeal any efforts by the project to block access to the patient's medical record. Typically, access to a record would be predicated on potentially harmful information contained in patient record.
2. The policy and procedure will be presented to the executive committee for approval. |
709.30(5) LICENSURE Client Rights
709.30. Client rights.
(5) The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
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Observations
The policy and procedure was missing.
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Plan of Correction
1. The Project Director and the Director of Performance Improvement will draft a policy governing how a patient may correct information in their Medical Record that they believe to be inaccurate, irrelevant, outdated or incomplete.
2. The policy will be presented to the executive committee for approval.
3. Following approval, the Medical Records Department staff will be trained in the policy and procedure. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluations were a summary of the client's history and did not provide an assessment by the counselor in ten of ten client records reviewed, # 3, 5, 6, 7, 8, 9, 10, 11, 12, and 15.
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Plan of Correction
1. The facility has contacted a trainer to train therapists in social workers in how to write a case conceptualization that is not a recap of previously dicussed demographic information, but rather an overall assessment of how the pieces fit together. The intention of the facility is to train primary therapists and social workers in the cognitive therapy guidelines of a case conceptualization. The trainer who has agreed to work with the facility has a doctoral degree in psychology and is a professor of cognitive therapy at the Philadelphia College of Osteopathic Medicine.
2. Following the training, the Clnical Supervisors will evaluate the assessments of 50 percent of all admissions over a four-month period.
3. Aggregate scores will be reported monthly to the executive committee for oversight and monitoring. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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 aftercare plan did not include the re-entry process and the how the client could contact the program if needed, in three of three client records reviewed, # 5, 7 and 15.
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Plan of Correction
1. The Aftercare/Continuing Care Plan is currently being revised by one of the Clinical Supervisors. The revisions will include the re-entry process and how clients may contact the program.
2. Following completion of the revisisions, the form will be forwarded to the Division of Drug and Alcohol Program Licensure for comment.
3. Following approval of the revised form by the executive committee, primary therapists will be trained in its use.
4. In addition, the facility at the request of one of its managed-care organizations has created a crisis plan form to be presented to patients upon discharge. The crisis plan provides information on emergency medications, suicidality, etc.
5. The Aftercare Plans and the Crisis Plans will be added to the closed-chart audits, which are conducted by the Medical Records Department, and reviewed by the executive committee monthly for oversight and monitoring. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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
The discharge summaries did not include the reason for treatment and the client's status upon discharge in four of five client records reviewed, # 5, 6, 7 and 15. The discharge summary was missing in one of five client records reviewed, # 8.
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Plan of Correction
1. The discharge summary form is currently being revised by one of the clinical supervisors to include the reason for treatment and the patient's status upon discharge. The revised form will be forwarded to the Division of Drug and Alcohol Program Licensure for comment.
2. The revised form will be presented to the executive committee for approval. Once approved, primary therapists will be trained by the Clinical Supervisors in execution of the new form.
3. Completion of discharge summaries is part of the closed-chart audits, completed by the Medical Records Department, which are reviewed monthly by the executive committee for oversight and monitoring. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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.
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Observations
Follow-up information was missing in four of five client records reviewed, # 5, 6, 7 and 8.
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Plan of Correction
1. The Facility Director and the Clinical Supervisors will review the requirement for follow-up information in the patient records with the primary therapists.
2. Follow-up is part of the closed-chart audits, completed by the Medical Records Department, which are reviewed monthly the executive committee for oversight and monitoring. |