INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 19 -22, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cornell Abraxas I 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 June 24, 2008.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the documentation of the supervision notes, the facility failed to document the monthly supervisory meetings for the clinical supervisor in employee record #3. Documentation of the monthly supervisory notes are missing for October 2007 and November 2007.
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Plan of Correction
The program manager will meet with each of the treatment supervisor II's to review the supervisory conference policy. The treatment supervisor II is then responsible for completing monthly supervisory conference sessions with the treatment supervisor I. Once these sessions are completed, the treatment supervisor II is responsible for providing a copy of the supervisory conference note to the program manager.
The program manager is responsible for providing supervision to the treatment supervisor II. The performance improvement coordinator will conduct random chart audits of the supervision files to ensure the supervisory conferences are being completed in a timely fashion. Any issues/concerns will be brought to and addressed by the Performance Improvement Council.
Person Responsible: Program Manager and Performance Improvement Coordinator |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on review of personnel files, documentation of the supervision of counselor assistants was missing for employees # 16, #7, #6, and #5. Clinical supervision notes were missing for February, March, April and May 2008 for employee #16. Clinical supervision notes were missing for September, October , November, and December 2007 and January, February, March and April of 2008 for employee #7. Clinical supervision notes were missing for August, October, and November of 2007 for employee #6 and clinical supervision notes were missing for August, October, and November of 2007 for employee #5.
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Plan of Correction
The program manager will meet with all of the treatment supervisors to review the process for supervising counselor assistants. Particular attention will be paid to the need to observe services provided, as well as complete supervisory conference notes, on a weekly basis. The program manager will conduct bi-weekly audits of the counselor assistant supervision files to monitor the completion of supervisory conferences. Any issues/concerns will be brought to and addressed by the Performance Improvement Council.
The program manager is also developing a file review tool, which will assist treatment supervisors in completing file audits to ensure supervisory conferences are being completed in a timely manner.
Person Responsible: Program Manager
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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 review of personnel records, the facility failed to meet the requirements at 704.10(b) Promotion of counselor assistant. The personnel record for employee #17 did not document that the counselor assistant was working toward the credentials necessary to qualify for counselor. The personnel record for employee #9 contained documents that were not dated. These documents, including two pieces of correspondence, did not demonstrate that employee #9 was working toward the qualifications for counselor. The personnel record for employee #7 has no documentation to demonstrate that this counselor assistant was working toward obtaining the credentials to qualify as a counselor. The personnel record for employee #6 contains documentation that is not dated. The documents did not demonstrate that the employee was working toward meeting the qualifications for the position of counselor.
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Plan of Correction
The program manager will meet with the counselor assistants and treatment supervisors to review the proper completion of annual letters. Particular emphasis will be placed upon the proper completion of a letter (i.e. signature & date lines) as well as indicating what progress is being made toward meeting the qualifications for counselor. The program manager and performance improvement coordinator will draft examples of letters to provide ideas to the counselor assistants.
Each counselor assistant will then be tasked with completing another letter, which includes the elements discussed previously. The program manager will review the letters and address any issues. These letters will then be provided to the program director and copied to the counselor assistant supervision file. All letters will be completed no later than July 18, 2008.
Going forward, the program manager will monitor the timely and proper completion of the letters.
Person Responsible: Program Manager and Performance Improvement Coordinator
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704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on review of personnel records, the facility failed to document 30 hours of training for a counselor assistant after his/her first year. Employee # 9 had less than 30 hours of training for 2007.
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Plan of Correction
At the end of the month, an email is sent to the entire facility, outlining training opportunities for the upcoming month. In addition, the annual training calendar is located in a computer directory, to which all employees have access. Employees are encouraged to sign-up for those trainings they are interested in attending. A target goal of 10 training hours per quarter is set for each employee. By meeting this goal, each employee will exceed the minimum number of training hours per year. The treatment supervisor of each dorm is responsible for contacting the training department to register the employee for training; the treatment supervisor must also then document the training on the staff schedule.
On a monthly basis, the training director will provide the supervisors with a detailed report, indicating the total number of hours each employee has. The treatment supervisors will focus their attention on those employees who are below the targeted number of hours for the quarter; the treatment supervisor will schedule employees for training to ensure they meet the required hours.
The program manager will assist the training director in monitoring the process to ensure everyone meets the mandatory training hours.
Person Responsible: Training Director, Program Manager, and Treatment Supervisor
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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 review of client records, the facility failed to document complete personal histories in 4 out of 7 client records reviewed, specifically client records # 4, 5, 6, and 7. The legal history was incomplete in four client records, specifically # 4, 5, 6, and 7. The educational history was incomplete in client records #4, 5, 6, and 7. Recreational histories were incomplete in client records # 4, 5, 6, and 7.
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Plan of Correction
The clinical director will meet with the assessment specialists to provide suggestions for documenting client histories appropriately and effectively utilizing tools currently in place (i.e. the Comprehensive Client Interview and Family Assessment). The clinical director will then review the documents as they are completed; he will provide feedback and supervision to the assessment specialists as necessary during their monthly supervisory conferences.
Person Responsible: Clinical Director
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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 review of client records, the facility failed to document complete psychosocial evaluations in 4 out of 7 client records, specifically client records # 4, 5, 6, and 7. Psychosocial evaluations did not include an assessment of the client's assets/strengths in client records # 4, 6 and 7. Psychosocial evaluations did not include an assessment of the support systems in client records # 6 and 7. Psychosocial evaluations did not include an assessment of coping mechanisms in client records # 5 and 7. Psychosocial evaluations did not include an assessment of negative factors that may inhibit treatment in client records # 4, 5, 6, and 7.
Psychosocial evaluations did not include the clients's attitude toward treatment in client records # 5, 6, and 7.
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Plan of Correction
The clinical director will meet with the assessment specialists to provide suggestions for assessing historical information and documenting an assessment of the historical information in the integrated summary (psychosocial evaluation). In addition, the clinical director will provide feedback regarding ways in which the assessment specialists can document and assess the client's attitude toward treatment, coping mechanisms, and assets/strengths. The clinical director will then review all of the integrated summaries as they are completed; he will provide feedback and supervision to the assessment specialists as necessary during their monthly supervisory conferences.
Person Responsible: Clinical Director
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