INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 27, 2006 to June 29, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on July 31, 2006.
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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
Employee 7 did not have documentation of counselor qualifications. All staff should have documentation of degree and experience which meet the counselor qualifications. If the employee does not have appropriate documentation, they will be reviewed as a counselor assistant at the appropriate level.
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Plan of Correction
Information on this student will be faxed or mailed to the Division asap. Awaiting return email on who to send it to. 8-14-06 |
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
Feedback was not consistently documented in employee charts. Feedback for all completed training must be consistently documented.
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Plan of Correction
The Stairways training program coordinator left the agency and was replaced a few months later. The new coordinator has substantially revised the agency training program but is aware of the D&A requirements. Effective immediately, staff will continue to document and provide the necessary feedback to the training coordinator. The coordinator will track and maintain this information in a database and by original hardcopy. The information will be available to the inspector for review. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Certificates for training were not documented for training year 2005. Documentation must be presented for training for all employees.
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Plan of Correction
Simlar to citation # 2, the Stairways training program coordinator left the agency and was replaced a few months later. The new coordinator has substantially revised the agency training program but is aware of the D&A requirements. Effective immediately, staff will continue to document and provide the necessary training information to the training coordinator. The coordinator will track and maintain this information in a database and by original hardcopy. The information will be available to the inspector for review.
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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
Alternate exit routes were not clearly documented on fire drill logs.
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Plan of Correction
The facility maintenance staff member conducting the fire drills is responsible for conducting the drill in accordance with D&A regs., e.g. using and documenting alternate routes. In this case, he has conducted the drills according to appropriate procedure; however, he had failed to document same. Effective immediately, he will document the use of alternate routes etc. in the fire drill log. |
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
There was no documentation showing that the annual report was available to the public.
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Plan of Correction
While the report is available for public viewing, there was no documentation of same. The current annual report is slated for board review on 7-28-06. It will then be posted on the Stairways website and an ad will be placed in the local paper stating it is available for review on the web or in person at the main agency. The corporate compliance officer will ensure that the above actions occur and that copies of documentation are available to the inspector. |
709.22(e)(2) 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:
(2) A financial statement of income and expenses.
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Observations
No financial statement was documented in the annual report.
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Plan of Correction
In last year's annual report, a financial section was not present. This year's report , 2005/2006, includes a financial section in accordance with D&A regs. The report is scheduled for review by the board on 7-28-06. The above actions and documentation will be monitored by the facility director. |
709.22(e)(3) 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:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
No statement disclosing the names of officers, directors or principal shareholders was included in the annual report.
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Plan of Correction
The board members information was available through HR and the administrative secretary but was not included in the annual report. For the current annual report, 2005/2006, the admin. secretary will include a list of board members and pertinent information. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Employee #5 did not have an annual evaluation completed.
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Plan of Correction
Employee #5's supervisor was placed on administrative leave and has since left the agency. She did not complete an annual evaluation on the employee prior to leaving the agency. The new supervisor and HR director are currently working on a plan to complete the evaluation. This evaluation will be completed within the next 30 calendar days and will be available for future inspections. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Policies for employee rights are documented in the manual. Employee personnel files reviewed did not include documentation verifying orientation to employee rights.
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Plan of Correction
The HR director and staff will orient all new staff members to employee rights and document same in the employee's personnel file. Current employees will also receive attention and documentation in this area from HR staff. The documentation will be posted in employee files for future inspection review. |
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
In clinical charts #1, 3, and 4, the notice of privacy practice form included a signature line for minors over the age of 14. The implication is that for clients under 14 years of age the consent of a parent or guardian would be required. State law at 71 P. S. subsection 1690.112 stipulates that not withstanding any other provisions of law, minors may seek treatment on their own, without parental consent. Federal regulations at 42 CFR Part 2, Subpart B, subsection 2.14(b) states that in states where minors may seek treatment on their own without parental consent, only the minor may consent to the release of information.
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Plan of Correction
The parental line had been removed from all forms in the past; however, with ongoing form revisions etc. it had somehow crept back into some of the charts as noted. The facility director will ensure that this parental line is once again removed. It will be removed asap but no later than 30 calendar days from today. In the meantime, therapists were instructed to strike a line through this sentence. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
In client chart #2 a request to obtain information was documented, but no consent to release information was completed stating that the client was allowing the agency to identify them as a participant in the drug and alcohol treatment program. No consent to release information form was documented in the clinical chart, the request to obtain information exceeded the limits imposed at 4 Pa. Code subsection 255.5(b), by identifying the client as a participant in a drug alcohol treatment program. A letter filed in client chart #4 indicated that a release of client identifying information had been made, but there was no corresponding release of information.
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Plan of Correction
In this situation, the release was to another supervisor within another Stairways program; however, the information should not have been released without an appropriate ROI. The facility director has spoken with all therapists regarding ROI's and the appropriate ROI will be secured on all clients from this point forward. The facility director and corporate compliance officer will monitor therapists compliance with the ROI issue. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
In client chart #3, 1, and 4 the purpose for the release of information was unclear and not consistent. The purpose should align with the agency or person the release was addressed to.
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Plan of Correction
In the charts reviewed, the purpose for release was vague to an outside observer. The therapists understood the language and references they were making but did need to be clearer. The facility director has already spoken with all therapists regarding clarity, consistency and documentation of purpose for ROI's. The facility director and corporate compliance officer will monitor ongoing compliance of the therapists on this issue. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
All client charts included drug and alcohol histories. The drug and alcohol histories did not consistently include the client's progression of use.
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Plan of Correction
Inconsistency was found regarding the clients progression of use. This section of the record is currently under review for improvement. The facility director has already spoken with all therapists regarding consistency in delineating clients progression and it will be documented in a narrative fashion. Any further improvments to this section of the record will occur within the next 30 calendar days and will be an ongoing part of all charts in the future. The facility director and corporate compliance officer will monitor all therapists compliance with this issue. |
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
Psychosocial evaluations were consistently documented in all charts reviewed. The psychosocial evaluations in all charts reviewed failed to consistently document a clear composite picture, client problems/needs, and counselor conclusion impressions. All areas should be consistently documented.
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Plan of Correction
In the charts reviewed, inconsistency was found in the conclusion section. The facility director has already spoken with all therapists regarding the need to specifically address all sections required in the conclusion. There is a need to beef up the impression or prognosis section and how amenable the client is to treatment. Therapists have already begun appropriate documentation to address this issue. The facility director and corporate compliance officer will monitor therapists compliance in this area. |