INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the February 16, 2010 licensure renewal inspection. The follow-up inspection was conducted on December 3, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Clinical Outcomes Group, Inc. 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 January 9, 2011.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based upon an interview with the Facility Director on 12/3/2010, the facility failed to provide documentation that the Project Director met the educational and experiential requirements for the position.
The findings include:
On December 3, 2010 the Facility Director was asked to provide documentation of the Project Director's educational background in the form of a diploma or a transcript and a resume. The Facility Director confirmed thea they were not on site.
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Plan of Correction
Following the 12/03/2010 LIC PA DOH on-site survey, the Project Director was informed that, by regulation, he is required to have on-site for review, copies of his college transcript, college diploma, and updated resume on file no later than 01/15/2011.
The HR Director will ensure that at time of hire all required educational documentation will be filed on-site no later than 30 days from the first date of employment.
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705.21 (2) LICENSURE General req. for nonresidential facilities.
705.21. General requirements for nonresidential facilities.
The nonresidential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
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Observations
Based upon observation the facility lacked a valid certificate of occupancy.
The findings include:
The facility had Certificate of Occupancy dated June 17, 2002; however it was issued by the local municipality. The Commonwealth of Pennsylvania was responsible for issuing Certificates of Occupancy for all municipalities with the exception of the cities of Pittsburgh, Scranton and Philadelphia up until 2004. The specific municipality issuing the June 17, 2002 Certificate of Occupancy opted in for conducting their own inspections and issuing their own Certificates of Occupancy on July 8, 2004. Any Certificates of Occupancy issued prior to that date would not meet the requirements for this standard.
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Plan of Correction
The facility Certificate of Occupancy dated June 17, 2002 was presented to City of Pottsville Building Code Official. A new Certificate of Occupancy was issued dated December 14, 2010. A copy of the new Certificate of Occupancy was FAXED to the Division of Drug and Alcohol Program LIC PA DOH on December 14, 2010. The orginal Cetificate of Occupancy is displayed on site. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based upon a physical plant tour at approximately 4:00 PM and an interview with the facility administrative assistant, facility failed to ensure that exits were not obstructed.
The findings disocclude:
The exit door located in the counseling office of the second floor was obstructed by file boxes.
The administrative assistant confirmed that he exit door was obstructed.
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Plan of Correction
The project director held a staff meeting on 12/04/2010 and implemented a plan to move all exit door obstructions in a timely manner and to educate the staff in the need to always make sure that all exit and entrance doors are kept free and clear of any type of obstruction. The project director directed that obstructions were to be removed as soon as possible.
The office manager was assigned the responsibility to ensure that all obstructions were removed in a timely manner. The office manager was instructed to report back to the project director no later than 12/31/2010 that all obstructions had been removed.
The office manager reported to the project director on 12/28/2010 that all obstructions had been moved and that, in addition, filling boxes and filing cabinets had been re-located to ensure that exists would not be obstructed in the future.
The office manager will conduct weekly office inspections for the next 60 days to determine that exits and entrances are free and clear of obstructions.
During the monthly fire drill, the office manager will conduct an office inspection to make sure that all exits and entrances are free and clear of obstructions. The results of said inspection will be recorded on the monthly fire drill record form.
Once a quarter, the project director will inspect all office spaces to make sure that exits and entrances are not obstructed. The results of said inspection will recorded on the appropriate monthly fire drill record form.
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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 upon a review of client records and an interview with the Facility Director, the facility failed to 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
The findings include:
Four client records were reviewed on December 3, 2010 for consent to release information forms. The facility field to obtain an informed consent. Four out of four record client records contained consent to release information. This was confirmed by the Facility Director
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Plan of Correction
The Project Director has instructed the Clinical Supervisor to develope and implement a new consent form to include verbal and written permission to revoke the consent. The Clinical Supervisor will ensure that active client charts that were reviewed will have the old consents removed and replaced with the new concent forms.
In addition, the Clinical Supervisor will review the facility Policy and Procedure Manual to ensure that the facility's consent policy is in full complicance with DOH D&A LIC regulations.
The facility will no longer be using the old form to ensure that this form does not end up in a client file. The old form will be immediately destroyed to ensure that it is not mistakenly used at a future date.
In addition, the Clinical Supervisor will conduct a staff meeting no later than 12/07/2010 to instruct counseling staff about the policy outlining proper use of verbal consents and introduce the new consent form.
The Clinical Supervisor will review client consent forms on a weekly basis for the next 60 days to ensure compliance. If client consent forms are found to be not in compliance within 60 days, weekly supervision with the counselor will be required to ensure compliance.
The facility will be in complete compliance by February 28, 2011 and the Clinical Supervisor, from that point forward, will conduct quarterly reviews of client consent forms, on a random basis, to ensure continued compliance.
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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 a review of client records and an interview with the facility director, the facility failed to document a psychosocial evaluation to include assets/strengths that can contribute to the resolution of the client ' s problems, support systems, and/or coping mechanisms in four of four client records reviewed.
The findings include:
Four client records were reviewed on December 3, 2010. Two client records did not include assets/strengths and four client records did not include support systems and coping mechanisms.
Client # 1 was admitted on May 21, 2010. The psychosocial evaluation was completed on May 21, 2010 and failed to include the client's assets/strengths, support systems, and coping mechanism.
Client # 2 was admitted on May 21, 2010. The psychosocial evaluation was completed on May 21, 2010 and failed to include the client 's assets/strengths and coping mechanisms.
Client # 3 was admitted on August 20, 2010. The psychosocial evaluation was completed on August 20, 2010 and failed to include the client 's support system and coping mechanisms.
Client # 4 was admitted on June 22, 2010. The psychosocial evaluation was completed on June 22, 2010 and failed to include the client 's support system and coping mechanisms.
An interview with the facility director on December 3, 2010 confirmed that the psychosocial evaluation in those client records did not include the information mentioned above.
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Plan of Correction
The clinical supervisor will meet with counseling staff no later than 12/07/2010 to discuss what is required to properly complete a psychological evaluation. In addition, the psychosocial evaluation has been updated with sections added to include evaluating the client's coping skills, strengths, and support systems.
The facility will no longer be using the old form to ensure that this form does not end up in a client file. The old form will be immediately destroyed to ensure that it is not mistakenly used at a future date.
The clinical supervisor will conduct a staff meeting no later than 12/07/2010 to instruct counseling staff in the use of the new psychosocial evaluation form and how the addition of sections relating to coping skills, strengths, and support systems relate to the treatment process.
Psychosocial evaluations will be reviewed by the clinical supervisor on a weekly basis, for the next 60 days, to ensure proper use and compliance. If psychosocial evaluations are found to be not in compliance within 60 days, weekly supervision with the counselor will be required to ensure compliance.
The facility will be in complete compliance by February 28, 2011 and the clinical supervisor, from that point forward, will conduct quarterly reviews of psychosocial evaluations, on a random basis, to ensure continued compliance.
With regard to clients 1-4, the counselor will update the psychosocial evaluation focusing on client strengths, coping skills, and support systems. Updates will be conducted at the time and date of each client's next scheduled appointment. Each newly revised psychosocial evaluation will be reviewed by the clinical supervisor to ensure compliance.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records and an interview with the facility director, the treatment plan updates failed to include an assessment on the client ' s progress as it relates to the goals identified on the individual treatment plan. The treatment plan updates did include an assessment of the client ' s progress in four of four outpatient client records reviewed.
The findings include:
Three client records were reviewed on December 3, 2010 for treatment plan updates. An assessment on the client ' s progress was required in four client records. The facility did not document an assessment of the client ' s progress in the treatment plan update for outpatient records # 1, 2, and 3.
Client # 1 was admitted May 21, 2010. Treatment plan was completed on 7/9/2010. Treatment plan update was completed on 9/9/2010; however, the clinician failed to document a report on the client's progress of goals.
Client # 2 was admitted May 21, 2010. Treatment plan was completed on 6/25/2010. Treatment plan update was due on 8/25/10; however, it was not completed 10/25/2010. In addition, the clinician failed to document a report on the client's progress of goals.
Client # 3 was admitted June 22, 2010. Treatment plan was completed on 7/16/2010.
Treatment plan update was completed on 9/16/2010; however, the clinician failed to document a report on the client's progress of goals.
An interview with the facility director on December 3, 2010 confirmed that the treatment plan update in those client records did not include an assessment of the client ' s progress.
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Plan of Correction
The clinical supervisor (counselor for clients 1,2,3,4) will make the necessary corrections to client charts. The treatment plan updates for clients 1, 2, 3 were immediately updated following the 12/03/2010 on-site survey, to include documentation of client progress. Additional updates were made to client 1's chart following review.
The clinical supervisor changed the treatment plan update form to include an area to assess client progress. The clinical supervisor will conduct a staff meeting no later than 12/07/2010 to instruct counselors on the use of the revised treatment plan update form.
The facility will no longer be using the old form to ensure that this form does not end up in a client file. The old form will be immediately destroyed to ensure that it is not mistakenly used at a future date.
The clinical supervisor will review client treatment plan update forms on a weekly basis for the next 60 days to ensure compliance. If client treatment plan update forms are found to be not in compliance within 60 days, weekly supervision with the counselor will be required to ensure compliance.
The facility will be in complete compliance by February 28, 2011. The clinical supervisor, from that point forward, will conduct quarterly reviews of client treatment plan update forms, on a random basis, to ensure continued compliance.
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed document a record of service which include a chronological listing of all services provided to the client in four of four client records.
The findings include:
Four outpatient client records were reviewed on December 3, 2010 for a record of service including all services provided to the client. The facility did not document a record of service in client records #1, 2, 3 and 4.
An interview with the facility director on December 3, 2010 confirmed that those client records did not include documentation of a record of service.
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Plan of Correction
The clinical supervisor has created a record of service form that will be implemented no later than 12/07/2010. In addition, clinical supervisor will conduct a staff meeting no later than 12/07/2010 to instruct counselors on the use of the new record of service form.
The facility will no longer be using the old form to ensure that this form does not end up in a client file. The old form will be immediately destroyed to ensure that it is not mistakenly used at a future date.
The clinical supervisor will ensure that all client charts have a record of service form and that said form is properly completed. Each counselor will be responsible for obtaining client signatures for their chart.
The clinical supervisor will review client record of service forms on a weekly basis for the next 60 days to ensure compliance. If client records of service forms are found to be not in compliance within 60 days, weekly supervision with the counselor will be required to ensure compliance.
The facility will be in complete compliance by February 28, 2011 and the clinical supervisor, from that point forward, will conduct quarterly reviews of client record of service forms, on a random basis, to ensure continued compliance.
All active clients charts (1,2,3,4) will immediately be updated by the clinical supervisor to include the appropriate record of service form.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client record and an interview with the facility director, the facility failed to document goals with timeframes in the aftercare plan in two of two client records.
The findings include:
Two client records were reviewed on December 3, 2010 for aftercare plans. The facility did not document goals with timeframes and the criteria for the re-entry process in the aftercare plan in client records #4 and 3.
An interview with the facility director on December 3, 2010 confirmed that those client records did not include goals with timeframes and the criteria for the re-entry process in the aftercare plan.
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Plan of Correction
The clinical supervisor will update client after care plan form to include goals with defined time frames and specific criteria for re-entry into the program no later than 12/07/2010. In addition, clinical supervisor will conduct a staff meeting no later than 12/07/2010 to instruct counselors on the use of the updated client after care plan form.
The facility will no longer be using the old form to ensure that this form does not end up in a client file. The old form will be immediately destroyed to ensure that it is not mistakenly used at a future date.
Discharged client after care plans that did not include goals, time frames, and re-entry criteria will be included in, updated, and completed during the client's 3-month follow-up consultation.
The clinical supervisor will ensure that all client charts have a client after care plan form and that said form is properly completed.
The clinical supervisor will review client after care plan forms on a weekly basis for the next 60 days to ensure compliance. If client after care plan forms are found to be not in compliance within 60 days, weekly supervision with the counselor will be required to ensure compliance.
The facility will be in complete compliance by February 28, 2011 and the clinical supervisor, from that point forward, will conduct quarterly reviews of client after care plan forms, on a random basis, to ensure continued compliance.
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