INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 15, 2012 to November 16, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Consortium 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:
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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
Based on a review of a personnel record, the facility failed to document a semiannual performance evaluation for a counselor assistant based upon measurable performance standards.
The findings include:
From November 6, 2012 to November 7, 2012, one personnel record requiring documentation of a semiannual performance evaluation was reviewed. The facility failed to document a semiannual work performance evaluation for a counselor assistant in one of one personnel record reviewed, specifically, personnel record # 11.
Employee # 11, a counselor assistant, was initially hired on July 6, 2010. On December 13, 2011 employee #11 changed position and was employed as a counselor assistant. Employee # 11 was due a semiannual performance evaluation by June 13, 2012. However, as of November 7, 2012, the most recent work performance evaluation in personnel record # 11 was completed on January 6, 2012.
The findings were confirmed during an interview with the Division Director on November 7, 2012 at approximately 3:30 P.M.
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Plan of Correction
Responsible Party: The Clinical Supervisor is responsible for ensuring documentation of a semiannual performance evaluation for a counselor assistant based upon measurable performance standards.
Plan of Correction: Employee #11 will have a semi annual performance completed by December 21, 2012 by the Clinical Supervisor.
Monitoring: The Program Director will meet with the Clinical Supervisor at least once per month to review status of all counselor assistants to ensure that all performance evaluations are completed semi-annually as required.
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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
Based on a review of supervision notes for a counselor assistant who is under a period of close supervision, the facility failed to document weekly close supervision notes that included at least one hour of direct observation with the counselor assistant. Also, the facility failed to document close supervision notes.
The findings include:
From November 6, 2012 to November 7, 2012 and on November 15, 2012, the facility's supervision notes were reviewed from the period covering June 2012 to November 2012. The facility failed to document supervision notes for the first two weeks of November 2012. Also, the facility failed to document at least one hour of direct observation per week as a part of the close supervision requirement from June 2012 to October 2012.
Employee # 11, counselor assistant, was initially hired on July 6, 2010 and was hired as a counselor assistant on December 13, 2011. Employee # 11 does not meet the credential requirements for counselor and was required to obtain three months of direct observation and nine months of close supervision to meet the supervision requirements. There was no documentation of close supervision for the first two weeks of November 2012. Also, there was no documentation of at least one hour of direct observation per week from June 15, 2012 to November 15, 2012.
The findings were confirmed during an interview with the facility director on November 15, 2012 at approximately 2:30 P.M.
This is a repeat citation. The facility was cited on June 6, 2012 for noncompliance with this regulation.
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Plan of Correction
Responsible Party:
The Clinical Supervisor is responsible for ensuring the documentation of weekly close supervision notes that include at least one hour of direct observation with the Counselor Assistant.
Also, the Clinical Supervisor is responsible for documenting close supervision notes for Counselor Assistants who do not meet educational/experiential state requirements, who are employed by the Consortium.
Plan of Correction:
The Clinical Supervisor of employee #11 must provide documentation of weekly close supervision notes that include at least one hour of direct observation with the employee.
the Clinical Supervisor will document the supervision notes for the month of November by 1/11/13. Monthly documentation will continue therafter.
The Clinical Supervisor of employee #11 must also document close supervision notes on a weekly basis,and provide documentation of missed supervision if the Counselor Assistant is out for a particular week.
The supervision notes will include documentation of at least one hour of direct observation per week.
Monitoring:
The Clinical Supervisor will document weekly supervision/observation of counselor assistant on a supervision note.
Supervision notes of Counselor Assistants will be maintained in a manual in the Clinical Supervisor's office.
The Clinical Supervisor will send all supervision notes documenting weekly supervision of the Counselor Assistant to the Program Director by the end of each week.
The Program Director, will also review weekly supervision/observation notes submitted with the Clinical Supervisor during bi weekly supervision, to ensure completion.
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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
Based on a review of the facility's Staffing Requirements Facility Summary Report form and an interview with the project's Division Director, the facility failed to document an individual training plan for each employee.
The findings include:
The Staffing Requirements Facility Summary Report was reviewed on November 6 and November 7, 2012. The facility failed to document individual training plans for three out of twelve staff reviewed that required individual training plans, specifically, employees # 13, 14, and 15.
Employee # 13 is a medical records clerk and was hired on July 19, 2011. The individual training plan for employee # 13 was due July 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on November 2, 2012, the most recent individual training plan for employee # 13 was completed on August 17, 2011.
Employee # 14 is the receptionist and was hired on December 9, 2004. The individual training plan for employee # 14 was due July 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on November 2, 2012, the most recent individual training plan for employee # 14 was completed on May 18, 2011.
Employee # 15 is the intake generalist and was hired on March 3, 1997. The individual training plan for employee # 15 was due July 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on November 2, 2012, the most recent individual training plan for employee # 15 was completed on May 20, 2011.
The findings were confirmed during an interview with the Division Director on November 7, 2012 at approximately 3:30 P.M.
This is a repeat citation. The facility was cited on June 6, 2012 and December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
Responsible Party: The Clinical Supervisor/Program Manager is responsible for ensuring that all employees that fall under their direct line of supervision recieve and document an individual training plan within 30 days of hire for new employees and by January 31st each year thereafter.
Timeframe: Employees # 13, 14, and 15 will have an individual training completed collaboratively with the Clinical Supervisor/Manager by January 13, 2013.
Monitoring:
The Program Director will review status of all needed individual training plans during monthly supervision with each Clinical Supervisor.
The Human Resource Director will monitor the personnel records of employees #13, 14 and 15 to ensure an individual training is completed and filed in the employee record by 1/31/13.
Ongoingly, the HR Director will be responsible for ensuring that all Supervisors and Mangers complete and file an individual training plan with each employee within 30 days of hire for new employees and by January 31st each year thereafter. |
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
Based on a review of personnel records, the facility failed to ensure that the project director completed 12 clock hours of required training.
The findings include:
From November 6, 2012 to November 7, 2012, two personnel records requiring documentation of 12 clock hours of training were reviewed. The facility failed to provide documentation of 12 clock hours of training in one of two personnel records reviewed, specifically, personnel record # 1.
Employee # 1, the project director, was hired on December 3, 2001. The facility's training year is from July 1, 2011 to June 30, 2012. Personnel record # 1 only included 6 clock hours of training for the July 1, 2011 to June 30, 2012 training year as of November 7, 2012.
The findings were confirmed during an interview with the Division Director on November 7, 2012 at approximately 3:30 P.M.
This is a repeat citation. The facility was cited on June 6, 2012 and December 14, 2011 for noncompliance with this standard.
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Plan of Correction
Responsible:
The Project Director employee #1 is responsible to complete 12 clock hours of training annually. Employee #1 will submit all documentation of completed trainings to Human Resource Department no later than one week after completed trainings.
Time Frame:
Employee #1 will complete 12 clock hours of training no later December 31st of each year.
Monitoring:
The Human Resource Director in conjunction with the Licensing/Clinical Training Director will monitor and schedule at least one to two trainings or webinars monthly to ensure the Project Director completes the required training hours.
The HR Director will also ensure the training evaluation and certificate documenting the completed trainings are placed in the personnel files of employee #1.
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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
Based on a review of personnel records, the facility failed to ensure that each counselor completed 25 clock hours of required training.
The findings include:
From November 6, 2012 to November 7, 2012, two personnel records requiring documentation of 25 clock hours of training were reviewed. The facility failed to provide documentation of 25 clock hours of training in one of two personnel records reviewed, specifically, personnel record # 5.
Employee # 5 is a counselor and was hired on March 26, 2007. The facility's training year is from July 1, 2011 to June 30, 2012. Employee # 5's personnel record only had documentation of 16 clock hours of training for the July 1, 2011 to June 30, 2012 training year as of November 7, 2012.
The findings were confirmed during an interview with the Division Director on November 7, 2012 at approximately 3:30 P.M.
This is a repeat citation. The facility was cited on June 6, 2012; December 14, 2011; October 15, 2010; November 18, 2009; and November 7, 2008 for noncompliance with this regulation.
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Plan of Correction
Responsible Party: The HR Director in collaboration with the Clinical Supevisors and Program Mangers are responsible for ensuring that counselor recieve 25 clock hours of training and submit verification of the training hours to verify meeting the state requirement.
Timeframe: All employees, including #5 will submit all documentation of completed trainings to the HR dept. within one week of each completed training.
Any documentation of additional completed training hours for the 2011-2012 training year for will be submitted to the HR Director by 1/4/13.
Monitoring: On a monthly basis, the HR Director will review the status of annual training hour documentation in the personnel records, to ensure annual hours are being accumulated on a monthly basis.
The Clinical Supervisors, will ensure that all counselors have completed the required 25 clock hours of training during the training year.
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on observations on November 16, 2012, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients and employees and visitors.
The findings include:
A physical plant inspection was conducted on November 16, 2012. From approximately 10:00 A.M. to 12: 15 P.M., the following items were identified:
1) During the inspection, the main hallways on the second floor were observed to have areas of cracking floor tiles and areas on the floor that were stained.
2) It was observed that the waiting area in section # 238 outside of offices 238 - 239 had areas of cracking and stained floor tiles.
3) During the inspection, the carpet in the waiting area in section # 240 outside of offices # 240 -244 was observed to have areas that were stained.
4) It was observed that the waiting area in section # 234 outside of offices 234 - 237 had areas of cracking and stained floor tiles.
The findings were confirmed during an interview with the maintenance staff at approximately 12:15 P.M.
This is a repeat citation. The facility was cited on June 6, 2012 and December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
Responsible:
The Maintenance and Facilities Department is responsible for the completion of repairs to keep the grounds of the facility clean, safe and sanitary and in good repair at all times for the safety and well being of persons in treatment, employees and visitors.
Time Frame:
(1) The main hallways on the second floor, which were observed to have areas of cracking floor tiles, will be reported to the Maintenance and Facilities Department by 12/21/2012.
Repairs to the reported areas will be completed by 12/31/2012.
(2) The waiting area in section # 238 outside of offices 238 - 239, which was reported to have areas of cracking and stained floor tiles, will be reported to the Maintenance and Facilities Department by 12/21/12.
Repairs to the reported areas will be completed by 12/31/2012
(3)The carpet in the waiting area in section # 240 outside of offices # 240 -244, which was observed to have areas that were stained will be reported to the Maintenance and Facilities Department by 12/21/2012.
Repairs to the reported areas will be completed by 12/31/2012.
(4) The waiting area in section #234 outside of offices 234-237 with areas of cracking and stained floor tiles will be reported to the Maintenance and Facilities Department by 12/21/12.
Repairs to the areas will be completed by 12/31/2012.
Monitoring: The Program Director will conduct a monthly walk through of the program grounds to ensure all areas are in compliance.
All findings will be reported to the Maintenance and Facilities Department within 72 hours.
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705.23 (2) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on observations on November 16, 2012, the facility failed to maintain counseling areas with furnishings which are in good repair.
The findings include:
A physical plant inspection was conducted on November 16, 2012. From approximately 10:00 A.M. to 12:15 P.M., the following items were identified.
1) During the inspection, the floor tiles in individual/group counseling room # 237 were observed to have areas of stained floor tiles. It was also observed that there were areas of chipping paint on the door of individual/group counseling room # 237.
2) During the inspection, the floor tiles in individual/group counseling room # 236 were observed to have areas that were stained.
3) During the inspection, the floor tiles in individual/group counseling room # 235 were observed to have areas that were stained.
4) During the inspection, the carpet in individual counseling room # 214 was observed to have areas that were stained.
5) During the inspection, it was also observed that there were areas of chipping paint on the door of individual/group counseling room # 239
6) During the inspection, the carpet in individual counseling room # 244 was observed to have areas that were stained. It was also observed that there were areas of chipping paint on the door of individual/group counseling room # 244.
7) During the inspection, the carpet in individual counseling room # 242 was observed to have areas that were stained. It was also observed that there were areas of chipping paint on the door of individual/group counseling room # 242.
8) During the inspection, the carpet in individual counseling room # 241 was observed to have areas that were stained. It was also observed that there were areas of chipping paint on the door of individual/group counseling room # 241.
9) During the inspection, the carpet in group counseling room # 121 was observed to have areas that were stained.
10) During the inspection, the carpet in individual counseling room # 124 was observed to have areas that were stained.
11) During the inspection, the carpet in group counseling room # 162 was observed to have areas that were stained.
12) During the inspection, the carpet in group counseling room # 158 was observed to have areas that were stained and torn.
13) During the inspection, the carpet in group counseling room # 157 was observed to have areas that were stained and torn.
14) During the inspection, the carpet in individual counseling room # 114 was observed to have areas that were stained.
15) During the inspection, the carpet in group counseling room # 148 was observed to have areas that were stained and torn.
16) During the inspection, the carpet in counseling room # 151 was observed to have areas that were stained.
17) During the inspection, the carpet in counseling room # 152 was observed to have areas that were stained.
18) During the inspection, the carpet in individual/group counseling room # 153 was observed to have areas that were stained.
19) During the inspection, the carpet in group counseling room # 249 was observed to have areas that were stained. It was also observed that there were areas of chipping paint on the door of group counseling room # 249.
The findings were confirmed during an interview with the maintenance staff at approximately 12:15 P.M.
This is a repeat citation. The facility was cited on June 6, 2012 and December 14, 2011 for noncompliance with this standard.
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Plan of Correction
Responsible: The Program Director will make all reports to the Maintenance and Facilities Department for repairs by 12/21/2012. The Maintenance and Facilities Department is responsible for the completion of repairs by 1/31/2013.
Time Frame:
(1) The floor tiles in individual/group counseling room # 237, which were observed to have areas of stained floor tiles and the chipping paint on the door of individual/group counseling room #237 will be reported to the Maintenance and Facilities Department for repairs by 12/21/2012.
Repairs to the reported areas will be completed by 1/31/2013.
(2) The floor tiles in the individual/group counseling room # 236, which was observed to have areas that were stained, will be reported to the Maintenance and Facilities Department by 12/21/2012.
Repairs to the reported areas will be completed by 1/31/2013.
(3) The floor tiles in the individual/group counseling room # 235, which was observed to have areas that were stained, will be reported to the Maintenance and Facilities Department by 12/21/2012.
Repairs to the reported areas will be completed by 1/31/2013.
(4) The carpet in group counseling room # 214, which was observed to have areas that were stained, will be reported to the Maintenance and Facilities Department by 12/21/2012.
Repairs to the reported areas will be completed by 1/31/2013.
(5) The chipping paint on the door of individual/group counseling room #239 will be reported and repaired by 1/31/2013.
(6) The carpet in group counseling room #244, which was observed to have areas that were stained and door of room 244 with chipping paint will be reported to the Maintenance and Facilities Department by 12/21/2012.
Repairs to the reported areas will be completed by 1/31/2013.
(7) The carpet in group counseling room # 242 and door of room #242 with chipping paint which was observed to have areas that were stained will be reported to the Maintenance and Facilities Department by 12/21/2012.
Repairs to the reported areas will be completed by 1/31/2013.
(8) The carpet in group counseling room # 241 which was observed to have areas that were stained and door of room # 241 will be reported to the Maintenance and Facilities Department by 12/21/2012.
Repairs to the reported areas will be completed by 1/31/2013.
(9) The carpet in group counseling room # 121 observed to have areas that were stained will be reported to Facilities by 12/21/12. Repairs to be made by 1/31/2013.
(10-19)The carpet in individual and group counseling rooms # 124, 162,158,157, 114, 148, 151, 152, 153, and 249 observed to have areas that were stained and/or torn will be reported to Facilities by 12/21/12. Areas of chipping paint on the door of room #249 will be reported as well by 12/21/12.
All Repairs to be made by 1/31/2013.
Monitoring: The Program Director will conduct a monthly walk through of the program grounds to ensure all areas are in compliance. All findings will be reported to the Maintenance and Facilities Department within 72 hours.
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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
Based on observations on November 16, 2012, the facility failed to ensure that the hot water temperature did not exceed 120 Fahrenheit.
The findings include:
A physical plant inspection was conducted on November 16, 2012. On November 16, 2012 nine restrooms were inspected. From approximately 10:00 A.M. to 12:15 P.M., the following were observed.
1)The sink in the unisex employee restroom located in the employee's lounge had a hot water temperature reading of 140 Fahrenheit.
2) The sinks in the men's public restroom on the second floor had a hot water temperature reading of 130 Fahrenheit.
The findings were confirmed during an interview with the maintenance staff at approximately 12:15 P.M.
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Plan of Correction
Responsible:
The Facilities and Maintenance Department will be responsible to ensure facility bathrooms shall have hot and cold water and the hot water shall not exceed 120F.
Time Frame:
(1) The sink in the unisex employee restroom located in the employee lounge shall have hot water not to exceed 120F no later than January 31, 2013.
(2) The sink in the men's public restroom on the second floor shall have hot water reading not to exceed 120F no later than January 31, 2013.
Monitoring:
The Facilities and Maintenance Department will monitor all restrooms on a weekly to monthly basis and test the hot water to show a reading not to exceed 120F.
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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on observations on November 16, 2012, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The findings include:
A physical plant inspection was conducted on November 16, 2012. On November 16, 2012, nine restrooms were inspected. From approximately 10:00 A.M. to 12:15 P.M., the following items were identified:
1)It was observed that the toilet flush pipe was broken and was detached from the toilet in the women's public restroom on the first floor near the dispense station.
2)It was observed that the water in the toilet in the men's handicap restroom on the first floor was steadily running and was unable to stop because the turn valve on the toilet was broken.
3) It was observed that the toilet flush arm of one of the three toilets was broken and there was no way to flush the toilet in the women's bathroom on the second floor.
4) It was observed that the flush arm of one of the two urinals was broken and there was no way to flush the urinal in the men's bathroom on the second floor.
The findings were confirmed during an interview with the maintenance staff at approximately 12:15 P.M.
This is a repeat citation. The facility was cited on June 6, 2012 and December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
Responsible:
The Maintenance and Facilities Director is responsible to maintain each bathroom in a functional, clean and sanitary manner at all times.
The Program director will report to the Maintenance and Facilities Director by 12/21/2012 the major areas of repair that are needed to maintain each bathroom in a functional, clean and sanitary manner at all times.
Time Frame:
(1) The toilet flush pipe that was observed broken and detached from the toilet in the women's public restroom on the first floor near the dispense station will be repaired no later than 12/31/2012.
(2) The valve on the toilet in the men's handicap restroom on the first floor where water was steadily running will be repaired no later than 12/31/2012.
(3) The flush arm of one of the three toilet observed broken in the women's bathroom on the second floor will be repaired no later than 12/31/2012.
(4) The flush arm of one of two urinals in the men's bathroom on the second floor will be repaired no later than 12/31/2012.
Monitoring: The Program Director will conduct a monthly walk through of the program grounds to ensure all areas are in compliance.
All findings will be reported to the Maintenance and Facilities Department within 72 hours. The maintenance and facilities department will make all repairs reported.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observations on November 16, 2012, the facility failed to ensure that heaters that are not permanently mounted or installed were not permitted in the facility.
The findings include:
A physical plant inspection was conducted on November 16, 2012. It was observed during the inspection at approximately 10:34 A.M., that there was a portable space heater in the individual counselor's office room # 152. Also, it was observed during the inspection at approximately 10:57 A.M., that there was a portable space heater in childcare room # 138.
The findings were confirmed during an interview with the maintenance staff at approximately 12:00 P.M.
This is a repeat citation. The facility was cited on December 14, 2011 and June 29, 2010 for noncompliance with this standard.
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Plan of Correction
Responsible:
The Program Director's/Managers/Supervisors will be responsible to ensure that heaters that are not permanently mounted or installed are not allowed in the facility.
The Program Directors will be responsible to remove from the facility the space heaters observed in counselor's room #152 and childcare room #138
Time Frame: The space heaters observed in rooms #153 and #138 were removed from the facility on 12/14/12.
Monitoring: The Managers/Supervisors will monitor staff offices to ensure space heaters are not in the facility or counseling or activity areas and office spaces.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment.
The findings include:
From November 6, 2012 to November 7, 2012, five personnel records requiring documentation of fire extinguisher training were reviewed. The facility did not provide documentation that they instruct staff in the use of the fire extinguisher upon staff employment in four of five personnel records reviewed, specifically, personnel records # 4, 7, 9, and 10.
Employee # 4 is a counselor and was hired on April 9, 2012. Employee # 4 was due to complete fire extinguisher training upon employment. However, employee # 4 did not complete fire extinguisher training until April 26, 2012.
Employee # 7 is a counselor and was hired on February 13, 2012. Employee # 7 was due to complete fire extinguisher training upon employment. However, employee # 7 did not complete fire extinguisher training until March 22, 2012.
Employee # 9 is a counselor and was hired on October 24, 2012. Employee # 9 was due to complete fire extinguisher training upon employment. However, personnel record # 9 did not include documentation of fire extinguisher training as of November 7, 2012.
Employee # 10 is a counselor and was hired on October 22, 2012. Employee # 10 was due to complete fire extinguisher training upon employment. However, personnel record # 10 did not include documentation of fire extinguisher training as of November 7, 2012.
The findings were confirmed during an interview with the Division Director on November 7, 2012 at approximately 3:30 P.M.
This is a repeat citation. The facility was cited on June 6, 2012; December 14, 2011; August 29, 2011; and October 15, 2010 for noncompliance with this regulation.
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Plan of Correction
Responsible:
The Training and Licensing Director in conjunction with Human Resource Director will be responsible to ensure new hires are instructed in the use of the fire extinguisher upon staff employment and documentation of the training is filed in personnel records.
The training will be provided by the Training and Licensing Director. New hires will sign?off on having participated in the fire extinguisher training and the sign-off sheet will be filed in their personnel record.
The Clinical Supervisor is responsible to meet with new hire and complete the On-Site Orientation Competency Checklist and Facility Orientation Checklist within two (2) weeks of hire date and complete Section C Facility Procedures: which includes site-specific emergency procedures, fire drill and smoking procedures, fire extinguisher, and fire system operation, emergency contact information, physical plant, appliances, security/keys, etc. within (7) days of hire.
Time Frame: As of 12/31/2012 staff #4, 7, 9, and 10 will have documentation of fire extinguisher training in their personnel records.
Monitoring: The Human Resource Director will monitor personnel records for the documentation of instruction in the use of the fire extinguisher and filing of the sign-off sheet for receiving fire extinguisher training along with employee on-site orientation competency checklist.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained upon employment to perform assigned tasks during emergencies.
The findings include:
From November 6, 2012 to November 7, 2012, five personnel records requiring documentation that all personnel on all shifts had been trained to perform assigned tasks during emergencies were reviewed. The facility failed to ensure that employees completed emergency training upon employment in four of five personnel records reviewed, specifically, employees # 4, 7, 9, and 10.
Employee # 4 is a counselor and was hired on April 9, 2012. Employee # 4 was due to complete emergency training by April 9, 2012; however, employee # 4 did not complete emergency training until April 26, 2012.
Employee # 7 is a counselor and was hired on February 13, 2012. Employee # 7 was due to complete emergency training by February 13, 2012; however, employee # 7 did not complete emergency training until March 22, 2012.
Employee # 9 is a counselor and was hired on October 24, 2012. Employee # 9 was due to complete emergency training by October 24, 2012; however, personnel record # 9 did not include documentation of emergency training as of November 7, 2012.
Employee # 10 is a counselor and was hired on October 22, 2012. Employee # 10 was due to complete emergency training by October 22, 2012; however, personnel record # 9 did not include documentation of emergency training as of November 7, 2012.
The findings were confirmed during an interview with the Division Director on November 7, 2012 at approximately 3:30 P.M.
This is a repeat citation. The facility was cited on June 6, 2012; December 14, 2011; August 29, 2011; and October 15, 2010 for noncompliance with this regulation.
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Plan of Correction
Responsible:
The Training and Licensing Director in conjunction with Human Resource Director will be responsible to ensure staff on all shifts is trained to perform assigned tasks during emergencies. The Training and Licensing Director will provide Disaster training to all new hires to be completed within 7 days of hire.
Time Frame:Employees # 4, 7, 9, and 10 will recieve training to perform assigned tasks during emergencies by the Licensing and Training DirecTor by 12/31/2012
Monitoring: The Human Resource Director will monitor personnel records of new hires for the documentation of staff on all shifts are trained to perform assigned tasks during emergencies. The Training and Licensing Director in conjunction with Human Resource Director will ensure the that existing employees that do not have the emergency training will be trained by 12/31/2012.
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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
Based on review of administrative documentation, the facility failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of the fiscal year.
The findings include:
The administrative documentation was reviewed from November 5, 2012 to November 7, 2012. The facility was required to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of their fiscal year. The facility's 2010 through 2011 fiscal year ended on June 30, 2011. However, the facility's financial audit for this period was partially completed on July 30, 2012 with a supplementary completion of the audit on September 24, 2012.
The findings were confirmed during an interview with the Division Director on November 7, 2012 at approximately 12:30 P.M.
This is a repeat citation. The facility was cited on August 29, 2011; June 29, 2010; and November 18, 2009 for noncompliance with this standard.
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Plan of Correction
Responsible:
The Chief Financial Officer (CFO) will be responsible to facilitate the financial statement audit process. An independent certified public accounting firm will be engaged by the organization's Board of Directors finance committee to complete the financial statement audit for the fiscal year end of June 30.
Time Frame: The CFO will ensure completion of the annual audit by independent public accountants by Sept. 1st of each year, following the close of the annual fiscal year, June 30th.
Monitoring:
The CFO will coordinate and monitor the process of obtaining the services of an independent certified public accounting firm to perform the financial statement audit for each fiscal year end.
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records and the facility's policy and procedure manual, the facility failed to document an initial work performance evaluation in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Performance Appraisal," states:
"It is The Consortium's policy to provide a performance appraisal process that measures employee performance and aids employees in their development. This is an ongoing process between employees and their supervisors; however, employees formally evaluated upon completion of their initial 90-days of employment and annually, thereafter, in their anniversary month."
From November 6, 2012 to November 7, 2012, three personnel records requiring documentation of an initial work performance evaluation were reviewed. The facility did not document an initial work performance evaluation according to their policy and procedures in two of three personnel records reviewed, specifically, personnel records # 4 and 7.
Employee # 4 is a counselor and was hired on April 9, 2012. Employee # 4 was due for an initial 90 day work performance evaluation by July 8, 2012. However, an initial work performance evaluation was not completed for employee # 4 until November 1, 2012.
Employee # 7 is a counselor and was hired on February 13, 2012. Employee # 7 was due for an initial 90 day work performance evaluation by May 13, 2012. However, an initial work performance evaluation was not completed for employee # 7 until November 1, 2012.
The findings were confirmed during an interview with the Division Director on November 7, 2012 at approximately 3:30 P.M.
This is a repeat citation. The facility was cited on December 14, 2011 and October 15, 2010 for noncompliance with this regulation.
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Plan of Correction
Responsible:
The Clinical Supevisor/Manager is responsible for ensuring that all new hires complete a performance appraisal within the first 90 days and annually, thereafter.
Timeframe:
Between January 1 and January 15, 2013 all existing employees will have an annual performance completed with their respective supervisor.
Employees 4 and 7 will have an initial 90 day performance appraisal completed by January 4, 2013.
Monitoring:
The HR Department will work with the Clinical Supervisors and Managers to ensure that all new hires recieve a 90 day initial performance appraisal and an annual performance appraisal done for existing employees from Jan 1 to Jan 15th each year.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of patient records, the facility failed to document a personal history or review and sign off on a psychosocial history completed within six months prior to admission by the SCA or other D & A treatment facility.
The findings include:
The facility's policy titled: "DAS 709.91 Intake & Admission," states:
"The Bio-Psycho-Social history and Evaluation are to be completed by the 30 th day of the person's admission date"
From November 15, 2012 to November 16, 2012, seven client records requiring documentation of a personal history were reviewed. The facility did not document a personal history in five of seven records reviewed, specifically, patient records # 1, 2, 3, 4, and 5. The facility also did not have documentation of a signature and date from the facility staff and patient indicating a personal history from a licensed drug and alcohol treatment provider or the Single County Authority was reviewed by both facility staff and patient in two of seven records reviewed, specifically, patient records # 6 and 7.
Patient # 1 was admitted August 6, 2012. The personal history was due September 5, 2012; however, patient record # 1 did not include documentation of a personal history as of November 16, 2012.
Patient # 2 was admitted August 14, 2012. The personal history was due September 13, 2012; however, patient record # 2 did not include documentation of a personal history as of November 16, 2012.
Patient # 3 was admitted August 15, 2012. The personal history was due September 14, 2012; however, patient record # 3 did not include documentation of a personal history as of November 16, 2012.
Patient # 4 was admitted September 4, 2012. The personal history was due October 4, 2012; however, patient record # 4 did not include documentation of a personal history as of November 16, 2012.
Patient # 5 was admitted September 4, 2012. The personal history was due October 4, 2012; however, patient record # 5 did not include documentation of a personal history as of November 16, 2012.
Patient # 6 was admitted September 20, 2012. The personal history was dated August 9, 2012. However, the personal history did not include documentation of a signature from the facility staff and patient indicating the personal history was reviewed by both facility staff and patient as of November 16, 2012.
Patient # 7 was admitted September 5, 2012. The personal history was dated August 10, 2012. However, the personal history did not include documentation of a signature from the facility staff and patient indicating the personal history was reviewed by both facility staff and patient as of November 16, 2012.
The findings were confirmed during an interview with the Assistant Program Director on November 16, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on June 6, 2012 and December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
Responsible Party:
Clinical Counseling staff is responsible for ensuring that the Bio-Psycho-Social history and Evaluation are completed by the 30 th day of the person's admission date.
Timeframe: Records 1, 2, 3, 4 and 5 will have a complete personal history completed by 12/31/12 by the counselor of record
Records # 6 and 7 will have documentation of a signature from the facility staff and patient indicating the personal history section of the Biopsycho Social History was reviewed by both facility staff and patient by 12/31/12.
The policy for completion of personal histories will be submitted to the board and approved by 1/11/13.
Staff will be trained by the Program Director in relation to the updated policy within 2 weeks of the approval date.
Staff will be trained by the Program Director in relation to signing off on a review of external personal histories by 12/31/12.
Monitoring: The Intake Supervisor will review all new admission records to ensure that personal histories are completed upon admission.
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709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of patient records, the facility failed to document a physical examination in accordance with 715.6(b)(1) performing a medical history and physical exam.
The findings include:
The facility's policy titled: "7:15.9 -Intake, 709.24-Treatment/Rehabilitation Management, 709.91-Intake, " states:
"Prior to being admitted to the program a client must be able to corroborate a one-year history of narcotic dependency. In addition, the program physician conducts a physical examination of each client, which includes the following:"
From November 15, 2012 to November 16, 2012, seven records requiring documentation of a physical examination were reviewed. The facility did not document a physical examination according to their policy and procedures in five of eight records reviewed, specifically, patient records # 1, 2, 3, 4, and 5.
Patient # 1 was admitted August 6, 2012. The physical examination was due prior to the patient being admitted on August 6, 2012. However, the physical examination was not completed until August 8, 2012.
Patient # 2 was admitted August 14, 2012. The physical examination was due prior to the patient being admitted on August 14, 2012. However, the physical examination was not completed until August 21, 2012.
Patient # 3 was admitted August 15, 2012. The physical examination was due prior to the patient being admitted on August 15, 2012. However, the physical examination was not completed until August 21, 2012.
Patient # 4 was admitted September 4, 2012. The physical examination was due prior to the patient being admitted on September 4, 2012. However, the physical examination was not completed until October 1, 2012.
Patient # 5 was admitted September 4, 2012. The physical examination was due prior to the patient being admitted on September 4, 2012. However, the physical examination was not completed until September 17, 2012.
The findings were confirmed during an interview with the Assistant Program Director on November 16, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on June 6, 2012 and December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
Responsible Party: Narcotic Treatment Physicians, Program Director, Nursing Staff are responsible for ensuring that a physical examination be completed prior to the patient's admisssion into the treatment program.
Timeframe: The policy for completion of the physical examination will be submitted to the Board and updated by 1/11/13.
Records 1, 2, 3, 4, and 5 will be reviewed for a physical examination by 12/31/12. If still in need, a physical will be completed by 1/11/13.
All staff will be trained in updated policy within 2 weeks of approval date.
Monitoring: Intake and admission Supervisor will review all new admission records to ensure that a physical examination is completed in accordance to approved program policy.
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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
Based on a review of patient records, the facility failed to document a psychosocial evaluation.
The findings include:
From November 15, 2012 to November 16, 2012, seven records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation in seven of seven records reviewed, specifically, patient records # 1, 2, 3, 4, 5, 6, and 7.
Patient # 1 was admitted August 6, 2012. The psychosocial evaluation was due September 5, 2012; however, patient record # 1 did not include documentation of a psychosocial evaluation as of November 16, 2012.
Patient # 2 was admitted August 14, 2012. The psychosocial evaluation was due September 13, 2012; however, patient record # 2 did not include documentation of a psychosocial evaluation as of November 16, 2012.
Patient # 3 was admitted August 15, 2012. The psychosocial evaluation was due September 14, 2012; however, patient record # 3 did not include documentation of a psychosocial evaluation as of November 16, 2012.
Patient # 4 was admitted September 4, 2012. The psychosocial evaluation was due October 4, 2012; however, patient record # 4 did not include documentation of a psychosocial evaluation as of November 16, 2012.
Patient # 5 was admitted September 4, 2012. The psychosocial evaluation was due October 4, 2012; however, patient record # 5 did not include documentation of a psychosocial evaluation as of November 16, 2012.
Patient # 6 was admitted September 20, 2012. The psychosocial evaluation was due October 20, 2012; however, patient record # 6 did not include documentation of a psychosocial evaluation as of November 16, 2012.
Patient # 7 was admitted September 5, 2012. The psychosocial evaluation was due October 5, 2012; however, patient record # 7 did not include documentation of a psychosocial evaluation as of November 16, 2012.
The findings were confirmed during an interview with the Assistant Program Director on November 16, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on June 6, 2012; December 14, 2011; October 15, 2010; June 29, 2010; November 18, 2009; November 7, 2008 for noncompliance with this standard.
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Plan of Correction
Responsible Party: Counselor of Record is responsible for completing a psychosocial evaluation within 30 days of the admission date of each client.
Timeframe:
Records # 1, 2, 3, 4, 5, 6, and 7. will have a completed Psycho Social Evaluation completed by 1/11/13.
The Clinical Supervisor is responsible for the review of all submitted bio psycho social evaluations to ensure completeness, and submission within 30 days of the client's admission date.
Monitoring: The Clinical Supervisor will review all new admission records to ensure that bio psycho social evaluations are completed fully and on time. This will be reviewed in bi-weekly supervision.
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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 patient records, the facility failed to document an individual treatment and rehabilitation plan or document an individual treatment and rehabilitation plan in accordance with their policy and procedures.
The findings include:
The facility's policy titled: " 709.92 Treatment And Rehabilitation Services," states:
"The individual treatment and rehabilitation plan is developed by staff in close collaboration with the person in recovery within the first 30 days of treatment upon the completion of the Psychosocial History and Psychosocial History and Psychosocial Evaluation."
From November 15, 2012 to November 16, 2012, nine records requiring documentation of an individual treatment and rehabilitation plan were reviewed. The facility did not document an individual treatment and rehabilitation plan according to their policy and procedures in three of nine records reviewed, specifically, patient records # 1, 2, and 5. The facility also did not document an individual treatment and rehabilitation plan in two of nine records reviewed, specifically, patient records # 3 and 4.
Patient # 1 was admitted and started treatment on August 6, 2012. The individual treatment and rehabilitation plan was due September 5, 2012; however, the individual treatment and rehabilitation plan was not completed until September 12, 2012.
Patient # 2 was admitted and started treatment on August 14, 2012. The individual treatment and rehabilitation plan was due September 14, 2012; however, the individual treatment and rehabilitation plan was not completed until September 20, 2012.
Patient # 3 was admitted and started treatment on August 15, 2012. The individual treatment and rehabilitation plan was due September 14, 2012; however, the patient record # 3 did not include documentation of an individual treatment and rehabilitation plan as of November 16, 2012.
Patient # 4 was admitted and started treatment on September 4, 2012. The individual treatment and rehabilitation plan was due October 4, 2012; however, the patient record # 4 did not include documentation of an individual treatment and rehabilitation plan as of November 16, 2012.
Patient # 5 was admitted and started treatment on September 4, 2012. The individual treatment and rehabilitation plan was due October 4, 2012; however, the individual treatment and rehabilitation plan was not completed until October 11, 2012.
The findings were confirmed during an interview with the Assistant Program Director on November 16, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on June 6, 2012 and December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
Responsible Party: The Counselor of record is responsible for completing all Master and updated treatment plans within 30 days of admission for Master Plans, and every 60 days for all updated plans.
The Clinical Supervisor is responsible for reviewing status of completed treatment plans by the counselor.
Timeframe: Patient records 1, 2, 3, 4 and 5 will be reviewed for updated treatment and/or Master plans. All outstanding treatment plans will be submitted by 1/11/2013.
Staff will be trained by 12/31/12 on the timeframes for the completion of Master and updated treatment plans.
Monitoring: The Clinical Supervisor will review status of treatment plan submission bi weekly in the supervision process. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of patient records, the facility failed to document a case consultation.
The findings include:
On November 15, 2012 and November 16, 2012, two patient records requiring documentation of a case consultation were reviewed. The facility did not document a case consultation in two of two records reviewed, specifically, patient records # 8 and 9.
Patient # 8 was admitted July 16, 2012. The case consultation was due September 14, 2012; however, patient record # 8 did not include documentation of a case consultation as of November 16, 2012.
Patient # 9 was admitted July 12, 2012. The case consultation was due September 10, 2012; however, patient record # 9 did not include documentation of a case consultation as of November 16, 2012.
The findings were confirmed during an interview with the Assistant Program Director on November 16, 2012 at approximately 3:00 P.M.
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Plan of Correction
Responsible:
Clinical Counseling staff is responsible for ensuring the completion of a case consultation for each quarter within the patient's first year of treatment and annually thereafer.
Timeframe:
The Counselor of record will document a case consultation for patient Records # 8 and 9 by 12/31/12.
Monitoring:
The Clinical Supervisor will review status of the completion of case consulations with their resepctive counselors during the supervision process at least once per month and ensure that case consultations are completed on time for each client.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of patient records, the facility failed to document follow-up information.
The findings include:
From November 15, 2012 to November 16, 2012, five patient records requiring documentation of follow-up information were reviewed. The facility did not document follow-up information in four of five records reviewed, specifically, patient records # 10, 11, 13, and 14.
Patient # 10 was admitted July 18, 2012 and was discharged October 2, 2012. The follow-up information was due November 1, 2012. However, patient record # 10 did not include documentation of follow-up information as of November 16, 2012.
Patient # 11 was admitted March 21, 2012 and was discharged September 20, 2012. The follow-up information was due October 20, 2012. However, patient record # 11 did not include documentation of follow-up information as of November 16, 2012.
Patient # 13 was admitted April 6, 2011 and was discharged September 19, 2012. The follow-up information was due October 19, 2012. However, patient record # 13 did not include documentation of follow-up information as of November 16, 2012.
Patient # 14 was admitted February 18, 2011 and was discharged October 2, 2012. The follow-up information was due November 1, 2012. However, patient record # 14 did not include documentation of follow-up information as of November 16, 2012.
The findings were confirmed during an interview with the Assistant Program Director on November 16, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on December 14, 2011 for
noncompliance with this standard.
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Plan of Correction
Resposnble Party:
The Counselor of record is responsible for ensuring that follow up is doucmented for each patient that is discharged from the treatment program by the 30th day of discharge.
Timeframe:
Patient records 10, 11, 13 and 14 will have outreach and follow up documented in the record by 12/31/12.
Monitoring: The Clinical Supevisor will review the status of all discharged patients and consequent follow up documentation with the counselor of record during supervision at least once per month.
The Clinical Supervisor will also ensure that that follow-up information is completed on time for each client as scheduled. |