INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 19, 2007 to June 21, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 23, 2007.
|
Plan of Correction
|
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.
|
Observations
Employee #3's major was not reviewed by Department to determine if it qualifies as a related major for the position of counselor.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(c)(1) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(1) A method of selection for membership.
|
Observations
The facility failed to provide clear documentation of the method of selection for membership.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(c)(2) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(2) Qualifications for membership.
|
Observations
The facility failed to provide a policy describing the qualifications for membership.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(c)(4) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(4) Frequency of meetings.
|
Observations
The facility failed to provide clear documentation of how and when meetings are scheduled.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
|
Observations
The facility failed to provide documentation of the governing body selecting a project director responsible to the governing body.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(d)(2) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(2) Identifying the project's purpose and philosophy.
|
Observations
The facility failed to provide documentation identifying the project's purpose and philosophy.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.24(a)(1) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(1) Defined target population.
|
Observations
The facility failed to provide a defined target population.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(a)(2) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(2) Utilization of volunteers.
|
Observations
The facility provided two distinct, conflicting policies in reference to the utilization of volunteers.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(e)(2) 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:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
|
Observations
The facility failed to provide documentation that employees were oriented to their complete rights to request the removal or correction of inaccurate, irrelevant, outdated or incomplete information, rather the orientation was limited the employee's right to only request the removal of incorrect information.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
The facility failed to correctly document the specific information to be disclosed in client record #8 and exceeded that allowed by 4 PA Code 255.5 in client record #6. In eight of eight client records reviewed, the specific information to be disclosed, while allowed by regulation, was not congruent with the purpose of the consent.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
The facility failed to include the correct purpose on the consent to release information in eight of eight client records reviewed. In particular, this was on the consents for probation and other treatment program referrals.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.29(a) & (b) LICENSURE Retention of Client Records
709.29. Retention of client records.
(a) Client records, whether original, reproductions or microfilm, shall be kept on file for a minimum of 4 years following the discharge of a client.
(b) If the project discontinues operation, it shall make known to the Department where its records are stored.
|
Observations
The facility failed to provide one distinct policy regarding the retention of client records, but rather had three different, distinct, and conflicting policies regarding the retention of client records.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
|
Observations
The policy and procedure manual provided by the facility states the physician is to sign verbal orders within 48 hours rather than 24 hours as required.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
|
Observations
The facility failed to provide complete information in the policy for the inspection of storage areas. Specifically, the facility failed to address time frames or how or by who the inspection was completed.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(c)(7) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(7) Medication errors and drug reactions.
|
Observations
The facility failed to provide a policy regarding medication errors and reactions, but instead provided two different, distinct, and conflicting policies regarding medication errors and drug reactions.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
The facility failed to ensure the documented personal medical histories included symptoms and illnesses of the patient in seven of seven client records reviewed.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
The facility failed to provide individualized preliminary treatment plans in eight of eight client records reviewed.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
The comprehensive treatment plans failed to include individualized, measurable action steps to achieve the formulated treatment goals, for seven of seven (#2, 3, 4, 5, 6, 7, 8) client records reviewed.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Treatment plans failed to include the type and frequency of services the patient needed in four of seven ( #4, 5, 6, 7 )client records reviewed.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(3) 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:
(3) Proposed type of support service.
|
Observations
The treatment plans failed to include the proposed support services the patient needed in seven of seven (#2, 3, 4, 5, 6, 7, 8) client records reviewed.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
The facility failed to provide documentation to determine whether counseling services are being provided according to the individual treatment plan in six of eight client records reviewed. In particular, there were no counseling notes for client #1, client #2 did not receive treatment services as required in the treatment plan and client #3 had no documentation of counseling services since May 16, 2007. There was no documentation of type and frequency of services to measure compliance in client records #4, 5, 6 and 7.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
The discharge summaries in two of two (#7, 8) client records reviewed failed to describe the reasons for treatment. In one of two (#8) discharge summaries reviewed, the focus was on the reason for discharge and not the client's response to treatment. Client record #8 also failed to document what services were offered to the client and the client's status upon discharge.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
The facility failed to provide follow-up documentation for two of two (#7, 8) client records reviewed.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |