INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 13, 19 and 20, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System Goldman Clinic 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 September 15, 2008.
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
Based on a review of four personnel and training records on August 11 & 12, 2008, the facility failed to document core curriculum training in clinical supervision for 1 of 1 employees where required.
Finding:
There was no documentation of the mandatory 30 hours of core curriculum training in the personnel and training records for employee # 2.
|
Plan of Correction
Employee #2 will be scheduled for the next 30 hours of Core Curriculum training for supervisors. The Program Director will assure that this is completed by 11/14/2008. |
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.
|
Observations
Based on a review of four personnel records on August 11 & 12, 2008, the facility failed to document the qualifications and credentials for one of three counselors.
Finding:
There was no documentation of the required credentials to demonstrate that employee # 5 met the qualification for the position of counselor.
|
Plan of Correction
Employee #5's credentials will be verified through the WES program as soon as possible. This will be completed by employee #5's clinical supervisor. Before anyone is hired as a counselor, the qualifications and credentials will be compared to the state regulations by the program director to ensure they meet the standards. These will then be documented by the administrative assistant. This is to begin immediately. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
|
Observations
Based on a review of four personnel and training records, the facility failed to document an assessment of staff training needs for the 2007/2008 training year in three of four personnel and training records.
Finding:
Documentation of a training needs assessment was missing from the personnel and training records of employees # 2, 3 and 4.
|
Plan of Correction
Each clinical supervisor will review all employee files reporting to them quarterly to assure required training is completed. This will begin immediately. During their January meeting each year, the supervisor will assure that each counselor will complete the appropriate documentation of an assessment of staff training needs. This process will also occur between the program director and the supervisor each January to ensure compliance at all levels. |
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.
|
Observations
Based on a review of four personnel and training records on August 11 & 12, 2008, the facility failed to document HIV/Aids training in one of four employee records where required; and failed to document TB/STD training in one of four employee records where required.
Findings:
Documentation of 6 hours of Department approved HIV/AIDS training was missing from employee record # 3. Documentation of 4 hours of TB/STD training was missing from employee record # 1.
|
Plan of Correction
Employee number 1 was scheduled for TB/STD training (4) hours on 9/11/2008. The Program Director was resonsible for assuring that this occurs. Employee #3 will be sceduled for the next 6 hour HIV/AIDs training by their clinical supervisor. This will occur prior to 10/14/2008. All employee files will be reviewed by the appropriate clinical supervisor on a quarterly basis to assure all required training is completed. The Program Director will review his file and the clinical supervisor files on a quarterly basis to assure all required education is completed. |
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.
|
Observations
Based on a review of four personnel and training records on August 11 and 12, 2008, the facility failed to document at least 25 clock hours of training for the 2007/2008 training year in two of two employee records where required.
Finding:
Documentation of 25 clock hours of training was missing from employee records # 3 and 4.
|
Plan of Correction
The clinical supervisors will be responsible for reviewing the need to document all hours of training and assure 25 hours are maintained for each employee for each year. This will occur during monthly one on one supervision meetings beginning in September, 2008. The employees will be expected to keep track of their education hours and submit them to their supervisor for review beginning immediately. This applies for employees #3 and #4 and all other employees in the Goldman Clinic. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of fire drill records, the facility failed to document unannounced fire drills on a monthly basis.
Finding:
There were no fire drills documented for the month of July 2008.
|
Plan of Correction
A mandatory in-service was held on Monday, August 25, 2008 at 10am. All managers from the Tower Building were required to attend. The Fire Marshall presented the education. A review was completed regarding the process for completing the fire drill documentation. A new process was put in place which requires all documentation of the fire drill from the unit to be submitted to the CEO's office within 24 hours of the fire drill. All documentation will be reviewed for content and completeness by the CEO. If any documentation is incomplete, the manager of the unit will be notified and instructed to correct the issues. This is to begin immediately. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of fire drill records on August 14, 2008, the facility failed to document the use of alternate exit routes during a fire drill.
Finding:
There were no exit routes documented in the fire drill log for the past nine of nine monthly fire drills.
|
Plan of Correction
A mandatory fire education in-service was provided to all the Tower building managers by the Fire Marshall on 8/25/2008 at 10am. One agenda item of this meeting was education regarding the use of the alternate back fire tower during fire drills. The Fire Marshall will review the process and physically go down the fire tower with each manager prior to the fire drill which will be conducted utilizing this tower. By December 1, 2008, all managers will be educated and a fire drill will be conducted by the Fire Marshall utilizing the back alternate fire tower. Appropriate documentation of the use of this exit will be completed and reviewed by the CEO and placed in the Fire Drill Manual. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of sixteen client records on August 14 and 15, 2008, the facility failed to document a complete or timely psychosocial evaluation in eleven out of sixteen records, #1, 2, 3, 5, 6, 8, 9, 10, 12, 15 and 16.
Findings:
Client records #1, 3, 5, and 6 were missing a clinical assessment. Client records #9 and 15 documented only minimal information regarding the client's assets, strengths, or other factors that can contribute to the resolution of identified problems. Client records #10 and 12 documented minimal information for the client's coping mechanisms. Client record #8 documented minimal negative factors that might affect treatment. Additionally, client record # 8 was missing four components of the evaluation including, client's problems/needs, assets/strengths, support systems, and coping mechanisms. The psychosocial evaluation was missing entirely from client record # 2. The psychosocial evaluation was late in client record # 16.
|
Plan of Correction
The clinical supervisors will conduct in-service education for all counselors regarding the proper completion of the Psychosocial evaluation. This will be completed by 9/15/2008. The Program Director will oversee the agenda: items included will be timeliness of completion of the evaluations. This will be monitored by the clinical supervisors as they meet with their assigned counselors each month. The proper completion of the evaluation will be another agenda item. This will include: review of client assests, strengths,and other behaviors that contribute to resolution of problems. Review of appropriate coping mechanisms will also be addressed, along with appropriate support system documentation. Chart audits for each counselor will be performed by the clinical supervisors each month. |
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.
|
Observations
Based on a review of 16 client records on August 14 and 15, 2008, the facility failed to document a complete individual treatment and rehabilitation plan for each client in four of sixteen client records..
Finding:
An individual treatment and rehabilitation plan was not documented for two of sixteen records reviewed, #2 and 4. The facility failed to document goals on the individual treatment and rehabilitation plan in terms of measurable criteria for four of sixteen records reviewed, #5, 7, 13, and 14.
|
Plan of Correction
The clinical supervisors will work with each counselor on a one to one basis and review existing treatment plans. They will be reviewed for completeness and appropriateness on a montly basis. Each supervisor will educate their counselors by 9/15/2008 with regard to specific treatment plan documentation goals which will include: measurable goals, individualization of the treatment plan and completeness of the treatment plan. The Performance Improvement department will do quarterly random review of record specifically monitoring the treatment plans for appropriateness and completeness. These results will be reported at the Hospital PI council and trended throughout the year. |
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.
|
Observations
Based on a review of 16 client records on August 14 & 15, 2008, the facility failed to document a treatment plan update in five of fifteen records where an update was required. The facility failed to document some of the treatment plan updates in client records where multiple treatment plan updates were required; and the facility failed to carry over unmet and partially unmet treatment goals to the next treatment plan update in five of fifteen client records where required.
Finding:
There was no documentation of treatment plan updates in five of fifteen client records where required, specifically client records #1, 2, 4, 14, and 16. The facility failed to document a complete treatment plan update in five of fifteen records where a treatment plan update was required, as unmet and partially unmet goals were not carried over into the next treatment plan update in client records # 3, 5, 6, 7, and 12. Client records #9 and 11 were missing some of the treatment plan updates that had been due.
|
Plan of Correction
The current policy of the Goldman Clinic indicates treatment plans must be updated at least every 60 days. The clinical supervisors will be meeting with each of their counselors on a one to one basis and as they review the appropriate documentation needed in the treatment plan as stated in the previous plan of correction, they will address the timeliness of updates. This education will occur prior to 9/15/2008. The supervisors will monitor the treatment plans to assure updates are completed on time. As a part of the performance improvement activity in Goldman clinic, the Performance Improvement department will do quarter random chart checks to monitor the content of the treatment plan along with the timeliness of the updates and the resolution of goals. |
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of sixteen client records on August 14 & 15, 2008, the facility failed to document, in the progress notes and the record of service, that counseling was being provided according to the individual treatment and rehabilitation plan for twelve of sixteen client records reviewed.
Finding:
There was no documentation demonstrating that counseling was being provided in accordance with the treatment plan in client records #1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, and 16.
|
Plan of Correction
The clinical supervisors will assure that all counselors are documenting that counseling is being provided as indicated by the treatment plan. The supervisors will meet with each of their counselors prior to 9/15/2008 to review their progress notes to educate the counselors of the need to document the counseling that has been provided as it links to the individualized treatment plans. On-going review of this documentation will occur during the monthly sessions between clinical supervisors and their counselors. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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:
|
Observations
Based on a review of client records on August 14 and 15, 2008, the facility failed to inform clients of their right to verbal revocation of consents to release information and failed to provide proper information regarding the need for a court order in lieu of the client's written consent relative to "Duty to Warn" issues.
Findings:
The Confidential Information section of the consent to treatment form failed to document the need for a Court Order to divulge information without consent for those clients expressing suicidal or homicidal ideation and/or intent. There was no documentation making the clients aware of their right to verbally revoke consent to release information.
|
Plan of Correction
The Confidential Information section of the consent to treatment form will be changed. The following two items will be added:
1. you have the right to verbally revoke consent to release information.
2. a court order is needed to divulge information without consent for clients expressing suicidal or homicidal ideation and/or intent.
This will be completed by the Director of Residential Services, the VP for Behavioral Medicine and the Director of Patient/Client Access. The date of completion will be 9/30/2008. |