INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on April 16-17, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Open Door Counseling at Mazzoni Center 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(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 the review of personnel records, the facility failed to document 3 months of direct observation supervision, for counselor assistants in one of one personnel records.
The findings include:
On April 17, 2012, one personnel record identified as a counselor assistant without a degree in a related field was reviewed for documentation of direct observation supervision. The facility did not document 3 months of direct observation supervision in personnel record # 6.
Counselor assistants who do not have a degree with a major in chemical dependency, psychology, social work, counseling, nursing or other related field are required counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first three months of employment.
Personnel record # 6 contained documentation of a Bachelor's Degree in Gender Study. Gender Study is not a related field.
An interview with the facility director on April 17, 2012 confirmed the findings.
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Plan of Correction
Staff #6, a Counselor Assistant, is no longer affiliated with this program.
Program Director is now aware of the degree and supervision requirements for Counselor Assistants. Counselor Assistants and/or staff hired hereafter will meet training and supervision requirements outlined in this standard. All counselor assistants without approved degree and experience will receive 3 months of direct observation supervision. PD will monitor for ongoing compliance.
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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 document a minimum of 6 hours of training in HIV/AIDS and 4 hours of training in TB/STD in one out of five personnel records.
The findings include:
On April 4, 2012 five personnel records were reviewed for documentation of 6 hours of training in HIV/AIDS and 4 hours of training in TB/STD, specifically records # 1, 2, 3, 4 and 5. The facility did not document 6 hours of training in HIV/AIDS and 4 hours of training in TB/STD, in record # 5.
Personnel # 5 was hired on 10/18/10. Personnel # 5 was required to receive 6 hours of training in HIV/AIDS and 4 hours of training in TB/STD by 10/18/12.
An interview with the facility director on April 17, 2012 confirmed the findings.
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Plan of Correction
Personnel #5 is registered for state-approved HIV/AIDS training on 5/18/12 and state-approved STD/TB training on 6/5/12. Certificates of completion will be submitted to HR and placed in personnel record.
All new staff will receive these trainings by a state-approved provider within one year of hire. Director has updated Policy & Procedures manual to reflect the need to have these trainings with a provider using state-approved curriculum. PD will monitor for compliance. |
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 the review of client records, the facility failed to document treatment plans to include a proposed type of support service in two out of three records reviewed.
The findings include:
On April 17, 2012, three client records were reviewed for support services, specifically records # 1, 2 and 3. The facility did not document treatment plans to include a proposed type of service in client records # 1 and 2.
Client # 1 was admitted on 12/1/11. The treatment plan in client # 1's record dated 1/5/12 did not include a proposed type of support service.
Client # 2 was admitted on 9/21/11. The treatment plan in client # 2's record dated 11/3/11 did not include a proposed type of support service.
An interview with the facility director on April 17, 2012 confirmed the findings.
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Plan of Correction
Treatment plans for clients #1 and #2 were reviewed and corrected with updated information regarding support services.
Program Director held meeting with staff on 5/7/12 to review the proper way to complete treatment plans to include support services and adjunct services to aid in a person's recovery. PD and clinical supervisor will monitor for ongoing 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 the review of client records, the facility failed to document treatment plan updates to include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan in four out of four records.
The findings include:
On April 17, 2012, four client records requiring treatment plan updates were reviewed, specifically records # 1, 2, 3 and 4. The facility did not document a treatment plan update to include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan in client records # 1, 2, 3 and 4.
Client # 1 was admitted on 12/1/11. The treatment plan update in client # 1 ' s record dated 3/6/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment.
Client # 2 was admitted on 9/21/11. The treatment plan update in client # 2's record was not signed or dated, so it was not possible to determine if it was completed at least 60 days after comprehensive treatment plan, which was completed on 11/3/11. Additionally, this unsigned treatment plan update did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 3 was admitted on 11/22/11. The treatment plan update in client # 3's record dated 3/26/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment.
Client # 4 was admitted on 2/9/11. The treatment plan updates in client # 4's record dated 7/7/11, 9/8/11, 10/10/11, 1/26/12, and 3/22/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment.
An interview with the facility director on April 17, 2012 confirmed the findings.
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Plan of Correction
Treatment plans for clients #1, #2, #3 and #4 were reviewed and amended with updated information pertaining to progress on recovery goals.
At team meeting on 5/7/14, Program Director instructed staff how to appropriately reflect progress of goals on treatment plans. Staff is now better prepared to explain progress on specific goals on all treatment plans. PD and clinical supervisor will monitor for ongoing compliance to ensure this standard is met consistently in the future. |