INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9, 2007 and April 10, 2007 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 May 4, 2007.
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Plan of Correction
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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
Individual training plans for the 2007 training year were not completed in six of six employees records reviewed, # 1, 2, 3, 4, 5 and 6.
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Plan of Correction
704.1 (b)(1) Individual training plan
The individual training plans will accompany all staff training folders.
Person(s) Responsible: Program Director, Supervisors,
and Administrative Assistant
Timeframe for Compliance: Immediate
POC. The Administrative Assistant will ready staff training packets that include the current year's training assessment in Janaury, or upon hire. The assessments will be distributed by the Program Director and collected by the Administrative Assistant at the annual retreat in September, or upon hire. The feedback from the assessments will be shared with the supervisors and be integrated into the annual training plan.
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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
Employee #5 earned only 16.5 hours of 25 for the 2006 training year. Employee # 6 earned only 15.5 hours of 25 for the 2006 training year.
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Plan of Correction
704.11 (f)(2) Trng Hours Req-Counselors
Counselors will achieve the required
number of hours annually.
Person Responsible(s): Program Director,Supervisors, Counselors, and Administrative Assistant
Timeframe for Compliance: Immediate
POC: A quarterly audit will be completed and distributed to the counselor, and their immediate supervisor. This system will allow for a review of the required hours and
trainings as identified in the Training
Needs Assessment form. All shortfalls will be addressed at that time with a plan to ensure compliance
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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
There were portable space heaters in two offices.
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Plan of Correction
705.26 (2) Heating and cooling.
All space heaters have been removed
from staff offices.
Person Responsible: Program Director
Timeframe for Completion: Immediate
POC: Quarterly monitoring to insure
Staff are compliant with physical plant
Regulations.
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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
Employee # 3 obtained this training three months after their hire date.
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Plan of Correction
705.28 (c)(4) Fire Safety
All new employee will received
Fire Safety Training within 7 days of
hire.
Person Responsible(s): Program Director and Administrative Assistant
Timeframe for Compliance: Within 7 days of hire
POC: 7-day training has now been included on the Employee's Orientation Checklist Orientation form. The Administrative Assistant
will monitor training compliance to ensure the training is completed within the 7 day timeframe.
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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
Employee #3 obtained this training three months after their hire date.
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Plan of Correction
705.28 (d)(4) Fire Safety
Fire drills will be properly documented
in the Fire Drill log.
Person Responsible(s): Program Director and Administrative Assistant
Timeframe for Compliance: Immediate
POC: A fire drill schedule has been developed and our own internal forms will be used in addition to the building management forms since our forms are more inclusive of the
information to be gleaned, particularly evacuation time.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The "Shelter In Place Drill" log does not include what exit routes were utilized during the drill. Ten of twelve fire drills conducted did not include the amount of time it took to evacuate the building during the drill.
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Plan of Correction
705.28 (d)(4) Fire Safety
Fire drills will be properly documented
in the Fire Drill log.
Person Responsible: Program Director
And Administrative Assistant
Timeframe for Compliance: Immediate
POC: A fire drill schedule has been developed and our own internal forms will be used in addition to the building management forms, since our forms are more inclusive of the information to be gleaned,particularly
evacuation time and evacuation routes.
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711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
The comprehensive treatment plan did not include specific and measurable criteria in which the client and counselor can utilize to have the client achieve the identified treatment goals in four of seven client records reviewed; #2, 5, 6 and 7.
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Plan of Correction
L0963: Comprehensive treatment plan was lacking in specific and measureable criteria.
Person(s) Responsible: Clinical Supervisor and Counselors
Timeframe for Completion: Immediate
POC: Counseling staff received documented training on April 20, 2007 regarding treatment plans and the need to indicate specific and measurable criteria which the counselor and client can utilize to have the client achieve the identified treatment goals. The treatment plan form will be revised to include a column specifying who is the responsible party for initiating the action step for achieving a specific treatment goal. Treatment plans will be reviewed during weekly supervision by the Clinical Supervisor. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Treatment plan updates did not provide a review of progress on previously started goals in seven of seven client records reviewed, #1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
L0969: TPU lack clinical reference to assessment of progress on previous goals.
Person Responsible(s): Program Director and Clinical Supervisor
Timeframe: Immediate
POC:The treatment plan form is being revised to include: the assessment of client's progress in achieving treatment goals. the Clinical Supervisor provided documented training on the assessment of the previous TPU goals to all clinical staff on April 20, 2007.
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711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Follow up information was not documented in three of seven client records reviewed, #10, 11 and 12.
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Plan of Correction
Follow-Up information missing from charts.
Peron(s) Responsbile: Program Director and Clinical Supervisor
Timeframe for completion: Immediate
POC: The form has been revised for clarity and a documented training was provided by the Program Director and the Clinical Supervisor on April 20, 2007 to all clinicians. When appropriate, the Clinical Supervisor will review the patient's chart to ensure the follow-up form has been completed. |
711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
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Observations
The Thomas Jefferson University hospital policy on confidentiality was part of the drug and alcohol program manual that allowed for the release of client information without consent in cases of elder abuse and/or domestic violence. The drug and alcohol confidentiality regulations do not allow information to be released without consent in these cases.
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Plan of Correction
711.93©(l)(i) Confidentiality ? Client identity/Records. The inclusion of the TJUH policy on confidentiality will be removed to eliminate any conflicts.
Person Responsible: Program Director
Timeframe for Compliance: Immediate
POC: The TJUH policy has be removed with reference to domestic violence and elder care.
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