INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 21, 2007 through May 23, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on June 14, 2007.
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Plan of Correction
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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
The facility failed to provide a statement that verified the intent of the project to comply with Chapter 704.
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Plan of Correction
After reviewing this more closely, it was determined that a statement in fact was present in the policy manual signed by the Board of Directors in 1997. The statement indicates that the Board is aware of and intends to fully comply with all ODAP regulations and specifically those related to staffing, their qualifications and continuing education. This document will be made available during all future licensing inspections. |
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
Individual training plans were not completed within thirty days of hire (Licensing Alert 03-05) in seven of eleven employee records reviewed, # 2, 3, 7, 8, 9, 10 and 11.
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Plan of Correction
New policy was implemented at the time of the survey by the Human Resources Director. Initial individualized training plan will be incorporated with department specific orientation checklist to be completed by supervisor, nurse educator or Human Resources Director. The training plan will be completed within 30 days of hire. Human Resources Department will monitor completion. |
709.123(c)(5) LICENSURE Follow-up information
709.123. Treatment and rehabilitation.
(c) Client records. 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) Follow-up information.
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Observations
The facility failed to document follow-up information in two of three client records reviewed, #7 and 8.
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Plan of Correction
Since there are a minimal number of drug and alcohol cases at our facility, this is an area that may be overlooked by new caseworkers or caseworkers who do not routinely handle these cases. The Administrative Assistant has provided re-education to the Director of the Department via memo and charts will be monitored regularly by the Medical Records Committee to determine that this has been done. |
709.123(d)(2) LICENSURE Aftercare Policy
709.123. Treatment and rehabilitation.
(d) Client management services.
(2) The project shall develop a written client aftercare policy.
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Observations
The aftercare policy did not address the drug and alcohol aftercare plan form. The policy did not indicate the staff members responsible for completing the plan, how it is to be developed and the format to be used.
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Plan of Correction
This policy was written by the Administrative Assistant at the time of the survey. This policy will be includd in the policy and procedure manual with the other policies and available for inspection at the next licensing visit. |
709.123(d)(3) LICENSURE Follow-up Policy
709.123. Treatment and rehabilitation.
(d) Client management services.
(3) The project shall develop a written client follow-up policy.
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Observations
The follow-up policy did not address the method and frequency of contact for clients who were not referred to another treatment program.
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Plan of Correction
Policy is currently being updated by Administrative Assistant in coordination with the Director of Social Service to include that clients who are not referred to another treatment program (i.e. AMA discharges) will have a follow-up call made to them by the caseworker one week after discharge. Documentation by the caseworker will take place as to the outcome of the phone call. Monitoring will be done by the Medical Records Department. |
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
The confidentiality policy and procedure stated that program staff must notify the authorities in cases of suspected or proven elder and spousal abuse.
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Plan of Correction
The Guidelines for Assessing Abuse will be revised by the Administrative Assistant in coordination with the Director of Social Service to indicate that suspected or proven elder and/or spousal abuse may not be reported in clients with a drug and alcohol diagnosis. However, MCES will follow the guidelines of Licensing Alert 5-97 and report to the Department of Health. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Case consultations were missing in four of four client records reviewed, # 1, 2, 3 and 4.
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Plan of Correction
Case consultations are routinely done with other members of the treatment team by the CEO/Medical Director who provides the majority of the outpatient service to the drug and alcohol clients. This is documented in the regular outpatient progress notes, but they are not labeled as case consultations. CEO/Medical Director will now clearly document case consultations as a separate note from the progress notes. Monitoring for compliance will be done by the Outpatient Secretary. |
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
The aftercare plan was missing in one of one client record reviewed, #4.
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Plan of Correction
No aftercare was done on the one drug and alcohol outpatient who was discharged. The psychologist was a relatively new employee and was not aware that this needed to be done. The psychologist has been re-educated by the CEO/Medical Director via memo that this needs to be done on any cases in the future. Monitor will be done by the Outpatient Secretary. |
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
The facility failed to document follow-up information in one of one client record reviewed, #4.
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Plan of Correction
No follow-up call was done on the one drug and alcohol outpatient who was discharged. The psychologist was a relatively new employee and was not aware that this needed to be done. The psychologist has been re-educated by the CEO/Medical Director via memo that this needs to be done on any cases in the future. Monitoring to be done by the Outpatient Secretary. |
709.94(d) LICENSURE Project management services
709.94. Project management services.
(d) The project shall develop a written client aftercare policy.
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Observations
The aftercare policy did not include the documentation of a contact person for the client and the re-entry criteria.
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Plan of Correction
The aftercare policy is being revised by the Administrative Assistant in conjunction with the Crisis Director and Outpatient Secretary to include documentation of a contact person for the client and re-entry criteria to the inpatient and/or outpatient program. |