INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from August 30, 2011 through August 31, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital Outpatient Treatment Program 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.
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Plan of Correction
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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of staff development records, the facility failed to document that a staff member, who is a counselor assistant, is working toward meeting the qualifications for the position of counselor.
Findings:
Five staff development records were reviewed on August 30, 2011 between 10:00 and 12:00 hours. One staff development record pertained to a counselor assistant. A counselor assistant shall document that he/she is working toward counselor status. The information shall be documented upon completion of each calendar year. The facility failed to provide documentation that the counselor assistant is working toward meeting the qualifications for the position of counselor in staff development record # 3.
Employee # 3 was hired on May 4, 2009. Employee # 3 failed to provide documentation by December 31, 2010 that he/she is working toward obtaining the qualifications for counselor.
The facility director was interviewed on August 31, 2011 and verified that employee # 3 has failed to document efforts toward qualifying for the counselor position through through certification or a college degree.
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Plan of Correction
The therapist who is credentialed as a Counselor Assistant is in the process of attending all pertinent and necessary training to meet all of the employment, education, and professional standards that have been laid out by the Pennsylvania Certification Board to reach the credential of Certified Addictions Counselor (CAC). Presently he is on the mailing list with Livengrin, Charter Fairmount, and the BHTEN Nertwork for trainings that will assist our Counselor Assistant to achieve the credential of CAC. There is an information session scheduled by the PCB to explain the credentialing process for those in pursuit of their CAC. The training is scheduled for 10-14-11 from 10:00 am to 11:30 am, and our clinical staff member, Blair Jordan will attend this session. His projected date for completion of the trainings and education requirements has been tentatively set for June 2012
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) 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, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in two of eight client records.
Findings:
Eight client records were reviewed on August 31, 2011. Two client records did not include documentation of treatment plan updates.
Client record # 2 - Admitted March 18, 2011. The preliminary treatment plan was dated March 18, 2011. The individualized treatment plan was dated April 18, 2011. A treatment plan update was dated June 18, 2011. The facility failed to document a treatment plan update for August 18, 2011.
Client record # 3 - Admitted November 5, 2010. The preliminary treatment plan was dated November 5, 2010. The individualized treatment plan was dated November 19, 2010. Treatment plan updates were dated January 18, 2011, March 18, 2011, May 17, 2011 and June 18, 2011. The facility failed to complete a treatment plan update for August 18, 2011.
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Plan of Correction
In our hasty attempts to meet the standards that relate to Treatment Plan Updates, there were two charts that were not updated with a current Treatment Plan. All clinical charts are to be reviewed and, when necessary, revised to meet the needs of the client, at that time in treatment. The first chart in question was being maintained by the newest member of our clinical staff and she had been on our staff for approximately two weeks prior to the audit and inspection. The chart was brought up to date with the missing Treatment Plan and is now current. The clinical chart was updated with the TPU within the first two work days after the site visit. The clinical staff is also beginning a supervisory process during which the Director of Behaviioral Services will be reviewing client charts that are due for clinical plan updates to ensure that the paperwork will be completed in a timely fashion to guarantee continuity of treatment in a timely and effecient manner. |
711.93(a) LICENSURE Complete Client Record
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
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Observations
Eight client records were requested for review on August 30, 2011, but the facility failed to provide one of the eight records requested for the review.
Findings:
On August 30, 2011 at approximately 14:00 hours facility staff were asked to provide eight randomly selected client records for review. On August 31, 2011 at approximately 13:00 hours facility staff reported that they were not able to locate one of the randomly selected client records.
Client record # 4 - admitted November 5, 2010, but facility staff were unable to produce the client record for review.
The Facility Director was interviewed on August 31, 2011 and confirmed that client record # 4 could not be located.
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Plan of Correction
The chart that was reported missing at the time of the inspection was found the day after the inspector completed his exit interview- 9-1-11.
Our plan of correction includes the assembling and maintaining a filing system that would come under the supervision of one clinical staff member.
That person would be responsible for tracking the charts through a card filing system to know where a chart is and who signed that file out to be used in a therapy session or for documentation of TPU's or other paperwork to keep the chart current. This is new filing system will be completed and fully operational by the end of the calendar year- 12-31-11
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