INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6-8, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penn Foundation for Mental Health Inc. 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based upon the review of employee records, the facility failed to ensure that each counselor met the qualifications for the position in one of two records reviewed.
The findings include:
Four personnel records requiring verification of qualifications for the position of counselor were reviewed on January 6, 2014. One out of four records, specifically record # 8, did not meet the qualifications of the position.
Employee # 8 was hired as a Drug and Alcohol Tech on January 12, 2013 and promoted to a Counselor on April 1, 2013 based on a Master's degree in Criminal Justice. The transcripts and resume for employee #8 were reviewed. The transcripts did not include a practicum or internship, and therefore was not eligible to be considered as a qualifying Master's degree.
The counselor does have a qualifying bachelor's degree in psychology, however lacks the required one year of clinical experience.
The findings were confirmed by administrative staff.
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Plan of Correction
It was discovered during the site visit that one employee did not meet the qualifications for counselor. This employee will be made a counselor assistant until the required one year of clinical experience is achieved. While a counselor assistant, Director of Inpatient will provide increased clinical supervision and documentation of progress towards becoming a counselor. Director of Inpatient will oversee this POC.
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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
Based on a review of personnel records the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff.
The findings include:
Three personnel record requiring documentation of HIV/AIDS and TB/STD training was reviewed on January 6, 2014. One out of three records, specifically record # 10, did not contain the required documentation. Employee # 10 was hired as a counselor on October 11, 2012. Training was due by October 11, 2013. As of the licensing inspection, there was no documentation of TB/STD training for employee #8.
The findings were confirmed with the facility staff.
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Plan of Correction
Employee #10 did not have TB/STD training completed. He has been scheduled to attend this training on January 30, 2014. The Recovery Center will implement a new procedure for ensuring the timely completion of required trainings. The mandatory trainings will be scheduled for new employees at the time of hire as part of their new employee orientation. Supervisors will be made aware to schedule new employees for the mandatory trainings within the first one month of hire. Special Projects Coordinator will oversee this POC. |
709.62(c)(3)(i) LICENSURE Medical history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to document the clients' medical, drug and alcohol, and personal history in one out of four detox patient records.
The findings include:
Per agency policy, the patient histories, which includes the medical, drug and/or alcohol, and personal histories, are to be completed within 3 days of admission.
Four client records requiring documentation of histories were reviewed on January 7, 2014. The facility failed to document all of the patient histories in record # 2.
Patient #2 was admitted to treatment on December 30, 2013. As of the date of inspection, there was no documentation of a current or updated medical, drug and alcohol, or personal history for client #1.
The findings were reviewed with facility staff prior to the exit interview.
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Plan of Correction
It was discovered during the site visit that clinicians were not signing off on the Biopsychosocial History document when it had been completed by another clinician in the past six months. Clinicians were completing the BPS update, but not documenting that the original document had been reviewed and updated as necessary. During team meeting following exit interview, clinical staff were made aware of the new procedure to document their review of the medical, drug and alcohol and personal histories. The new procedure will be incorporated into the Policy and Procedure Manual. Directors of Inpatient and Outpatient will oversee this POC. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include proposed types of supportive services in three out of eight outpatient records reviewed.
The findings include:
Nine outpatient client records were reviewed for comprehensive treatment plans, which included support services on January 7, 2014. One client record did not document a treatment plan at all. Three out of nine outpatient client records lacked documentation of a treatment plan that included a proposed type of support service, specifically client records # 12, 13, and 14.
The comprehensive treatment plan for client #12 was documented on December 5, 2013; however it did not include a proposed type of support service for client #12.
The comprehensive treatment plan for client #13 was documented on April 25, 2013; however it did not include a proposed type of support service for client #13.
The comprehensive treatment plan for client #14 was documented, however it was undated and did not include a proposed type of support service for client #14.
The findings were confirmed with administrative staff.
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Plan of Correction
It was discovered during the site visit that OP clinicians were not routinely documenting a proposed type of support service for clients. During treatment team meeting and reinforced via email, clinicians were made aware of the need to include this on all treatment plans. Clinicians were given a list of support services we frequently refer to, to use as a resource when developing treatment plans with clients. Clinicians will begin incorporating support services in the treatment plan immediately. Director of Outpatient will oversee this POC.
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709.93(a) 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:
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Observations
Based on the review of outpatient client records, the facility failed to document a complete client record to include a treatment plan, case consultation, and/or an aftercare plan in three out of nine outpatient client records.
The findings include:
Nine outpatient client records were reviewed for documentation of treatment plans, case consultations, and aftercare plans on January 7, 2014. The facility failed to document a treatment plan in one out of nine records, specifically # 10.
Additionally, four out of those nine client records were required to include documentation of a case consultation. The facility failed to document a case consultation in two out of four outpatient client records, specifically #'s 14 and 16.
Four out of the nine outpatient records reviewed were discharged clients of which three were required documentation of an aftercare plan. One of the three discharged outpatient records failed to include an aftercare plan as required, specifically # 14.
Client #10 was admitted to treatment on December 4, 2013. The treatment plan was due by December 18, 2013. As of the date of inspection there is no documentation of a treatment plan for client #10.
Client # 14 was admitted to treatment on April 22, 2013 and discharged on November 8, 2013. A case consultation was due by July 22, 2013 and an aftercare plan was due prior to discharge. As of the date of inspection, there was no documentation of case consult or an aftercare plan for client #14.
Client # 16 was admitted to treatment on April 15, 2013 and discharged on September 24, 2013. A case consolation was due by July 15, 2013. As of the date of inspection, there was no documentation of case consult for client #16.
The findings were confirmed with facility staff prior to the exit interview.
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Plan of Correction
It was discovered during the site visit that some documentation was missing from the clinical record in OP files. Clinicians will be reminded of paperwork expectations during team meeting. OP Director will monitor the timely completion of all documentation via our internal computer tracking system. In addition, paperwork will be monitored during personal supervision time with clinicians. Finally, random chart checks will be used as a final checks and balances system to ensure completeness of the clinical record. Outpatient Director will oversee this POC.
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