INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection regarding the plans of correction for the August 13 - 19, 2008 licensure renewal inspection. The follow-up inspection was conducted on February 27, 2009 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 March 25, 2009.
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Plan of Correction
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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.
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Observations
Based on a review of personnel and training records, the facility failed to document core curriculum training in clinical supervision for one of one employee where required.
Findings:
Six personnel and training records were reviewed during a plan of corrections follow up inspection on February 27, 2009. The core curriculum training in clinical supervision was required for one employee. The facility indicated on their original Plan of Correction that the training would be completed by 11/14/08. The facility failed to document the core curriculum training in clinical supervision for employee #2 as of the date of this inspection.
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Plan of Correction
Due to space availability employee #2 was not able to complete the Core Curriculum training in Clinical Supervision by 11/14/08 as planned. However on 3/9/09 employee #2 began attending the Core Curriculum trainings being provided by BHTEN. This is a 10 week course that is approved by BDAP. Out facility will submit a request for exception to the BDAP course for the BHTEN course approval. We will also include the BHTEN curriculum and supporting documentation. If this request is not approved, the supervisor will have to enroll in the next BDAP core curriculum training. Employee #2 is expected to complete the core curriculum trainigs in clinical supervision by 5/25/09. Program Director will monitor for completion and compliance.
Employee #1 was able to comple TB/STD Trainin in 3/12/09. Documentation of completion is filed in personnel file. |
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 on a review of personnel records, the facility failed to document the qualifications for one of three counselors.
Findings:
Six personnel records were reviewed during a plan of corrections follow up inspection conducted on February 27, 2009. Documentation of qualifications was required for three counselors. The facility failed to document the qualifications for employee #5.
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Plan of Correction
Employee #5 have requested all degree certificates and transcripts to be submitted directly to the World Education Services (WES).
On 3/18/09 employee #5 was able to provide WES with original transcripts and needed documentation. Received documents are now awaiting verification and approval by WES.
Furthermore, on 3/13/09 employee #5 was scheduled to take CAC test. Both outcomes pending at this time. The Program Director along with the Director of Human Resources will verify the employee's qualifications prior to hiring the employee. The employees will be hired upon WES verification.
Completion date 5/30/09
Clinical Supervision to monitor for completion
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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 and training records, the facility failed to document HIV/Aids training for one of four employees and failed to document TB/STD training for one of four employees.
Findings:
Personnel and training records were reviewed during a plan of corrections follow up inspection conducted on February 27, 2009. HIV/AIDS and TB/STD training was required for four employees. The facility failed to document HIV/AIDS training for employee #3 by 10/14/08 as per the original Plan of Correction. The facility failed to document TB/STD training for employee #1 by 9/11/08 as per the original Plan of Correction.
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Plan of Correction
Employee #3 was scheduled to attend HIV/AIDS training prior to date line of 9/11/08. Due to training cancellations, last cancellation being 3/24/09. Employee #3 has not been able to meet State standards. Employee #3 is now schedule to attend HIV/AIDS training on 4/7/09. Employee #3 shall complete training as scheduled and certificate will be faxed to State as evidence of training completion.
The employee's clinical supervisor will monitor for compliance. Date of Competion 4/8/09.The Program Director will monitor for compliance if the employee is a clinical supervisor.
Employee #1 completed STD/TB training in 3/12/09 certificate of completion in personnel file. |
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
Based on a review of personnel and training records, the facility failed to document at least 25 clock hours of training for the 2007/2008 training year for one of two employees.
Findings:
Personnel and training records were reviewed during a plan of corrections follow up inspection conducted on February 27, 2009. 25 clock hours of training was required for two employees. The facility failed to document 25 clock hours of training for employee #4. The facility documented 12 hours of training for employee #4.
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Plan of Correction
In order to meet all employees training needs, we have revised our training schedule. Employees are now receiving in-house trainings as wells as more external trainings.This will be coordinated by the Department of Education and the Clinical Supervisors.
All employees will receive training hours according to State Standards. Clinical supervisior and Program Director will monitor for compliance. Our goal is for 100% compliance by end of training schedule, June 2009. |
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.
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Observations
Based on the review of fire drill records, the facility failed to document unannounced fire drills on a monthly basis.
Findings:
Fire drill records were reviewed during the plan of correction follow up inspection on February 27, 2009. The facility failed to document an unannounced fire drill for the Goldman Clinic in August 2008 and December 2008.
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Plan of Correction
Unannounced fire drills will occurr on a monthly basis during the clinic business hours.
Monitor by the Program Director and Mr. Barry Floyd. |
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.
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Observations
Based on a review of fire drill records, the facility failed to document the use of alternate exit routes during a fire drill.
Findings:
Fire drill records were reviewed during a plan of corrections follow up inspection on February 27, 2009. The facility indicated in their original Plan of Correction (POC) that a training would be conducted on August 2008 and that alternate exits would be documented by December 1, 2008. The facility failed to document any exit routes for fire drills conducted for Goldman Clinic as per their original POC for the months of December 2008 and January 2009.
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Plan of Correction
All fire drills will be conducted by B.F., Director of Safety. In addittion one of the Goldman supervisors (S.P.) will be trained on how to conduct fire drills.
S.P. and B.F. will ensure that alternate exit routes are utilized and documented. This will be monitored monthly to ensure compliance. |
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
Based on a review of client records, the facility failed to document a treatment plan update in one of six client records where an update was required. The facility failed to review progress on all the goals stated in the prior treatment plan in the treatment plan update in four of six client records.
Findings:
Ten client records were reviewed during a plan of corrections follow up inspection conducted on February 27, 2009. A treatment plan update was required in six client records. The facility failed to document a treatment plan update in client record #3. Client #3 was admitted on 10/10/08. The comprehensive treatment plan was completed on 12/3/08. A treatment plan update was due on 2/3/09. The facility failed to document a review of progress on all goals stated on the prior treatment plan in client records #1, 4, 5 and 6.
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Plan of Correction
Clinical staff have been receiving extensive training on treatement plans and treatement plan updates. Clinical staff have shown considerable improvements in better documentation and measureable and attainable goals.
Clinical Supervisors will continue to provide on going training, chart reviews and supervision to assure all treatemnt plans/updates are completed on a timely basis.
Completion date ongoing. |
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.
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Observations
Based on a review of client records, the facility failed to document, in the progress notes and the record of service, that counseling was being provided as prescribed in the individual treatment and rehabilitation plan in six of ten client records reviewed.
Findings:
Ten client records were reviewed during a plan of corrections follow up inspection conducted on February 27, 2009. The facility failed to document through progress notes and the record of service that counseling was being provided as prescribed in the individual treatment and rehabilitation plan in client records # 2, 3, 4, 5, 9 and 10. Individual sessions were prescribed one time per week for client #2. Client #2 was admitted on 11/21/08. No individual sessions were documented in 12/08 and individual sessions in January were documented for 1/14 and 1/21/09. Client #3 was admitted on 10/10/08. Individual sessions were prescribed one time per week. The client attended one session on 12/3/08 and then had three sessions documented as "no shows" in 12/08. Two individual sessions were documented for 1/09, one on 1/15 and another on 1/22/09. There was one "no show" documented on 2/19/09 and no documentation that any other sessions were scheduled. Client #4 was admitted on 10/21/08. Four individual sessions a month were prescribed in the treatment plan. The facility documented individual sessions on 12/5/08, 12/15/08 and 1/12/09. Client #5 was admitted on 11/10/08. Individual sessions were prescribed for one per week. The facility documented individual sessions on 12/10/08, 12/17/08, 12/29/08, 1/12/09. 1/26/09 and 2/2/09. Client #7 was admitted on 10/20/08. Individual sessions were prescribed for one per week. The facility documented individual sessions on 12/9/08, 12/11/08 and 12/26/08. No other sessions were documented. Client #9 was admitted on 11/14/08. Weekly individual sessions were prescribed in the treatment plan. The facility documented individual sessions on 12/15/08, 12/24/08, 12/31/08, 1/7/09, 1/27/09, 2/20/09 and 2/24/09. Client #10 was admitted on 10/10/08. Weekly individual sessions were prescribed. The facility documented individual sessions on 11/21, 11/24, 12/3, 12/4, 12/12, 12/17/08, 1/26, 2/2 and 2/10/09.
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Plan of Correction
Clients will receive a minimum of 2.5 hours of treatement a month according to State standards. Throughout supervision and charts review from Supervisors and Performance Improvement Departement, we will be able to monitor that standards are being met.
Counselors will document on a progress note, all "no shows" or cancellations. Counselor will document plan of action to follow.
Completion date Immediately. |
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:
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Observations
Based on a review of client records, 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:
Ten client records were reviewed during a plan of corrections follow up inspection conducted on February 27, 2009. The Confidential Information section of the consent to treatment form signed by clients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 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. The facility also failed to make the clients aware of their right to verbally revoke consents to release information in ten of ten client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
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Plan of Correction
During the admission process and orientation all clients will be informed of their rights to verbally revoke consent to release information and will receive information on Duty to Warn. (i.e.the need for a court order to divulge information without consent for those clients expressing suicidal or homicidal ideations.)There is a space in the Confidential Information section of the consent for treatment form to document this.
The release of information form has been revised and specifically addresses the client's rights for verbal or written revocation of consent to release information are already in effect. All clients are receiving orientation about the releases and are being provided with a copy of the form. They can verbally revoke consents to release information at any time.This will be corrected immediately. Clinical supervisors and counselors will monitor this process for compliance. |