INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7 and 8, 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 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 September 8, 2008.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records on August 7, 2008, the facility failed to document that the lead counselor completed a core curriculum in clinical supervision.
Finding:
The lead counselor, hired on 5/6/08, did not have documentation of 2 years of prior experience as a supervisor in the provision of clinical services. There was no documentation of completion of the core curriculum in clinical supervision.
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Plan of Correction
The Project Director will assure that the Lead Counselor complete the state approved core curriculum in clinical supervision by September 30, 2008 and documentation of the completion of the core curriculum will be maintained in the counselor's record; documentation will include the date, total training hours and location (provider) of the training. |
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 three personnel records, The facility failed to document HIV/AIDS training in one of one personnel records reviewed.
Finding:
There was no documentation of HIV/AIDS training in personnel record # 1.
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Plan of Correction
The Project Director shall assure that all staff receive HIV/AIDS training within 30 days of hire. Current staff in need of HIV/AIDS training will receive training by September 30, 2008. |
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 8/7/08, the facility failed to document that the general public was made aware of the availability of the annual report for fiscal year 2007.
Finding:
There was no documentation demonstrating that the general public had been made aware of the availability of the annual report.
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Plan of Correction
The Project Director shall assure that the annual report is made available to the general public within 6 months of the close of the fiscal year. The annual report will be publicized in a local newspaper every year as required by state regulations. |
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 8/7/08, the facility failed to document an audit for FY 2007.
Finding:
There was no documentation of an audit for the fiscal year 2007. The documentation was due by June 30, 2008.
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Plan of Correction
The Project Director shall assure that the facility obtain an audit within 6 months of the close of every fiscal year. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records on 8/8/08, the facility failed to demonstrate efforts toward informing clients of their rights for inspecting his/her own records, appealing a decision limiting access to his/her records, requesting the correction of inaccurate, irrelevant, outdated or incomplete information from his/her records; and to submit rebuttal data to his own records in six of six client records reviewed.
Findings:
There was no documentation demonstrating that clients were informed of their rights was missing form client records # 1, 2, 3, 4, 5 and 6.
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Plan of Correction
The Project Director shall assure that client records contain documentation to verify that clients are informed of their rights. The Project Director will develop a form for client signature and date to verify that the client is informed of his/her rights. The Project Director shall train staff on the use of this form at time of hire. Current staff will be trained on the use of the form by 9/30/2008. |
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 seven client records, seven were required to have psychosocial evaluations. The facility failed to document complete psychosocial evaluations in seven of seven of seven client records reviewed.
Finding:
Psychosocial evaluations were a repeat of historical data and did not include a clinical assessment of the client's assets/strengths, support systems and negative factors that may inhibit the potential for treatment in client records # 1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
The Project Director shall assure that complete psychosocial evaluations are provided for each client and that the evaluations are documented in the client record. The Project Director shall provide training on the psychosocial evaluations to current staff by 9/30/2008 and to new staff within 2 days of hire. All clinical evaluations will include a clinical assessment of the client's strenths/assets, support systems and negative factors that may inhibit the potential for treatment
Steps the facility will take to assure that this deficiency does not recur include auditing of all client charts on a bi weekly basis by the Project Director; further, Clinical staff through post training testing will demonstrate comprehension and mastery of this standard and as such will be held accountable through formal disciplinary action for failure to fully comply with this standard. |
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 seven client records, six were required to have comprehensive treatment plans. The facility failed to document treatment plan goals stated in terms of measurable criteria in five of six client records reviewed.
Finding:
The treatment plan goals were not measurable in client records # 1, 2, 4, 6 and 7.
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Plan of Correction
The Project Director shall assure that treatment plans include measurable criteria. The Project Director shall revise treatment planning forms to include measurable criterial and shall train staff on completing treatment plans to include measurable criteria by 9/30/2008. New staff will be trained on the treatment plan forms within 2 days of hire.
Steps to be taken by the facility to ensure that this deficiency will not recur include the Project Director will audit all client files on a bi-weekly basis to assure that comprehensive treatment plans include measurable criteria |
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 seven client records, three were required to have treatment plan updates. The facility failed to document a complete treatment plan update in three of three client records reviewed.
Finding:
Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the treatment plan in client records # 1, 4 and 7.
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Plan of Correction
The Project Director shall assure that treatment plan updates are completed and the updates will include an assessment of the client's progress in relationship to the stated goals of the treatment plan. The Project Director shall train staff on completion of updates by 9/30/2008 and new hires will be trained within 2 days of hire on the treatment plan update.
Steps the facility will take to assure that this deficiency will not recur include the Project Director will audit all client charts on a bi-weekly basis to assure that treatment plan updates are developed in accordance with the schedule established by state standards. |
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 seven client records, three were required to have case consultation notes. The facility failed to document case consultation notes in three of three client records reviewed.
Finding
Case consultation notes were missing from client records # 1, 4 and 7.
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Plan of Correction
The Project Director shall assure that all client records contain case consultation notes
Steps the facility will take to assure that this deficiency shall not recur include the Project Director shall conduct a bi-weekly audit of all client records to assure that case consultation notes are included in all client records where required as per state standards. |
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 seven client records, six were required to have a physician's signature on treatment plans. The facility failed to document a physician's signature on treatment plans in six of six client records reviewed.
Finding:
Documentation of the physician's signature on treatment plans and treatment plan updates was missing from client records # 1, 2, 4, 5, 6 and 7.
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Plan of Correction
The Project Director shall assure that the physician signs each treatment plan |