INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7 - January 8, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family A.C.T.S., Incorporated 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 February 11, 2008.
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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 review of 2 personnel records employees # 2 and 4 did not meet the qualification requirements for a counselor position. Employee # 4 does not have a related degree. Employee # 2 has a related degree but does not have 1 year of clinical experience.
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Plan of Correction
Employees that do not meet the requirement for a counselor, will be directly observed by a full-time clinical supervisor or a full-time counselor. Documentation of direct supervision will be reflected in the clients charts and weekly supervision notes and will be available upon request by the Licensing Specialist or other Department of Health staff. Direct observation will be for a period of three months. For a period of nine months beyond the initial three months, said employee will be closely supervised by a lead counselor or clinical supervisor. At 'east one hour a week will be under direct supervision from a lead counselor or clinical supervisor, documented as such. All other supervision notes will demonstrate that close supervision is occurring. In addition, deficiencies will be addressed through individual training plans. |
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 review of personnel files, individual training plans were completed but were not dated. There was no way to determine if the facility was complying with required time frames for completion of the plans.
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Plan of Correction
Project Director will add dates to the corresponding training plans, gto show compliance with specified time frames. |
709.22(d)(3) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(3) Describing the project's organizational structure.
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Observations
Based on review of the policy and procedure manual the facility failed to document the organizational structure.
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Plan of Correction
Facility Director/Project Director will immediately place an organizational structure chart in the addendum of the Policies and Procedures Manual. |
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 review of the policy and procedure manual the written procedures for the management of treatment and rehabilitation services contained contradictory information relative to time frames for completion and the staff person designated to complete those tasks. Several polices contained contradictory time frames for histories, assessments and evaluations, at one point indicating that the document would be completed at intake while another would state the document would be completed within 30 days or 3 sessions. Procedures identified different staff as responsible for completing the same task.
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Plan of Correction
Project Director will make the necessary modifications to the section regarding treatment and rehabilitation services in the facilities Policies and Procedures manual. All time frames for histories, assessments and evaluations, will be consistent and one staff mmber will be responsible for completing this task. |
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 review of personnel records the facility failed to document reference checks for two staff, specifically employees # 2 and 4.
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Plan of Correction
The Facility Director/Project Director will monitor and insure that references for all new hires will be contacted and documented as such. Documentation of contact with references will be placed in the employees personnel file. |
709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based on review of personnel files the facility failed to document salary information in personnel records # 2 and 4.
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Plan of Correction
Administrative Officer will add salary information in all personnel files. With each yearly contract, documentation supporting salary will be added to said contracts for each employee. |
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 review of the policy and procedure manual, the facility failed to comply with state law at 71 P. S. subsection 1690.112 and the federal regulations at 42 CFR Part 2, Subpart B, subsection 2.14(b) by including language indicating that parents or guardians will need to consent to the release of information regarding the minor, or would have to co sign such a consent. The policy also fails to indicate that, for suicide protocol, information can be released without the client's consent only when the client's life is in immediate jeopardy and only to medical personnel for the purposes of treating the client as detailed in state law at 71 P. S. subsection 1690.108(b).
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Plan of Correction
Project Director will omit signature line requiring parental/guardian signature for treatment on all Addiction Recovery forms, particularly the consent form.
Project Director will add, "clents that are in the Addiction Recovery Program will not be identified as such", to the suicide protocol policy. In addition, wording that states, "information can be released without the client's consent only when the client's life is in immediate jeopardy and only to medical personnel for the purposes of treating the client", will be added to said policy. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on review of two client records, HIPAA forms included in both client records did not contain a disclaimer for drug and alcohol treatment records. The HIPAA form advised the client of releases of information that could be made by the facility that would not be compliant with state law at 71 P. S. subsection 1690.108, state regulations at 28 Pa. Code Subsection 709.28 and 4 Pa. Code subsection 255.5 and federal regulations at 42 CFR Part 2, Subparts A through E. Subparagraphs 3, 4, 5, 6, 10 and 11 of the facility's HIPAA form is inconsistent with these regulations.
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Plan of Correction
Facility Director/Project Director will add a disclaimer to HIPAA forms for Drug and Alcohol Treatment, likewise, the facility will amend its HIPAA form to correspond with state regulations by adding, "except under the provisions in 71 P.S. subsection 1690.108, state regulations at 28 Pa. Code Subsection 709.28 and 4 Pa. Code subsection 255.5 and Federal regulations at 42 CFR Part 2, Subparts A through E" to said HIPAA forms. |
709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on review of two client records, specifically client records # 2 and 3, information to be released was not specifically defined on the release of information form found in both client records. The consent to release information forms in those client records stated that the "entire record" would be released. The recipient of the "entire record" could not be identified because only initials were used and the relationship to the client and/or function of the recipient could not be determined.
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Plan of Correction
Project Director will create a new "Release of Information" form that will obtain only specifically defined information to be released. This form will list the clients name, the facilities name, name of requesting person or organization and the purpose release. Information released will be limited to specific criteria. |
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 review of two client records, specifically client records # 2 and 3 medical histories failed to contain the family medical history.
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Plan of Correction
Project Director will immediately add medical histories that contain family medical history to the facilities screening tool. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on review of two client records on January 8, 2008, the facility failed to document a drug and alcohol history that included lengths and patterns related to the progressions of use. The lengths and patterns pertaining to the client's drug and alcohol history was not documented in client records #2 and 3. The facility also failed to provide for a complete listing of the substances abused by the client in each record reviewed.
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Plan of Correction
Project Director will immediately facilitate changing the screening tool used to include a drug and alcohol history that includes lengths and patterns related to the progressions of use. The lengths and patterns pertaining to the client's drug and alcohol history and a complete listing of the substances abused by the client. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on review of client records, the facility failed to document a complete personal history in 2 out of 2 client records reviewed, specifically client records # 2 and 3. The personal histories were incomplete in the following areas: employment, education, recreational, and sexual.
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Plan of Correction
Project Director will change screening tools by adding questions that include personal history as it relates to employment, education, recreation and sexual history. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on review of client records, the facility failed to document a psychosocial evaluation in 2 out of 2 client records reviewed, specifically client records # 2 and 3.
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Plan of Correction
Project Director will facilitate documentation of psychosocial evaluations in clients records. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on review of client records the facility failed to document preliminary treatment plans in 2 out of 2 client records reviewed, specifically client records # 2 and 3.
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Plan of Correction
Project Director and Clinical Director will provide preliminary treatment plans for all clients and include said plans in the clients records. |
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 review client records the facility failed to include support services on the individual treatment and rehabilitation plan in 2 of 2 client records reviewed, specifically client records #2 and 3.
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Plan of Correction
Project Director and Clinical Director will include as part of a clients treatment and rehabilitation plan, support services for said client. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on review of client records the facility failed to include the reasons for treatment on the discharge summary in one of one client records where the discharge summary was due, specifically client record #3.
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Plan of Correction
Project Director and Clinical Director will facilitate the inclusion of the reason for treatment as part of a clients discharge summary and submit to clients record. |