INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26, 2009 through May 27, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights, 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 and a plan of correction is due on June 27, 2009.
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Plan of Correction
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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 the review of personnel records, the facility failed to ensure that all staff received a minimum of 6 hours of HIV/AIDS training within the required amount of time in one personnel record. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training with the first 2 years of employment.
Findings:
Five personnel records were reviewed on May 26, 2009. The facility did not document required HIV/AIDS training in personnel record #4. Employee #4 was hired 5/12/08 and was required to have HIV/AIDS training by May 12, 2009. This was not documented in the personnel record reviewed and the facility did not produce documentation of the completion of the training.
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Plan of Correction
Employee # 4 who was required to have obtained the training on HIV/AIDS was scheduled on April 24, 2009 for the first available training on this topic. Employee # 4 was scheduled on that date for this required course taking place in Longhorne, PA on July 14, 2009. In order to prevent any future omissions of the required training topics being obtained within the required time frame, the Executive Director will include this monitoring during the quarterly reviews of staff training hours. Upon conducting the regular quarterly reviews of total training hours, specifiic attention will be made to review the required trainings for each staff member. To assure future compliance, any required trainings due will be addressed at least six (6) months prior to the deadline of (1) or (2) years. The rationale for this safe guard is that often these required trainings fill-up fast (no vacancy) or they are cancelled. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of personnel records and an interview with Project Director on May 26, 2009 is was revealed that the facility did not have CPR and first aid coverage for Monday evenings for the month of May 2009 for the hours 5 PM to 9 PM.
Findings:
Personnel training records and schedules were reviewed on May 26, 2009.
A review of staff schedule revealed the facility failed to schedule CPR certified staff during their Monday evening programming
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Plan of Correction
The Executive Director scheduled the Annual CPR refresher presented by the American Red Cross to take place on June 12, 2009 at the Lemoyne facility. There has also been arrangements for two additional staff working at the Lemoyne site to obtain current CPR certification. This provides a total of (10) staff members with current CPR certification and assures coverage at both sites during all hours of operation. This task was addressed by the Executive Director. The Executive Director will construct a grid of staff coverage for both sites during all hours of operation. This coverage grid will be available at both sites to reference when there is a change in staff hours (termination, vacation, change in hours, etc.) As mentioned additional staff are being certified to provide adequate staff adjustments for coverage at both sites. These CPR coverage grids will be presented at the respective staff meetings, and the need to work as a team to confirm coverage during changes in staff hours. Any staff change will be reported to the Executive Director with the corresponding staff adjustment for CPR coverage, if needed. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the facility's fire drill record, the facility failed to conduct fire drills on different times of the day and on different staffing shifts.
Findings:
The fire drill record was reviewed on May 26, 2009. For the months of December 2008, January 2009, February 2009, March 2009, April 2009 and May 2009 the drills were either conducted in the morning or afternoons. None documented on the evening shift. The facilities hours of operation is Monday through Thursday 9 am to 9 PM, Friday 9 am to PM, Saturday 9 am to 1 PM.
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Plan of Correction
A fire drill will be conducted at the Lemoyne facility on June 18, 2009 during the evening hours of operation. This drill will be conducted and documented by the Senior support staff person in Lemoyne. Upon conducting a fire drill at either facility, the Facility Office Manager (York) (or) Senior Support Staff (Lemoyne) will forward a copy of the results that are documented in the Fire Drill log to the Executive Director. This will provide confirmation of the drill being conducted and any safety issues that are indicated. For example: (smoke alarm status, use of appropriate exits, time to conduct, the time it took place, etc.) The Executive Director will address any safety issues indicated on the Fire Drill Reports. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to complete psychosocial evaluations in four of six client records.
Findings:
Thirteen client records were reviewed on May 27, 2009. Psychosocial evaluations were required in six client records. The counselors did not document an evaluation of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment in client record #8, 10, 11, 12 and 13.
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Plan of Correction
The clinical supervisor will review with the clinical staff, at the staff meeting on 7/22/09 New Insights standard psycho-social profile including the last page, which documents the client's preferred coping mechanisms, strengths, problems identified for treatment and negative factors that might interefere with treatment. An example "composite" will be given to the clinical staff to illustrate that it should not be a narrative, but interpretive and must include, but not limited to the client's assets/strengths, support systems, coping mechanisms and any negative factors that might interefere with treatment. The clinical supervisor will remind the clinical staff that this must be completed in the proper time period, and before the initial comprehensive treatment plan. The clinical supervisor will randomly review one chart from each of the counselors during their clinical supervision to monitor for compliance. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to obtained informed and voluntary consents in four of thirteen client records.
Findings:
Thirteen client records were reviewed on May 28, 2009. Consent to release forms were required in thirteen records.
Client record #9; fax that contained patient specific information was sent to a funding source on 5/19/09 (2 pages). There was no consent to release form signed by the client in the record .
Client record #10; consent to release form signed and dated by client and counselor with no documentation that identified where the information would be sent, dated 4/22/09. The consent to release form to client # 10's employer, dated 4/24/09, exceeded the information that the facility could provide to the employer. A letter sent out to an employer (no date on the letter), exceeded the confidentiality standards as the letter documented the client's poly substance dependency, major depressive disorder recurrent, that the client was to continue treatment and that he was making progress in treatment. Also, the letter provided the client's recommended release date to return to work (7/20/09).
Client record #12; a consent to release form dated 1/12/09 had nine people listed on one release. Consent to release forms are required to be filled out individually for each person.
Client record #13; consent to release form dated 2/6/09 had four people listed on one release. Consent to release forms are required to be filled out individually for each person.
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Plan of Correction
The clinical supervisor will review with the clinical staff at the staff meeting on 7/22/09 255.5 confidentiality standards and the specifica information that can be released. The clinical staff will be reminded that a signed consent must be obtained by all clients before any information is to be released. The clinical staff will also be reminded that New Insights has a pre-printed consent to release information specific to employers that should be utilized, and is specific to the information that is premitted to be released to the employer. The clinical supervisor will review with both the clinical staff and the support staff, at the staff meeting on 7/22/09 that all consents to release information must be specific to one individual, and that multiple names may not appear on the same consent. The clinical supervisor will randomly review one chart from each of the counselors during their clinical supervision to monitor for compliance. |
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 client records, the facility failed to complete psychosocial evaluations in seven of seven client records.
Findings:
Thirteen client records were reviewed on May 27, 2009. Psychosocial evaluations were required in seven client records. The counselors did not document an evaluation of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment in client record #1, 2, 3, 4, 5, 6 and 7. Also, client records #3 and 4 were completed after the clients comprehensive treatment plans were completed. Client Record #3's comprehensive treatment plan was completed on 3/24/09 and their psychosocial evaluation was completed on 4/1/09. Client Record #4's comprehensive treatment plan was completed on 12/30/08 and their psychosocial evaluation was completed on 1/5/09. Based on regulations and the facility's policy and procedures comprehensive treatment plans are to be developed after the psychosocial assessment and psychosocial evaluations are completed.
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Plan of Correction
The clinical supervisor will review with the clinical staff at the staff meeting on 7/22/09, New Insights facilities policy to not develop an initial comprehensive treatment plan until after the psycho-social profile has been completed in its entirety. The clinical supervisor will review with the clinical staff at the staff meeting on 7/22/09 New Insights standard psycho-social profile including the last page which documents the clients preferred coping mechanisms, strengths, problems identified for treatment and negative factors that might interefere with treatment. An example "composite" will be given to the clinical staff to illustrate that it should not be a narrative, but interpretive and must include, but not be limited to the client's assets/strengths, support systems, coping mechanisms and any negative factors that might interefere with treatment. The clinical supervisor will remind the clinical staff that this must be completed in the proper time period, and before the initial comprehensive treatment plan. The clinical supervisor will randomly review one chart from each of the counselors during their clinical supervision to monitor for compliance. |
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
Based on a review of client records, the facility failed to document a complete treatment plan updates three of seven client records.
Findings:
Thirteen client records were reviewed on May 27, 2009. Treatment plans updates were required in six client records. In client record #4 treatment plan update did not include the client's progress in relationship to the stated goals of the treatment plan, but rather stated generalized comments that were not specific to the client's progress in treatment. Client record #5 and 7 did not have documentation of clients treatment plan updates. Client record #5 comprehensive treatment plan was completed on 3/12/09 and as of to date no treatment plan update no documented. Client record #7 comprehensive treatment plan was completed on 3/03/09 and as of to date no treatment plan update no documented.
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Plan of Correction
The clinical supervisor will review with the clinical staff at the staff meeting on 8/5/09 the proper time frames for completing treatment plan updates for clients in outpatient, intensive outpatient and partial hospitalization level of care. The clinical staff will also be reminded that all treatment plan updates must document specifically the clients progress in the previously stated goals rather than general, nonspecific statements. The clinical supervisor will randomly review one chart from each of the counselors during their clinical supervision to monitor for compliance. |