INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15-17, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northwestern Human Services of Delaware County 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 January 15, 2009.
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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, the facility failed to document a core curriculum in clinical supervision in one of one personnel record.
Findings:
Nine personnel records were reviewed on December 15-16, 2008. A core curriculum in clinical supervision was required in one personnel record. The facility did not document a core curriculum in clinical supervision in personnel record # 3.
Personnel # 3 has not previously functioned for two years as a supervisor in the provision of clinical services.
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Plan of Correction
The NHS Administrative Services Unit of Delaware County will alert the Program Director of the date of the next 30 hour core curriculum for clinical supervision. The Program Director will assure compliance with this standard and alert the clinical supervisor as to when this training should be attended. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document at least 12 clock hours of training annually for project directors and facility directors in two of two personnel records.
Findings:
Nine personnel records were reviewed on December 15-16, 2008. At least 12 clock hours of training annually were required for project directors and facility directors in two of two personnel records. The facility did not document at least 12 clock hours of training annually in personnel records # 1 and 2.
Personnel record #1 documented 0 hours of training for the 2007-2008 training year.
Personnel record #2 documented 7 hours of training for the 2007-2008 training year.
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Plan of Correction
The NHS Administrative Services Unit of Delaware County will develop an annual training schedule for the program outlining at least 12 clock hour of on site training. Each project director will be required to attend the on site trainings.
The Executive Director will assure compliance with this standard through regular supervision. The ASU will ensure compliance with this standard through auditing of the employee credentialing record. |
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
Based on a review of personnel records, the facility failed to document at least 25 clock hours of training annually for counselors in one of one personnel record.
Findings:
Nine personnel records were reviewed on December 15-16, 2008. At least 25 clock hours of training annually were required for counselors in one of one personnel record. The facility did not document at least 25 clock hours of training annually in personnel record # 8.
Personnel record #8 documented 2 hours of training for the 2007-2008 training year.
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Plan of Correction
The NHS Administrative Services of Delaware County will develop an annual training schedule for the program outlining at least 25 hours of on site training. Each counselor will be required to attend the on site trainings. The NHS Administrative Unit of Delaware County will also alert the Program Director to possible trainings within the area which counselors can take advantage of. The Program Director will ensure compliance with this standard through regular supervision. The ASU will ensure compliance with this standard through auditing of the employee credentialing record. |
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
Based on a review of personnel records, the facility failed to document performance evaluations annually in three of five personnel records.
Findings:
Nine personnel records were reviewed on December 15-16, 2008. Performance evaluations were required to be completed annually on or before the date of hire anniversary date in five personnel records. The facility did not document annual performance evaluation on or before the date of hire anniversary date in personnel records # 1, 2 and 7.
Personnel record #1 date of hire 11/1/07, no performance evaluation documented at time of inspection.
Personnel record #2 date of hire 10/6/07, last performance evaluation completed 7/25/07.
Personnel record #7 date of hire 5/23/07, last performance evaluation completed 9/8/08.
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Plan of Correction
The Program Director and/or Clinical Supervisor will ensure that performance evaluations are completed on or before the date of hire anniversary. The NHS Administrative Services Unit of Delaware County will also alert the Program Director with a schedule of staff annual evaluations and through auditing of the employee record to ensure compliance with this standard. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment plan in five of six client records.
Findings:
Eight client records were reviewed on December 16-17, 2008. Individual Treatment plans were required in six client records. The facility did not document treatment plans within 30 days of admission as stated in their policy and procedures manual in client records # 1, 2, 3, 4 and 6.
Client record # 1 admitted 8/5/08, treatment plan documented 9/16/08.
Client record # 2 admitted 8/6/08, treatment plan documented 9/18/08.
Client record # 3 admitted 8/5/08, treatment plan documented 10/7/08.
Client record # 4 admitted 8/4/08, treatment plan documented 10/15/08.
Client record # 6 admitted 6/12/08, treatment plan not documented.
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Plan of Correction
All comprehensive treatment plans will be completed within 30 days of the client's admission into treatment. The Program Director and/or Clinical Supervisor will ensure compliance with this standard through regular supervision with the counselor and auditing of the counselor's clinical records. The ASU department will train clinical staff on the timeline for completion of the document. |
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 client records, the facility failed to document case consultation notes in three of six client records.
Findings:
Eight client records were reviewed on December 16-17, 2008. case consultation notes were required in six client records. The facility did not document a case consultation note every ninety days in client records # 1, 2 and 6.
Client record #1 admitted 8/5/08, case consultation not documented at time of inspection.
Client record #2 admitted 8/6/08, case consultation not documented at time of inspection.
Client record #6 admitted 6/12/08, case consultation not documented at time of inspection.
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Plan of Correction
All case consultations will be completed, minimally, at the 3,6,9 and 12 month anniversaries of the client's admission date. They will also be completed annually thereafter. The Program Director and/or Clinical Supervisor will ensure compliance with this standard through regular supervision with the counselor and the auditing of the counselor's clinical records. By 4-15-09, the ASU department will train clinical staff on timeline for completion of the document. |
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 a review of client records, the facility failed to document follow-up information in three of three client records.
Findings:
Eight client records were reviewed on December 16-17, 2008. Follow-up information was required in three client records. The facility did not document follow-up information within 30 days of discharge as stated in the facility ' s policy and procedures manual in client records # 6, 7 and 8.
Client record #6 discharged 10/27/08, follow-up not documented at time of inspection.
Client record #7 discharged 10/24/08, follow-up not documented at time of inspection.
Client record #8 discharged 10/24/08, follow-up not documented at time of inspection.
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Plan of Correction
The Program Director will ensure that follow up is completed by the counselor of record for each discharged client. The Program Director and/or Clinical Supervisor will ensure compliance with this standard through regular supervision with the counselor and auditing of the counselor's discharged clinical records. By 4-15-09, the ASU department will train clinical staff on the timeline for follow-up procedures. |