INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 17 - 18, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Jade Wellness Center, LLC 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 December 15, 2010.
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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 on a review of personnel records and an interview with the facility director, the facility failed to ensure that each counselor met the qualifications for the position in one of two personnel records.
The findings include:
Seven personnel records were reviewed on November 17, 2010. Two personnel records pertained to counselors. Two personnel records were required to include documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel record # 4.
Employee # 4 was hired as a lead counselor on August 2, 2010. Employee record # 4 contained a copy of a Bachelor of Arts degree dated June 12, 2005. The degree did not include documentation of the major. Employee record # 4 did not include college transcripts; which would document the degree major. Without this verification; it is unknown if employee # 4 meets the qualifications for the position of counselor.
Per regulation, a counselor who has a Bachelor's Degree from an accredited college is required to have 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.
The facility director was interviewed on November 17 - 18, 2010. The facility director reported that employee # 4 does not have a copy of the college transcripts; but has requested them from the college. Verification of this employee's qualifications was not available at the time of the review on November 17 - 18, 2010.
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Plan of Correction
On November 23, 2010, Employee #4 produced an official transcript from Ohio State University where he earned his B.A. The transcript indicates that he majored in Psychology which meets the qualification requirement for a counselor.
This was verified by the Facility Director who will ensure that all future hires will have evidence of meeting the qualifications for the specific job. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to provide documentation of individual training plans upon employment in five of six personnel records.
The findings include:
Seven personnel records were reviewed on November 17, 2010. Individual training plans were reviewed in six personnel records. Per agency policy, individual training plans are due to be completed no later than January 31. The facility training year is from January through December. The facility began providing services on April 27, 2010. The facility did not document individual training plans upon employment in personnel records # 1, 3, 4, 5 and 6.
Employee # 1 is a co-owner. The facility began providing services on April 27, 2010. An individual training plan was not completed until October 10, 2010.
Employee # 3 was hired on August 5, 2010. An individual training plan was not completed until November 7, 2010.
Employee # 4 was hired on August 2, 2010. An individual training plan was not completed until November 7, 2010.
Employee # 5 was hired on March 1, 2010. The facility began providing services on April 27, 2010. An individual training plan was not completed until September 1, 2010.
Employee # 6 was hired on March 1, 2010. The facility began providing services on April 27, 2010. An individual training plan was not completed until September 1, 2010.
The facility director was interviewed on November 17, 2010 and confirmed these individual training plans were not completed timely and should have been completed upon staff employment.
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Plan of Correction
The Facility Director will ensure that ll staff will have individual training plans, which each staff person will complete by January 11, 2011 and they will be placed in the respective HR files. Facility Director will monitor this process for future compliance. All new hires will complete training plans at the time of hire and the Facility Director will monitor that process for compliance. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection conducted on November 18, 2010, and an interview with the facility director, the facility failed to provide a well-secured railing for a ramp located at the rear emergency exit of the building.
The findings include:
A physical plant inspection was conducted of the interior and exterior of the building, from approximately 2:20 PM - 2:45 PM, on November 18, 2010. Per regulation, the nonresidential facility shall maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing. The facility has an emergency exit at the rear, right side of the building. There is a ramp located off this emergency exit that does not have a handrail. The facility failed to provide a well-secured railing for the ramp located off the rear emergency exit. The facility director viewed the ramp at approximately 2:40 PM, during the physical plant inspection, and confirmed a railing was not present.
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Plan of Correction
A ramp will be installed by January 14, 2011. Progress and completion will be monitored by the Facility Director. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in six of six personnel records.
The findings include:
Seven personnel records were reviewed on November 17, 2010. One personnel record was not reviewed for fire extinguisher training. Six employee records required documentation of fire extinguisher training upon employment. Per regulation, the nonresidential facility shall instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records # 1, 2, 3, 4, 5 and 6.
Employee # 1 is a co-owner of the program. The facility began providing services on April 27, 2010. Verification of fire extinguisher training was not documented for employee # 1, at the time of the review on November 17, 2010. Fire extinguisher training was not completed upon staff employment, as required.
Employee # 2 was hired on August 2, 2010. Employee # 2 did not complete fire extinguisher training until October 29, 2010. Fire extinguisher training was not completed upon staff employment, as required.
Employee # 3 was hired on August 5, 2010. Employee # 3 did not complete fire extinguisher training until October 29, 2010. Fire extinguisher training was not completed upon staff employment, as required.
Employee # 4 was hired on August 2, 2010. Employee # 4 did not complete fire extinguisher training until October 29, 2010. Fire extinguisher training was not completed upon staff employment, as required.
Employee # 5 was hired on March 1, 2010. The facility began providing services on April 27, 2010. Employee # 5 did not complete fire extinguisher training until October 29, 2010. Fire extinguisher training was not completed upon staff employment, as required.
Employee # 6 was hired on March 1, 2010. The facility began providing services on April 27, 2010. Verification of fire extinguisher training was not documented for employee # 6, at the time of the review on November 17, 2010. Fire extinguisher training was not completed upon staff employment, as required.
The facility director was interviewed on November 17, 2010 and confirmed that employees # 1 and 6 had not completed fire extinguisher training. The facility director also confirmed that employees # 2, 3, 4 and 5 had not completed fire extinguisher training upon employment.
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Plan of Correction
All current staff have received Fire Extinguisher training. The Facility Director will ensure that all new staff are trained upon hiring. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies, in two of six personnel records.
The findings include:
Seven personnel records were reviewed on November 7, 2010. One personnel record was not reviewed for emergency training. Six personnel records required documentation of emergency training. Per regulation, the nonresidential facility shall ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies. The facility failed to document the completion of emergency training in personnel record # 1 and 6.
Employee # 1 is a co-owner of the program. The facility began providing services on April 27, 2010. Verification of emergency training was not documented for employee # 1, at the time of the review on November 17, 2010.
Employee # 6 was hired on March 1, 2010. The facility began providing services on April 27, 2010. Verification of emergency training was not documented for employee # 6, at the time of the review on November 17, 2010.
The facility director was interviewed on November 17, 2010 and confirmed that employees # 1 and 6 had not completed emergency training.
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Plan of Correction
All staff have completed emergency safety training. The Facility Director oversaw the completion of those trainings. All new hires will complete the training upon hiring. The Facility Director will ensure compliance. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill logs and an interview with the facility director, the facility failed to document the number of persons in the facility at the time of the drill, and the problems encountered during six of six fire drills. The facility failed to document the exit route used in five of six fire drills.
The findings include:
Fire drill logs were reviewed on November 17, 2010. Fire drill logs were reviewed for the following dates: May 27, 2010, June 23, 2010, July 23, 2010, August 3, 2010, September 28, 2010 and October 21, 2010. Per regulation, the nonresidential facility shall maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The facility failed to document the total number of persons in the facility at the time of the drills on the following dates: May 27, 2010, June 23, 2010, July 23, 2010, August 3, 2010, September 28, 2010 and October 21, 2010. The facility only documented staff that were present for the fire drill. There was no documentation of how many other persons were present in the building at the time of the drills.
The facility failed to document if any problems were encountered at the time of the drills on the following dates: May 27, 2010, June 23, 2010, July 23, 2010, August 3, 2010, September 28, 2010 and October 21, 2010.
The facility failed to document the exit route used on the following dates: May 27, 2010, June 23, 2010, July 23, 2010, August 3, 2010, and September 28, 2010
On November 17, 2010, the facility director was interviewed and confirmed that exit routes had not been documented on five of the fire drills conducted. The facility director also confirmed that the total number of persons in the facility at the time of the drill and the problems encountered were not documented on six of the fire drills conducted.
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Plan of Correction
The Fire Drill Log was corrected on 11/18/10 to include the number of people in the building. All old forms have been destroyed. The Facility Director corrected the form and disposed of old forms. The Facility Director will ensure ongoing compliance. |
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 the fire drill logs and an interview with the facility director, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on November 17, 2010. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. Fire drill logs were reviewed for the following dates: May 27, 2010, June 23, 2010, July 23, 2010, August 3, 2010, September 28, 2010 and October 21, 2010. The facility did not document that alternate exit routes were used during fire drills. The front door was the exit route during the October 21, 2010 fire drill. There was no documentation of the exit route used during the following fire drills reviewed: May 27, 2010, June 23, 2010, July 23, 2010, August 3, 2010 and September 28, 2010. Verification of alternate exit routes was not documented on the fire drill logs, at the time of the review on November 17, 2010.
On November 17, 2010, the facility director was interviewed and confirmed that alternate exit routes were not documented on the fire drill logs.
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Plan of Correction
The Fire Drill Log was corrected on 11/18/10 to include docuentaion that alternate exit routes were used. All old copies of the form were destroyed. The Facility Director corrected the form and confirmed disposal of old forms. The Facility Director will ensure compliance going forward. |
709.22(c)(1) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(1) A method of selection for membership.
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Observations
Based on a review of administrative policy and procedures, shareholders meeting minutes and an interview with the project and facility director, the facility failed to document that the governing body adopted a written policy which included a method of selection for membership.
The findings include:
Administrative policies and procedures were reviewed on November 17 - 18, 2010. Per regulation, if the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to: a method of selection for membership.
The governing body consists of a board of directors. On November 17, 2010, a document titled "Board of Directors List" was reviewed. This list included the Chief Executive Officer and the Chief Financial Officer, who are co-owners, and one shareholder, who is not an employee. On November 17 - 18, 2010, the following shareholders meeting minutes were reviewed: August 5, 2010, September 2, 2010, September 10, 2010, September 17, 2010, September 24, 2010, October 20, 2010 and October 28, 2010. The shareholders meeting minutes documented discussion on hiring new employees, financial activities, and resolution of issues presented at these meetings.
Verification that the governing body adopted a written policy which included a method of selection for membership was not documented at the time of the review on November 17 - 18, 2010.
The project director was interviewed on November 17, 2010. The project director reported that she did not believe the board of directors had written any policies regarding membership.
The facility director was interviewed on November 17 - 18, 2010. The facility director confirmed that the board had not written or adopted any policies regarding a method of selection for membership.
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Plan of Correction
After consultation with legal counsel, it has been determined that the existing JADE Wellness Center LLC Operating Agreement will be revised to include the method for selection of board members. That revision will be completed and Board endorsement will take place by January 14, 2011. Ongoing compliance will be monitored by the President. |
709.22(c)(2) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(2) Qualifications for membership.
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Observations
Based on a review of administrative policy and procedures, shareholders meeting minutes and an interview with the project and facility director, the facility failed to document that the governing body adopted a written policy which included qualifications for membership.
The findings include:
Administrative policies and procedures were reviewed on November 17 - 18, 2010. Per regulation, if the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to: qualifications for membership.
The governing body consists of a board of directors. On November 17, 2010 a document titled "Board of Directors List" was reviewed. This list included the Chief Executive Officer and the Chief Financial Officer, who are co-owners, and one shareholder, who is not an employee. On November 17 - 18, 2010, the following shareholders meeting minutes were reviewed: August 5, 2010, September 2, 2010, September 10, 2010, September 17, 2010, September 24, 2010, October 20, 2010 and October 28, 2010. The shareholders meeting minutes documented discussion on hiring new employees, financial activities, and resolution of issues presented at these meetings.
Verification that the governing body adopted a written policy which included qualifications for membership was not documented at the time of the review on November 17 - 18, 2010.
The project director was interviewed on November 17, 2010. The project director reported that she did not believe the board of directors had written any policies regarding membership.
The facility director was interviewed on November 17 - 18, 2010. The facility director confirmed that the board had not written or adopted any policies regarding qualifications for membership.
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Plan of Correction
After consultation with legal counsel, it has been determined that the existing JADE Wellness Center, LLC Operating Agreement will be revised to include the required qualifications for Board members. That revision will be completed and Board endorsement will be made by January 14,2011. Ongoing compliance will be ensured by the President. |
709.22(c)(3) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(3) Criteria for continued membership.
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Observations
Based on a review of administrative policy and procedures, shareholders meeting minutes and an interview with the project and facility director, the facility failed to document that the governing body adopted a written policy which included criteria for continued membership.
The findings include:
Administrative policies and procedures were reviewed on November 17 - 18, 2010. Per regulation, if the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to: criteria for continued membership.
The governing body consists of a board of directors. On November 17, 2010 a document titled "Board of Directors List" was reviewed. This list included the Chief Executive Officer and the Chief Financial Officer, who are co-owners, and one shareholder, who is not an employee. On November 17 - 18, 2010, the following shareholders meeting minutes were reviewed: August 5, 2010, September 2, 2010, September 10, 2010, September 17, 2010, September 24, 2010, October 20, 2010 and October 28, 2010. The shareholders meeting minutes documented discussion on hiring new employees, financial activities, and resolution of issues presented at these meetings.
Verification that the governing body adopted a written policy which included criteria for continued membership was not documented at the time of the review on November 17 - 18, 2010.
The project director was interviewed on November 17, 2010. The project director reported that she did not believe the board of directors had written any policies regarding membership.
The facility director was interviewed on November 17 - 18, 2010. The facility director confirmed that the board had not written or adopted any policies regarding criteria for continued membership.
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Plan of Correction
After consultation with legal counsel, it was determined that the existing JADE Wellness Center, LLC Operating Agreement will be revised to include criteria for continued membership on the Board. That revision will be completed and Board endorsement will take place by January 14,2011. Ongoing compliance will be ensure by the President. |
709.22(c)(4) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(4) Frequency of meetings.
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Observations
Based on a review of administrative policy and procedures, shareholders meeting minutes and an interview with the project and facility director, the facility failed to document that the governing body adopted a written policy which included the frequency of meetings.
The findings include:
Administrative policies and procedures were reviewed on November 17 - 18, 2010. Per regulation, if the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to: frequency of meetings.
The governing body consists of a board of directors. On November 17, 2010 a document titled "Board of Directors List" was reviewed. This list included the Chief Executive Officer and the Chief Financial Officer, who are co-owners, and one shareholder, who is not an employee. On November 17 - 18, 2010, the following shareholders meeting minutes were reviewed: August 5, 2010, September 2, 2010, September 10, 2010, September 17, 2010, September 24, 2010, October 20, 2010 and October 28, 2010. The shareholders meeting minutes documented discussion on hiring new employees, financial activities, and resolution of issues presented at these meetings.
Verification that the governing body adopted a written policy which included the frequency of meetings was not documented at the time of the review on November 17 - 18, 2010.
The project director was interviewed on November 17, 2010. The project director reported that she did not believe the board of directors had written any policies regarding board members.
The facility director was interviewed on November 17 - 18, 2010. The facility director confirmed that the board had not written or adopted any policies regarding the frequency of meetings.
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Plan of Correction
After consultation with legal, it was determined that the existing JADE Wellness Center, LLC Operating Agreement will be revised to include the frequency of Board meetings. That revision will be completed and Board endorsement will take place by january 14, 2011. The President will be responsible for ongoing compliance. |
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on a review of administrative materials and an interview with the facility director, the facility failed to document that the duties of the governing body shall include selecting a project director as the person officially responsible to the governing body.
The findings include:
The policy and procedure manual and organizational chart were reviewed on November 17 - 18, 2010. Per regulation, the duties of the governing body include, but are not limited to, the following: selecting a project director as the person officially responsible to the governing body. The facility failed to provide documentation that the duties of the governing body shall include selecting a project director as the person officially responsible to the governing body. The facility director was interviewed on November 17 - 18, 2010 and confirmed there was no documentation of this regulation.
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Plan of Correction
After consultation with legal counsel, it was detrmined that the existing JADE Wellness Center, LLC Operating Agreement will be revised to include language indicating that it is the duty of the governing body to select a Project Director as the person officially responsible to the governing board. That revision will be completed and Board endorsement will take place by January 14, 2011. The President will ensure ongoing compliance. |
709.24(a) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
Based on a review of the administrative policy and procedure manual, shareholders meeting minutes and an interview with the facility director, the facility failed to document that the governing body adopted a written plan for the coordination of client treatment and rehabilitation services.
The findings include:
The policy and procedure manual was reviewed on November 17 - 18, 2010. Per regulation, the governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services.
The policy and procedure manual included a governing body sign off sheet dated February 15, 2010. This sign off sheet indicated the governing body had approved the written plan for the coordination of client treatment and rehabilitation services. Part of this plan included written procedures for the management of treatment/rehabilitation services for clients. These written procedures had been revised on May 3, 2010 and September, 2010. Verification of the governing body adopting the revised written plan was not documented at the time of the review on November 17 - 18, 2010.
The governing body consists of a board of directors. The board of directors consists of the shareholders of the corporation. On November 17 - 18, 2010, the following shareholders meeting minutes were reviewed: August 5, 2010, September 2, 2010, September 10, 2010, September 17, 2010, September 24, 2010, October 20, 2010 and October 28, 2010. There was no documentation that the governing body reviewed or adopted the revised written plan for the coordination of client treatment and rehabilitation services.
The facility director was interviewed on November 17 - 18, 2010 and confirmed the governing body did not review or adopt the revised written plan for the coordination of client treatment and rehabilitative services.
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Plan of Correction
This policy will be revised and presented to the Board of Directors at the 12/16/10 for review and approval. All new and/or revised policies will be presented at Board meetings for review and approval. The review or new or revised policies will be a permanent agenda item for each Board meeting. The President will ensure ongoing compliance with this process. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of administrative policies and procedures and an interview with the facility director, the facility failed to provide documentation of complete written procedures for the management of treatment/rehabilitation services for clients.
The findings include:
Administrative policies and procedures were reviewed on November 17 - 18, 2010. The written plan revised on May 3, 2010 and September, 2010 did not include time frames or who, by job title, would be responsible for the development, approval, monitoring and evaluation of client services in the following policy/procedure statements:
Medication records including the name of the drug, dosage, and frequency of use were not documented in the written procedures for the management of treatment and rehabilitative services.
Progress notes including date, assessment and plans relative to treatment were not documented in the written procedures for the management of treatment and rehabilitative services.
Client related correspondence was not included in the written procedures for the management of treatment and rehabilitative services.
Records of services were not addressed in the written procedures for the management of treatment and rehabilitation services.
Case consultations including who, by job title, was responsible for documenting the case consults, the required content of the case consultation and when it would be conducted were not addressed in the written procedures for the management of treatment and rehabilitative services.
The facility director was interviewed on November 18, 2010 and confirmed the written procedures did not include all of the components of client services from intake through discharge.
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Plan of Correction
This policy will be revised by the Facility Director to include the person who is responsible for the development, approval, monitoring and evaluation of the client services. The policy will be revised to include a medication record including the name fo the drug, dosage and frequency. Currently, this form is a part of the client chart, but the policy did not reference the form. This policy will be revised to include progress notes with data, assessment and plans relative to the treatment plan. The form is currently in the chart and used, but was not included in the policy. This policy will be revised to include the Record of Service form which is currently in the chart and being used, but was not part of the policy. This policy will be revised to include Case Consultation forms which are currently in the chart and being used, but was not included in the policy. This policy will be revised by January 28, 2011. Ongoing compliance will be ensured by the Facility Director. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to document the results of a reference investigation in two of four personnel records.
The findings include:
Seven personnel records were reviewed on November 17, 2010. Four personnel records required the completion of reference investigations. Per regulation, the personnel records shall include the results of reference investigations. Personnel records # 2 and 4 did not include the results of a reference investigation.
Employee # 2 was hired on August 2, 2010. There was no documentation of a reference investigation in personnel record # 2.
Employee # 4 was hired on August 2, 2010. There was no documentation of a reference investigation in personnel record # 4.
The facility director was interviewed on November 17 - 18, 2010 and confirmed there were no reference investigations completed for employees # 2 and 4.
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Plan of Correction
Employee #2 was one of the original staff and #4 was hired in August, 2010. The Facility Director began full-time in August and had no knowledge of the hiring process when employee #2 was hired in May. Employee #4 was supervised by the Facility Director in a recent position and, subsequently, no references were obtained. In the future, 3 references will be obtained for all new hires. Compliance will be ensured by the Facility Director. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of administrative policy and procedures and an interview with the facility director, the facility failed to document a written procedure that complies with 4 Pa. Code 255.5 relating to disclosure of client oriented information.
The findings include:
Administrative policies and procedures were reviewed on November 17 - 18, 2010. The confidentiality policy reviewed was dated October 2009, April 5, 2010, and September 2010. Per regulation, a written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to: confidentiality of client identity and records.
The confidentiality policy indicates that information released to judges, probation or parole, insurance companies or government officials will comply with 4 Pa. code 255.5. The confidentiality policy does not document how the facility will comply with 4 Pa. Code 255.5 or that information released to these entities is restricted to the following parameters: (1) whether the client is or is not in treatment, (2) client's prognosis, (3) the nature of the project (4) a brief description of the client's progress (5) a short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
The confidentiality policy incorrectly addressed the components of a valid consent. The confidentiality policy indicates the consent must include the dated signature of the parent or guardian and witness. The policy does not document that a consent must include the dated signature of the client, per State and Federal regulations.
The facility director reviewed the confidentiality policy on November 18, 2010. The facility director confirmed that the confidentiality policy did not correctly address 4 Pa. Code 255.5 or the components of a valid consent.
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Plan of Correction
The Confidentiality Policy will be revised by the Facility Director to include the five parameters of 4Pa. Code 255.5 and the componenets of a valid consent. The revised policy will be presented to the Board of Directors for review and approval on 1/14/11. Future compliance will be ensured by the Facility Director. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document a complete medical history in three of four client records.
The findings include:
Six client records were reviewed on November 18, 2010. Four client records required the documentation of a medical history. Two client records were from a timeframe outside of the current licensing inspection. Per regulation, intake procedures shall include documentation of a medical history. Per facility policy, the medical history is completed at intake; which is completed on the admission date. The facility failed to provide documentation of a family medical history in client records # 4 and 6 and did not document any medical history in client record # 5.
Client # 4 was admitted into treatment on September 9, 2010. A history which includes the client's personal medical history, family medical history, and a history of illness and symptoms was due to be completed no later than September 9, 2010. The facility failed to document a family medical history. Verification of the family medical history was not documented for client # 4, at the time of the review on November 18, 2010.
Client # 5 was admitted into treatment on September 13, 2010. A history which includes the client's personal medical history, family medical history, and a history of illness and symptoms was due to be completed no later than September 13, 2010. The facility failed to document any medical history. Verification of the medical history was not documented for client # 5, at the time of the review on November 18, 2010.
Client # 6 was admitted into treatment on October 4, 2010. A history which includes the client's personal medical history, family medical history, and a history of illness and symptoms was due to be completed no later October 4, 2010. The facility failed to document the completion of a medical history which included family medical history. Verification of the family medical history was not documented for client # 6, at the time of the review on November 18, 2010.
On November 18, 2010, the facility director reviewed client records # 4, 5 and 6. The facility director confirmed there was no documentation of any medical history for client # 5 and no documentation of family medical history for client's # 4 and 6.
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Plan of Correction
The Needs Assessment will be revised to include information regarding family medical history which will be collected at the time of intake. That revision will be completed by 1/3/11. Staff will be trained to utilize that section of the Needs Assessment by the Facility Director. Ongoing compliance with be ensured by the Facility Director. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document attempts to follow up on clients in two of three client records.
The findings include:
Six client records were reviewed on November 18, 2010. Three client records were closed and required the completion of a follow up. Per the facility policy, the counselor will follow up with all clients within seven days of discharge. The facility did not document follow up in client records # 1 and 2.
Client # 1 was admitted into treatment on August 4, 2010 and discharged on October 14, 2010. Follow up was required to be completed no later than October 21, 2010. There was no documentation of a follow up in client record # 1.
Client # 2 was admitted on June 29, 2010 and discharged on October 14, 2010. Follow up was required to be completed no later than October 21, 2010. There was no documentation of a follow up in client record # 2
The facility director was interviewed on November 18, 2010. The facility director reviewed client records # 1 and 2 and confirmed a follow up had not been conducted.
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Plan of Correction
A consent for follow up contact has been developed by the Facility Director and it is now part of the intake process and follow up is to be completed within 7 days of discharge. All staff have been trained to utilize the new process. Compliance ensured by the Facility Director. |