INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 2008 -January 29, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, PA Organization for Women in Early Recovery 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 29, 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 client records employee # 16 does not meet counselor qualifications. There was no documentation to support that this employee's credentials were consistent with the requirements for counselor. Employee #17, an intern, made an entry in client record # 2 on 11/8/07, he co-signed a group progress note, but he was not listed as a counselor assistant or counselor and there was no documentation to support that his credentials were consistent with the regulation.
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Plan of Correction
Regarding employee# 17, who is a Bachelor's level intern , she does not facilitate any treatment groups. She co-facilitates with a senior counselor. She co-signed the group note in compliance with her learning plan from the University. Effective immediately, she will not sign or co-sign any counseling notes. Moving forward, the Halfway House Manager will ensure that all Interns meet the qualifications for a Counselor Assistant or Counselor. The Field Supervisor will provide supervison and all documentation in accordance with. The Program Managers will keep all the required documentationon file. The Associate/Clinical Director will list all Interns on the long form from this point forward.
Employee #16 is a Music Therapist by education, training and experience. However, Duguense University records her degree as a Masters in Music Education, with a major in Music Therapy. The Associate Director will request clarification from Dugnese University and will submit, the results to Liscensing. We expect to be in compliance with this standard by 5/31/08. |
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 review of the facility's staffing compliance plan it was determined that the facility failed to comply with support staff completing training for STD/TB training. Employee #18 has been employed with the project for over 2 years and has not completed the required training.
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Plan of Correction
This is an oversite on our part and employee #18 will be scheduled for the next STD Training. Once completed documentation will be provided and entered into her personnel record. It is anticipated this will occur by June 30, 2008 due to the lack of this training in this area. The Executive Assistant will monitored the training files on a quartley basis and advise the Associate/Clinical Director of all deficiencies. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on review of personnel records job descriptions were not documented in two of the personnel files reviewed. Employee # 13 and #14 did not have job descriptions documented in their employee records.
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Plan of Correction
This was an oversite on our part. Job descriptions will be signed at Orientation and placed in the Personnel file. The Exective Assistant will monitor this process on an quartley basis and advise the Associate/Clinical Director of any deficiencies. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. 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 a review of client records on January 24, 2008, the facility failed to document a complete personal history. In client record # 2 and 3 family histories were incomplete. In client record # 1 and 3 the legal history was incomplete. In client record # 1 and 2 the employment history was incomplete. In client record # 1, 2 and 3 the education history was incomplete. In client record # 2 and 3 recreational histories were incomplete. In client records # 1, 2, and 3 sexual histories were incomplete.
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Plan of Correction
full day, mandatory training on Clinical Documentation has been developed and is scheduled on March 15, 2008 for all clinical staff. This training will focus on documenting all facets of the client's personal history, which includes but not limited to family, legal, employment, education, recreational and sexual histories.
The Program Manger will review two bio psychosocial assessments a week for completeness. This review will take place during weekly supervision with all Counselors/Therapists. The Associate/Clinical Director will randomly review one client record from each program on a quarterly basis.
This is effective immediately.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of the client records on January 24, 2008, the facility failed to ensure that the psychosocial evaluation contained a clinical analysis of the client's problems/needs and support systems. In client records # 1 and 3 assets/strengths were not evaluated. In client record # 1 coping mechanisms and negative factors were not evaluated.
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Plan of Correction
A full day mandatory training on Clinical Documentation has been developed and is scheduled on March 15, 2008 for all clinical staff. In additional to completely documenting the bio-psychosocial assessment, the training will devote three hours on developing the bio psychosocial evaluation (narrative). Specific attention will be focused on the clinical assessment/impression of the clients' strengths, assets, support systems, needs/problems and coping mechanisms.
During the above stated supervision with Counselors/Therapists, the Program Manager will review all the bio psychosocial evaluations for completeness. The Associate/Clinical Director will randomly review one client record from each Program on a quarterly basis.
This is effective immediately.
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709.52(a)(1) LICENSURE Short/Long term TX Goals
709.52. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on review of client records on January 24, 2008, the facility failed to document short and long term goals that were realistic and stated in terms of measurable criteria in client records #1 and 2.
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Plan of Correction
On March 15, a training was conducted for all clinical staff. The training addressed effective strengths-based treatment planning, including addressing attainable and measurable long- and short-term goals. The Program Managers will approve all Treatment Plans in weekly supervision. The Associate/Clinical Director will randomly review the clinical records on a quarterly basis.
Effective immediately. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on a review of client records on January 24, 2008 , the facility failed to document complete group progress notes in three out of three client records reviewed, # 1, 2, and 3. In client record #1 group notes documented on 11/19/07, 11/20/07, 11/30/07, 1/07/08, 12/10/07,and 01/04/08 failed to include data, assessment and plan. In client record #2 group notes documented on 11/5/07, 11/08/07, 11/15/07, 12/03/07, 12/07/07, 1/13/08 and 01/10/08 failed to include data, assessment and plan. In client record # 3 group notes documented on 10/08/07, 10/10/07, 10/29/07, 11/14/07, 12/07/07, 01/09/08 and 01/11/08 failed to include data, assessment and plan. All above group notes failed to include the counselor's assessment of the data.
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Plan of Correction
POWER's Group Progress Form has been revised and all clinical staff have been trained on documenting the clinical impressions/assessment of each client during the group process. This training took place on March 15, 2008. Monitoring for compliance will be the responsibility of the Program Manager and Associate/Clinical Director. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 review of client records the facility failed to document attempts to follow up on clients who had been discharged from the facility. In accordance with project policy follow up is to take place 30 days, 6 months and 1 year from the date of discharge. The 30 day follow up was not documented in client record #4.
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Plan of Correction
Effective immediately, in all instances, when a client is discharged from one of POWER's programs and referred to another agency or program, the POWER staff will contact the receiving agency/program to determine if the client followed through with the appointment. |