INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 26, 2010 through April 27, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Case De Consejeria Drug and Alcohol Counseling Program 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 May 24, 2010..
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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 a review of the facility self reporting staffing form, the employee records and interviews with administrative staff, the facility failed to employ staff who met the credential and experiential criteria for the position of counselor in two of four employee records. The findings included : During the onsite inspection, conducted on April 26, 2010, the records of five clinical staff were reviewed. Four of these staff were designated as counselors. Employees #4 and 6 did not have documentation of one year of clinical experience at the time of hire and therefore were not qualified for their designation as counselors.
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Plan of Correction
The Executive Director will meet with employees and explain that they must be demoted to Counselor Assistants. The Clinical Supervisor will complete appropriate and necessary supervision documents and conduct supervisory meetings until each counselor obtains their one year clinical experience. The Executive Director and Director of Operations will carefully review resumes from new potential employees and send employee work verifications in order to verify clinical experience. If clinical experience seems to not be clear then we will request job descriptions from the potential employees' previous employments that may demonstrate and describe further any clinical experience. |
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 the audit for January 1, 2008 through December 31, 2008, the project failed to complete a fiscal audit by the end of the project's fiscal year.The findings include:A review of the annual audit was conducted on April 26, 2010. The project's audit for January 1, 2008 through December 31, 2008 was due to be completed no later than June 30, 2009. The project's audit was not completed until November 13, 2009.
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Plan of Correction
The Exectuive Director has contracted an outside Certified Public Accountant that will complete and provide an annual financial audit for 2009 no later than June 30, 2010. The agency has also contracted a financial bookeeper that will regularly input the agency's financial data and reconcile monthly financial statements to ensure the timely completion of the audit. The Director of Operations signs all fiscal reconciliations monthly in order to also ensure the timely completion of the upcoming fiscal audit. These measeures will assist in preventing this deficiency from reocurring. |
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
Based on interviews with the facility's project director and a review of the facility's confidentiality policy and procedure, the facility failed to develop written procedures to address how the confidentiality of their electronic records storage system will be maintained.The findings include:Interviews with the project director were conducted on April 26, 2010. The facility's policy and procedures on the confidentiality of client identifying information were reviewed on April 26, 2010. The policy did not identify who, by job title, has access to this system, did not have a Qualified Service Organization Agreement (QSOA) with the agency that handles the electronic records and did not include that jump drives or other portable media are prohibited. The policy failed to state that electronic client records can not be removed from the facility by staff.
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Plan of Correction
The Director of Operations will revise and develop the Electronic Record Keeping policy to include staff access, a Service Organization Agreement with agency or agencies that maintain our electronic records, no copies may be taken or accessed by any employee or staff member through jump drives or any other portable media source, and that all other requirements stated by regulation 42CFR are inlcuded and met. This policy will be reviewed and signed by all employees and staff members. |
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 on the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in five of nine client recordsThe findings include:Nine client records were reviewed on April 27, 2010. Informed and voluntary consent forms were required in nine client records reviewed.Client #1 - A letter dated 12/17/09, pertaining to the client's admission to the program, was addressed to "To Whom It May Concern" and there was no corresponding consent to release client identifying information.Client #2 - A letter dated 2/24/10, pertaining to client's social security number and their admission to the program, was addressed to "To Whom It May Concern" and there was no corresponding consent to release client identifying information.Client #4 - A telephone contact was documented on 3/23/10 and 3/29/10 with the client's case manager. There was no corresponding consent to release information form for the case manager or the agency.Client #5 - A letter pertaining to the client was mailed out, but there was no corresponding consent to release information form in the client's record. A contact note dated 7/9/09, in reference to a telephone contact, was in the client record but there was no corresponding consent to release information form permitting the facility to release information to the person contacted on the phone. In addition, a reference letter dated 7/9/09 to Kensington Hospital was documented in the client record but there was no corresponding consent to release information form in the client record.
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Plan of Correction
The Clinical Supervisor has verbally advised the clinicians at this time regarding client confidentiality and how to address letters and ensure that confidentiality forms are always completed for all individuals needing information on any part of the client's treatment. However, the clinical supervisor with the assistance of the Director of Operations and the Executive Director will conduct an official meeting where the confidentiality process will be discussed and reviewed. It will emphasize the process of writing letters for clients, completing confidentiality forms and all form sections, and for whom the confidentiality forms must be completed for. The clinical supervisor will review all new admissions to ensure the accuracy of all releases of information completed when a new client id admitted. During the weekly quality assurance and record checks conducted by the clinical supervisor, an emphasis will be placed on letters written for clients by the counselors and completion of releases of information with any outside party documented in the record in order to prevent the reoccurrence of the deficiency. |
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
Based on the review of client records, the facility failed to document follow-up information in three of five closed client records reviewed.The findings include:Nine client records were reviewed on April 27, 2010. Follow-up information was required in four closed client records, #6, 7, 8 and 9. In accordance with the facility's policy and procedure, all attempts to follow-up on clients will be done within 30 days of the clients' discharge date.Client #6 was admitted on 1/25/10 and discharged on 3/5/10. There was no documentation of an attempt to follow up on the client as of 4/27/10.Client #7 was admitted on 12/23/08 and discharged on 1/8/10. There was no documentation of an attempt to follow up on the client as of 4/27/10.Client #8 was admitted on 7/7/09 and discharged on 11/23/09. There was no documentation of an attempt to follow up on the client as of 4/27/10.
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Plan of Correction
The Clinical Supervisor with the assistance of the Director of Operations and the Executive Director will conduct a meeting where discharge and follow-up is discussed with the counselors. The meeting will include the review of the discharge and follow-up policy. The meeting will emphasize the point that discharges must include a 30 day follow-up regardless of the reason or type of discharge completed. The clinical supervisor reviews all discharges to ensure accuracy and will include checking all follow-ups on discharge records regardless of the type of discharge in order to eliminate and prevent the deficiency. The Program Director reviews all work completed by the Clinical Supervisor to ensure accuracy as well. |