INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5, 2006 to September 12, 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 October 10, 2006.
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Plan of Correction
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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Two out of 18 counselor assistants, staff numbers 17 and 33, were missing the required performance evaluation.
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Plan of Correction
Performance evaluations were not completed for two counselor assistants within the required timeframe (semi-annually until a positive assessment of skill level is documented).
A core competency tracking form has been developed and serves as a performance evaluation for counselor assistants. It is completed on a quarterly basis and provides an evaluation of a counselor assistant's performance in key areas of their job. Treatment supervisors have been instructed to complete these core competency tracking forms for all counselor assistants. Effective 10/01/06, the clinical directors will monitor the timely completion of these tracking forms, at least quarterly, during their file reviews of counselor assistant supervision files. The clinical directors will report compliance monthly during Performance Improvement Council (senior management) meetings. |
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
Three out of 18 counselor assistants, staff numbers 8, 9, and 40, were missing documentation demonstrating supervision as required by the standard.
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Plan of Correction
Three counselor assistants were missing documentation demonstrating supervision as required by the standard.
The procedures for supervision of counselor assistants was reviewed with the treatment supervisors during the week following the licensing inspection. Treatment supervisors are required to document weekly conference notes indicating services that were observed for the week, as well as providing an overview of the discussion. The clinical directors will be conducting weekly chart audits of counselor assistant supervision files to ensure that supervisory conferences are being documented consistently. There will be additional focus on the three counselor assistants mentioned in the deficiency. The clinical directors will complete a chart audit form for each supervision file that is reviewed and submit the form to the assistant program director. The assistant program director will report compliance monthly during the Performance Improvement Council meetings. |
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
Sixteen out of 48 staff files reviewed, staff numbers 3, 5, 10, 11, 13, 16, 17, 21, 24, 31, 32, 33, 36, 42, 43, and 45, contained training plans that were completed later than 2/1/06 for a training year that began 1/1/06.
One of the 48 files reviewed, staff number 19, was missing an individual training plan for the 2006 training year.
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Plan of Correction
One employee was missing an individual training plan for the 2006 training year. Sixteen other employees had trainig plans that were completed later than 2/1/06 for a training year to begin 2/1/06.
During October and November, employees will meet with their supervisors and complete individual training plans for the upcoming year. Throughout December, the training department staff will review the plans and complete a training needs assessment. The 2007 training calendar will then be developed based upon the needs assessment. The training director will monitor the completion of all individual training plans to ensure they are completed by December 8, 2006. He will provide a progress report to the Performance Improvement Council during the October, November and December 2006 meetings. |
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
Four out of 58 staff files reviewed, staff numbers 10, 16, 53, and 57, did not have the required TB/STD training.
Five out of 58 staff files reviewed, staff numbers 49, 54, 55, 56, and 58, did not have the required HIV/AIDS training.
Three out of 58 staff files reviewed, staff numbers 50, 51, and 52, did not have the required HIV/AIDS and TB/STD training.
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Plan of Correction
Four employees did not have the required TB/STD training; five employees did not have the required HIV/AIDS training. Three employees did not have both the TB/STD and HIV/AIDS traings.
Three of the identified employees completed the required training on September 18, 2006. The remaining employees are scheduled for trainings to be held on October 9 and 19, 2006. Their attendance at these trainings will bring everyone into compliance with the standard. The training department has contacted the supervisors of these employees to ensure they are scheduled to attend.
With regard to new employees, TB/STD training is held during each orientation class; new employees will complete this training during their orientation period. HIV/AIDS is held on a quarterly basis. The training department developed a tracking system for employees that need HIV/AIDS training. The training department will send out monthly reminders to supervisors indicating the need to schedule someone for the HIV/AIDS training. Specific training dates will be included in the reminder. Clinical directors will follow up with treatment supervisors when there is an indication that a problem exists with regard to scheduling a staff person into the training.
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704.12(a)(3)(ii) LICENSURE NonHosp Rehab/Adol
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(ii) Projects serving adolescent clients shall have one FTE counselor for every six clients.
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Observations
The facility has failed to submit a time frame for primary care hours that can be approved by the Department. The facility continues to submit primary care hours that run concurrent with school hours. The facility does not provide for a 6:1 ratio of clinical treatment staff to residential drug and alcohol clients at any time of the day other than during school hours.
There are also five counselor assistants, numbers 8, 9, 14, 18, and 38 that are currently under 3 month direct supervision and cannot be included in the ratio count.
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Plan of Correction
A settlement agreement regarding primary care hours was signed by the Department of Health and Cornell Abraxas Group, Inc. on January 11, 2008. Please refer to that document for further clarification.
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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 Cornell Companies, Inc. annual report does not include the activities and accomplishments of the drug and alcohol treatment projects.
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Plan of Correction
Cornell Companies Inc. annual report does not include activities and accomplishments of the D&A treatment projects.
The performance improvement director and divisional director will develop an annual report for the D/A project which will include the activities and accomplishments of the previous year. After receiving governing body approval, the report will be made available to the public. |
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
The financial statement included in the Cornell Companies, Inc. annual report does not indicate or differentiate between the income and expenses relative to the drug and alcohol treatment project.
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Plan of Correction
A financial statement included in Cornell Companies Inc. annual report does not indicate or differentiate between the income and expenses relative to the D/A treatment project.
The performance improvement director and divisional director will develop an annual report for the D/A project which will include specific financial information relative to the D/A project, including a financial statement of income and expenses. After receiving governing body approval, the report will be made available to the public. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
The audit for the year ending June 2005 and June 2004 was made available to the public January 30, 2006. Audits should be completed within six months following the end of the project's fiscal year.
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Plan of Correction
An audit for year ending 6/2005 and 6/2004 was made available to the public 1/30/06; this was beyond the required timframe of within 6 months following the end of the project's fiscal year.
The divisional director and project director will meet with the divisional financial officer to discuss the importance of meeting this time frame. The DFO will work with the auditors to attempt to meet the time frame for this past fiscal year.
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Termination letters were missing from 2 of 2 involuntarily discharged client's records, # 15 and 16.
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Plan of Correction
Two clients that were involuntarily discharged never received a letter of termination. Clients that were discharged as a result of an AWOL or failure to return from pass are notified of their termination from the program. However, it was not agency practice to notify clients that were discharged for medical/psychiatric reasons or for continued violation of rules. One of the clients noted in this citation was discharged as a result of psychiatric issues, while the other was discharged for continued violation of rules.
The Community Services Department oversees correspondence regarding termination notification. Both of the clients cited were provided with termination letters following the exit interview with the licensing specialists. The procedure has been clarified with the coordinator of court reporting. She is responsible for typing letters for each client that is involuntarily discharged from the program. Throughout the next year, the community services supervisor will double check to ensure letters are sent to all involuntarily discharged clients. The performance improvement coordinator is revising the appropriate policy to ensure compliance with standard. |
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
Psychosocial evaluations were not completed within the 14 days required by agency policy in 5 out of 15 client records reviewed, specifically client record numbers 5, 9, 11, 13, and 4.
It was determined that 2 out 15 records reviewed, record numbers 10 and 15, had psychosocial evaluations that did not have dates, therefore compliance with the agency timelines could not be determined.
Four out of fifteen client records reviewed, record numbers 10, 12, 13, and 15, had psychosocial evaluations that repeated information from the history with little counselor interpretation/evaluations.
Fifteen out of fifteen client records reviewed had psychosocial evaluations that did not consistently include support systems.
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Plan of Correction
Several client records did not have psychosocial evaluations completed within 14 days as required by agency policy; two additional records contained psychosocial evaluations that were not dated. Four psychosocial evaluations repeated information from the history with little counselor interpretation/evaluation. All of the psychosocial evaluations reviewed did not consistently include support systems.
Clinical Leadership has agreed to revise the Clinical Assessment policy to reflect a different time frame for completion of the integrated summary (psychosocial evaluation). This document must be completed no later than 19 days after the client's admission to the program. The revision to the policy will be reviewed with the assessment specialists who are responsible for the completion of the integrated summary. They will print and sign the document when complete, verifying it's "completion" on that date. This will be effective 10/2/06.
The performance improvement coordinator and performance improvement director met with the assessment specialists on 09/25/06 to review the details of the deficiencies and provided suggestions for enhancing the quality of the integrated summaries. Effective 10/9/06, the clinical director (or assistant program director) will review all integrated summaries as the assessment specialists complete them. In addition to other qualitative elements, he will monitor for completion dates, evaluative assessment information, and documentation of support systems. He will provide feedback and supervision to the assessment specialists as necessary during their monthly supervisory conferences.
The clinical director who oversees the assessment unit and the assistant program director will develop and conduct a training for the assessment specialists to enhance their skills with regard to documenting assessment of client information. This training will focus on documenting clinical interpretation and evaluation, in addition to the other required elements of the integrated summary, including documentation of support systems. Training for all assessment specialists will be complete no later 10/27/06.
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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
Three out of seven client records reviewed, client record numbers 7, 12, and 15, did not document follow-up contacts as defined by agency policy.
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Plan of Correction
Three client records did not have documented contacts as defined by agency policy.
The performance improvement coordinator will review the follow-up / continuing care policy with the treatment supervisors and counselors. The need to complete at least one follow-up contact, within the first week of discharge, will be emphasized during the policy review. Treatment supervisors will use a tracking system to monitor the completion of the initial contacts as they are due to be completed. The performance improvement coordinator will monitor the use of the tracking system facility-wide.
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