INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 18, 2008 through November 19, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights Inc. 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 December 18, 2008.
|
Plan of Correction
|
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.
|
Observations
Based on the review of personnel records and the facility's policy and procedure manual, the facility failed to document feedback forms in four of six personnel records.
Findings:
Six personnel records were reviewed on November 19, 2008. The facility's policy (What is the policy name)states that feedback forms will be completed within 7 days of every training, whether they are internal or external trainings. Feedback forms were required in six personnel records. The facility did not document feedback forms in personnel records #1, 2, 3 and 4.
|
Plan of Correction
The Executive Director revised policy to eliminate the seven (7) day time frame for staff to submit their feedback forms from trainings attended. The Executive Director will review the revised policy at the facility staff meetings at both facilities. At that time the requirement to submit a feedback form for all external trainings along with certification document. The support person who reviews the training binder on a quarterly basis will confirm that feedback forms are submitted with all external and internal trainings. Upon submitting evidence of a training by a staff member, the support person will make sure that the feedback form is attached; if not, the feedback form will be required to be completed by the staff member while the training experience is still fresh in their minds. This plan of action is the ultimate responsibility of the Executive Director and will be completed in full by December 17th, 2008. |
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.
|
Observations
Based on the review of personnel records, the facility failed to ensure that all staff received a minimum of 4 hours of TB/STD training within the required (what's the required time) amount of time in one personnel record. 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.
Findings:
Six personnel records were reviewed on November 19, 2008. The facility did not document required TB/STD training in personnel record #6.
Employee # 6 was hired January 3, 2006 and was required to have TB/STD training by January 3, 2008. This was not documented in the personnel record reviewed and the facility did not produce documentation of the completion of the training.
|
Plan of Correction
In order to rectify the current situation, the employee who did not receive this training was registered for the next available BDAP sponsored event. The training will take place on January 15, 2009 at the Sheraton Harrisburg/Hershey.
To prevent further omissions of the required training for any staff member, the following plan will be implemented. The senior support staff person at the Lemoyne facility, who maintains the staff training and credential binder, reviews the tally of staff training hours on a quarterly basis. Upon conducting these quarterly reviews and providing a status report to the Executive Director, special attention will be made to be aware of any staff member who has not obtained the required trainings. At that time, a training event will be located and designated to be attended by any staff member in advance of the time frame requirement.
One (1) year ? clinical staff
Two (2) years ? administrative, business office, and support staff
This action is the ultimate responsibility of the Executive Director who will monitor this activity. The next quarterly review will be due the first week of January 2009.
|
704.12(a)(5) LICENSURE Partial Hosp Ratio
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
|
Observations
Based on the review of the staffing requirements facility summary report, the facility failed to meet a minimum of one full-time equivalent (FTE) counselor who provides direct counseling services to every ten clients.
Findings:
Based on the hours of clinical services listed for counselors and the number of clients documented by the Project Director and presented to the Licensing Specialist on November 18, 2008, it was determined that the client to counselor ratio for the partial hospitalization activity was 19:1.
This ratio calculation was based on the report by the facility that a total of 24 clinical service hours per week were provided by a clinical supervisor and three counselors. The facility reported a 40 hour work week. Twenty-four hours of a 40 hour work week represents an FTE of 0.6. The facility reported a total of 11 active clients in the partial hospitalization activity which resulted in a client to counselor ratio of 19:1. The facility reported that all remaining clinical service hours provided by qualified clinical staff were used for the outpatient treatment activity.
|
Plan of Correction
The Executive Director contacted the Division of Licensing on December 5, 2008 to obtain instruction on properly completing the Staff Requirement Facility Summary Report in the section that factors the 'client/couselor ratio'. I corrected my error in not including a total twenty-one (21) group hours that are devoted to partial hospitalization clients. During future site visits the Executive Director will be more careful in factoring the distribution of client hours. |
709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
Based on the review of client records, the facility failed to document medical histories in two of four client records.
The findings include:
Four client records were reviewed on November 18, 2008. Medical histories were required in four client records. The facility policy states that medical histories will be completed by the first session. The facility did not document medical histories at all in two of four client records where required. Client #1 was admitted on 8/25/08 and client #2 was admitted on 10/13/08. Medical histories were not documented in either client record as of November 18, 2008, the date of the licensing inspection.
|
Plan of Correction
The program supervisor will review with the counseling staff at the staff meeting on 1/21/09 that all clients presenting for their initial drug and alcohol evaluation, need to complete New Insights standard medical history prior to their session. The Clinical Supervisor will also inform all front office staff that when scheduling a client's inital evaluatin, the client should arrive 15 minutes early to complete the medical history form. The clinical supervisor will randomly review 1 partial hospitalization chart from each clinician for compliance during clinical supervision. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to complete psychosocial evaluations in four of four client records.
Findings:
Four client records were reviewed on November 18, 2008 for the partial hospitalization treatment activity. Psychosocial evaluations were required in four client records. The psychosocial evaluations failed to include clinical assessments of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, the client's attitude toward treatment and overall impressions/conclusions in client records #1, 2, 3 and 4.
|
Plan of Correction
The program supervisor will review with the clinical staff at the staff meeting on 1/21/09 how to properly complete the final page of the psycho/social profile, which New Insights refers to as "the composite". An example of a properly completed composite will be presented to the clinical staff for review and discussion. The clinical supervisor will randomly review 1 partial hospitalization chart from each clinician for compliance during clinical supervision. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document complete psychosocial evaluations in five of nine client records.
Findings:
Thirteen client records were reviewed from November 18, 2008 through November 19, 2008 for the outpatient treatment activity. Nine of those client records required psychosocial evaluations. The psychosocial evaluations did not document a clinical evaluation of the clients' assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the client's attitude toward treatment in client records #5, 6, 7, 12 and 13.
|
Plan of Correction
The program supervisor will review with the clinical staff at the staff meeting on 1/21/09 how to properly complete the final page of the psycho/social profile, which New Insights refers to as "the composite". An example of a properly completed composite will be presented to the clinical staff for review and discussion. The clinical supervisor will randomly review 1 outpatient chart from each clinician for compliance during clinical supervision. |
709.93(a)(5) 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:
(5) Progress notes.
|
Observations
Based on the review of client records, the facility failed to document complete progress notes in five of nine client records.
Findings:
Thirteen client records were reviewed on November 18, 2008 through November 19, 2008. Complete group progress notes were required in nine of the thirteen client records.
There was no assessment of the individual clients' participation in the group treatment sessions in nine of the nine client records where group progress notes were required.
|
Plan of Correction
Since some of the group notes that were assessed were not therapeutic groups, but were 1 hour educational lectures, the client's individual assessment would not be indicated in those notes. The program supervisor will revise the group note that is used for those lectures and indicate at the top of the note that it is an educational lecture, not a therapeutic group. This will be done by the time of the staff meeting on 1/7/09. The program supervisor will also review with the clinical staff at the staff meeting on 1/21/09 that the individual client's participation in group, is well. This will include, but not limited to the client's participation in group, attentiveness and a general statement as to the clinician's impression as to the client's progress in treatment. |
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.
|
Observations
Based on the review of client records and the facility's policy and procedure manual, the facility failed to document case consultation notes in two of three client records.
The findings include:
Thirteen client records were reviewed on November 18, 2008 through November 19, 2008 Case consultation notes were required in three client records. The facility's policy states that case consultations are to be done every 90 days from the clients admission date. The facility did not document case consultation notes in two of three client records where required.
Client record #8 includes documentation of an admission date of 8/3/08, but there was no documentation of case consultations as of November 18, 2008.
Client record #10 included documentation of an admission date of 7/22/08, but there was no documentation of case consultations in client records as of November 18, 2008.
|
Plan of Correction
The clinical supervisor will remind the clinical staff at the staff meeting on 1/21/09 that case consult/reviews are due no later than 90 days from the admission date and no later than every 90 days there after. The clinical staff will be encouraged to do any up and coming case reviews during each staff meeting. Each counselor is required to maintain an active client list with required dates of initial treatment plans, treatment plan updates, and case reviews. The clinical supervisor will review with each clinician during clinical supervision that clinician's client list and any pending case reviews. |
709.11(a) LICENSURE Subchapter B.Licensing Procedures.Application
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
|
Observations
Based on a review of the facility WEB site, television advertisements and a review of program material, the facility is operating an unlicensed residential treatment activity and has failed to apply for a residential license.
The findings include:
The facility advertises that it provides a "Residential - Partial Hospitalization" activity. The facility does not hold a license for residential treatment activities, nor has the facility made application for a residential treatment activity. The facility has aired television advertisements in the Harrisburg area over local television media specifically marketing the "Residential - Partial Hospitalization" treatment activity. The facility also markets this activity on the facility WEB site. A feature article in the November 9, 2008 edition of The Patriot News, Section C, pages C1 and C8 reports that the facility provides "a wide range of drug and alcohol treatment programs and services. It's licensed by the state Department of Health." The article also reports that "The facility has 14 beds." The facility does not hold a license for residential treatment activities from the Department of Health. The facility has not applied for a license for the residential treatment activity.
|
Plan of Correction
The Executive Director did not believe he was misrepresenting this level of care by avoiding the term inpatient. I do understand how the term "residential" could be confused with traditional inpatient treatment. In acknowledging this possibility, the Executive Director will change all the program literature, internal forms, and website information to not include the term "residential". The Executive Director will also refrain from using that term with any future editorial (or) advertisement with the various forms of media. This task will be the prime responsibility of the Executive Director and in conjunction with the
Communications Coordinator. This task will be addressed in two parts: (1st) part - immediate- no future media promotion that would include the word "Residential". (2nd) part-by end of December 2008-change all literature to remove term "residential". |
709.14(b)(4) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(4) Change in activity/discontinuance of an activity.
|
Observations
Based on a review of the facility WEB site, television advertisements and a review of program material, the facility is operating an unlicensed residential treatment activity.
The findings include:
The facility advertises that it provides a "Residential - Partial Hospitalization" activity. The facility does not hold a license for residential treatment activities, nor has the facility made application for a residential treatment activity. The facility has aired television advertisements in the Harrisburg area over local television media specifically marketing the "Residential - Partial Hospitalization" treatment activity. The facility also markets this activity on the facility WEB site. A feature article in the November 9, 2008 edition of The Patriot News, Section C, pages C1 and C8 reports that the facility provides "a wide range of drug and alcohol treatment programs and services. It's licensed by the state Department of Health." The article also reports that "The facility has 14 beds." The facility does not hold a license for residential treatment activities from the Department of Health. The facility has not notified the Department that it provides a residential treatment activity service or that it changed the partial hospitalization activity to a residential treatment activity.
|
Plan of Correction
The Executive Director did not believe he was misrepresenting this level of care by avoiding the term inpatient. I do understand how the term "residential" could be confused with traditional inpatient treatment. In acknowledging this possibility, the Executive Director will change all the program literature, internal forms, and website information, to not include the term "residential". The Executive Director will also refrain from using that term with any future editorial (or) advertisement with the various forms of media. This task will be the prime responsibility of the Executive Director and in conjunction with the Communications Coordinator. This task will be addressed in two parts: (1st) part - immediate- no future media promotion that would include the word "residential". (2nd) part- by end of December, 2008 - change all literature to remove term "residential". |