INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16 and 17, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Women's Institute for Family Health was found not be be in compliance with the applicable chapters of 28 Pa Code which pertain to the facility. The following deficiencies were identified during the inspection and a plan of correction is due on May 12, 2008.
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Plan of Correction
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704.5(b) LICENSURE Clinical Supervisor
704.5. Qualifications for the positions of project director and facility director.
(b) If the facility does not have a clinical supervisor on staff, clinical responsibilities shall be addressed in one of the following ways:
(1) A facility director who has direct responsibility for clinical services shall meet the qualifications in at least one of the paragraphs of 704.7 (b) (relating to qualifications for the position of counselor).
(2) If the facility director does not meet counselor qualifications and the facility employs less than eight counselors, a lead counselor or part-time clinical supervisor shall be appointed.
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Observations
Based on a review of personnel records, the facility director did not meet counselor qualifications and a lead counselor or part-time clinical supervisor was not appointed to address clinical responsibilities.
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Plan of Correction
The Project Director will hire a lead counselor by 5/30/2008 to address clinical responsibilities. The lead counselor will have education, training and experience as specified by state standards |
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 on April 16, 2008, the facility failed to document that one counselor met the qualifications for the position of counselor, #3.
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Plan of Correction
The Project Director will assure that all counselors meet state qualifications and that their qualifications are documented in agency records |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of training records on April 16, 2008, the facility failed to document feedback on completed training in one of two records reviewed, #4.
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Plan of Correction
The Project Director will assure that feedback on all counselor training is received with one week of training event and the feedback is documented and stored in employee training records |
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 training records on April 16, 2008, the facility failed to document a complete individual training plan in four of four records reviewed, #1, 2, 3 and 4. Individual training plans did not include potential resources and the date the individual plan was completed.
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Plan of Correction
The Project Director will assure that an individual training plan is completed on all drug and alcohol staff and all plans will be dated and include potential resources |
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 a review of training records on April 16, 2008, the facility failed to document the number of training hours for HIV/AIDS in one of one record reviewed, #1.
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Plan of Correction
The Project Director will assure that all personnel records contain documented number of training hours for HIV/AIDS within 60 days of date of hire. The Project Director will implement a time keeping system to monitor staff completion of training hours in accordance with schedules established by state standards. The Project Director will monitor personnel files on a monthly basis to assure that all training hours are documented. |
705.27 (5) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(5) Notify the Department within 48 hours of a fire, other disaster or situation which affects the continuation of services.
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Observations
Based on a review of administrative documents on April 17, 2008, the facility failed to notify the Department within 48 hours of the discontinuation of services due to the flooding at the facility's prior location.
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Plan of Correction
In the event of another catastrophe that causes the immediate closure of the facility,in addition to placing a telephone call to the department, the Project Director will forward a letter by certified mail within 48 hours to advise the department of the emergency closure. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on the physical plant inspection on April 17, 2008, the facility failed to provide lighted interior exits for all three exit doors.
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Plan of Correction
The Project Director will assure that lights are installed at the three interior exit doors by 5/30/2008 |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records on April 17, 2008, the facility failed to document fire drills at least once a month. The facility did not document a fire drill in January 2008 and March 2008.
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Plan of Correction
The Project Director will assure that fire drills are conducted at least once a month and that all fire drills are recorded/documented in a fire drill log. |
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 record on April 17, 2008, the facility failed to document a fire drill record which included the exit routes used and problems encountered. for January through March, 2008.
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Plan of Correction
The Project Director will assure that the facility maintain a fire drill record of monthly fire drills that include exit routes used and problems encountered |
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 fire drill records on April 17, 2008, the facility failed to document alternate exit routes to be used during fire drills.
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Plan of Correction
The Project Director shall assure that alternate routes are used during monthly fire drills and that the fire drill record reflects the use of alternate exit routes |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative documents on April 16, 2008, the facility failed to document that the 2006 annual report was made available to the public.
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Plan of Correction
The Project Director will assure that all annual reports are made available to the public within 6 months of the close of the fiscal year. Annual reports will be made available to the public through newspaper announcements. The Project Director will submit the annual report to local newspapers and will document the publication by maintaining a copy in agency files that indicate the name of the newspaper and date of the announcement. The Project Director will assure tht the ad will be documented by a written statement from the newspaper that the ad was placed and on what date. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documents and an interview with the project director on April 16, 2008, the facility failed to document an annual audit for the 2006 fiscal year.
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Plan of Correction
The Project Director will assure that an annual audit is completed and documented within 6 months of the close of the prior fiscal year for each fiscal year |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records on April 17, 2008, the facility failed to obtain an informed and voluntary consent to release information from the client in six of six records reviewed, #1, 2, 3, 4, 5 and 6. Consent to release information forms did not include that a copy of the consent was offered to the client.
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Plan of Correction
The Project Director will add a statement to consent forms to state that a copy of the form was offered to the client; the form will include a statement to verify that the client did or did not accept a copy of the form; the form will be dated and signed by the client. The Project Director will assure that this procedure is adhered to through monthly review of client records |
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 on April 17, 2008, the facility failed to document a complete psychosocial evaluation in six of six records reviewed, #1, 2, 3, 4, 5 and 6. The psychosocial evaluation was missing in one record, #1. Psychosocial evaluations did not include an assessment of the client's problems/needs, assets/strengths, support systems and negative factors that may inhibit treatment in five records, #2, 3, 4, 5 and 6.
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Plan of Correction
The Project Director will revise the agency psychosocial evaluation form to include more information that will allow for a comprehensive assessment of the clients problems/needs,assets, strengths and support systems and also negative factors that may inhibit treatment. The Project Director will provide training to program staff on completing psychosocial evaluations and will assure that psychosocial evaluations are completed through monthly review of client records. The revised form will be completed by 5/1/2008, staff training on the form will be completed by 5/30/2008 |
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 a review of client records on April 17, 2008, the facility failed to document that preliminary treatment plans were completed within the required timeframe in six of six client records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
The Project Director shall assure that preliminary treatment plans are completed within the required time frame, this will be accomplished through monthly review of client records. The Project Director will assure that drug and alcohol counselors receive training on proper completion of the preliminary treatment plan at orientation and the Project Director will assure that counselor's sign and date all completed treatment plans through training and monthly monitoring of client records |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records on April 17, 2008, the facility failed to document treatment plan goals stated in terms of measurable criteria in six of six client records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
The Project Director will assure that treatment plan goals are stated in measureable criteria, this will be accomplished through monthly review of client records. Drug and alcohol staff will receive training in utilizing measurable criteria in treatment planning. New staff will receive training at orientation, existing staff will receive training by May 31, 2008. Training will be conducted by the Project Director |
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 a review of client records on April 17, 2008, the facility failed to document support services on treatment plans in three of six client records reviewed, #1, 2 and 3.
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Plan of Correction
The Project Director shall assure that there is documentation of support services on treatment plans; this shall be accomplished through monthly review of client records. The Project Director will provide training to staff on the proper way to document support services on treatment plans. New hires will recieve training at orientation, existing staff will receive training by May 31, 2008 |
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 on April 17, 2008, the facility failed to document a complete treatment plan update in one of one client record reviewed, #6. The treatment plan update did not include an assessment of progress in relationship to the stated goals of the treatment plan
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Plan of Correction
The Project Director shall assure that treatment plan updates are completed in accordance with agency and department standards; treatment plan updates will include an assessment of progress in relationship to the stated goals of the treatment plan; this will be accomplished through monthly review of client records. The Project Director will train staff on how and when to complete treatment plan updates. New hires will receive training at orientation and existing staff will receive training by May 31, 2008 |
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 on April 17, 2008, the facility failed to document a complete record of services in five of six client records reviewed, #2, 3, 4, 5 and 6. The record of services did not include the type of service provided to the client for all of the entries.
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Plan of Correction
The Project Director shall assure that the type of service provided to the client is documented for each service date entered in the client record; this shall be accomplished through monthly review of client records. The Project Director will train staff on the proper completion of record of service. New hires will receive training at orientation and existing staff will receive training by May 31, 2008 |
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
Based on a review of client records on April 17, 2008, the facility failed to document a case consultation in one of one client record which required a case consultation, #6.
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Plan of Correction
The Project Director shall assure documentation of case consultations in client records where required; this will be accomplished through monthly review of client records |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records on April 17, 2008, the facility failed to document that a physician signed the treatment plan for Medicaid clients in six of six client records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
The Project Director shall assure that there is documentation of the physician's approval of client treatment through signature on treatment plans for medicaid clients; this will be accomplished through monthly review of client records |