INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2006 through July 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 August 15, 2006.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
The overall plan for addressing training needs for the 2006 training year (January through December) was missing.
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Plan of Correction
The Project Director will create the training plan. It will be completed annually, and be presented to the managers annually. Corrected by 8/10/2006.
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
The annual evaluation of the overall plan was missing for 2005 training year.
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Plan of Correction
An overall evaluation for the 2005 training plan was compiled by the Director Tom Whiteman, using the individual evaluations from each of the therapists. For 2006 Tom Whiteman will use the evaluations collected from each individual therapist to compile a summary of the overall evaluation of the training plan. |
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
Employee # 3 did not have documentation of HIV/AIDS and TB/STD training.
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Plan of Correction
Employee #3 was told they must produce documentation of HIV/AIDS and TB/STD training. If they are unable to produce proof of completion they must attend the HIV training at Eagleville Hospital September 7, 2006 9am-4pm or December 14, 2006 9am-4pm. They must also attend the TB/STD training at Eagleville Hospital November 2, 2006 9am-4pm. They will bring back the certificate and submit it to Tom Whiteman no later than 1 week after the training. |
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
Employee #3 did not receive the required 25 hours training for the 2005 training year.
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Plan of Correction
An access database will be created to track employee progress toward training goals. Employees not making proper progress toward trainings will be placed on probation. |
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 hot water temperature was measured at 130 degrees Fahrenheit.
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Plan of Correction
Staff will notify the maintenance man and request that the water heater be turned down below 120 degree Fahrenheit. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Fire drill logs were not completed from mid-2005 to January 2006.
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Plan of Correction
Starting in Aug 11, 2006 Hank Cocoran will fill out a monthly fire drill log which will be submitted to the director Tom Whiteman. Hank will bring the log to the managers meeting which is the second Friday of every month. |
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
The use of alternate exit routes was not documented.
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Plan of Correction
The site managers will include on their fire drill logs the use of alternate exit routes when submitting them monthly to the Director. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
An alternate procedure has been approved by the Department, however, documentation that a smoke detector or fire alarm system was inspected and operational was not provided as required.
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Plan of Correction
Effectively immediately, when Hank Corcoran submits the fire drill logs on the second Friday of every month they must include documentation paperwork from the fire alarm inspection company and when the fire alarm or smoke detector was tested for that month. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The project goals and objectives did not identify any available resources.
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Plan of Correction
The goals and objectives will be created each year by the Project Director who will ensure that they will include the available resources or responsible personnel.
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
A written agreement for 24-hour emergency psychiatric and medical coverage was missing.
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Plan of Correction
A revised referral agreement will be sent to Main Line hospitals. It will include the 24 hour emergency psychiatric and medical coverage agreement |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
The clinical records storage room and filing cabinets where the records were kept was unlock at the time of the inspection.
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Plan of Correction
The administrative assistant will check the lock on the chart room several times per day to ensure that no one has left the room unlocked. If a staff person does not relock the door the manager will be notified. Repeat offenders will be fined. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluations did not assess the client's assets/strengths, support systems, coping mechanisms, and negative factors that may inhibit treatment in four of four client records reviewed, # 1, 2, 3 and 4.
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Plan of Correction
Each site manager will have a staff training by September 30, 2006 which will address the following objective:
” Creating an accurate psychosocial which includes strengths, weaknesses, support systems, coping mechanisms and risk assessment
Staff will submit to the manager 3 psychosocial evaluations for review by October 15, 2006. The manager will continue to review charts on monthly basis and give inidividual feedback to each therapist.
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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
Treatment plan updates did not include a review the progress of the client's goals and action steps from the previous treatment plan in four of six client records, # 1, 3, 5 and 6. The treatment plan update was missing in client record # 3.
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Plan of Correction
Each site manager will have a staff training by September 15, 2006 which will address the following objectives:
” Creating a treatment plan which has measurable goals, and a review process of those goals from previous treatment plans
Each staff person will submit 3 charts for review by October 1, 2006. The manager will review to verify completion of treatment plan updates as well as for content of update. Content should include a review of client's goals and action steps from the treatment plan.
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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 aftercare plan was missing in client record # 8.
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Plan of Correction
Each site manager will have a staff training by September 15, 2006 which will address the following objective:
Correct procedures for an aftercare plan up when clients are completing the program.
By October 1, 2006 each therapist will submit 3 charts with aftercare plans to be reviewed by the manager.
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