INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9 and 10, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, 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 May 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 and training records on 4/9/08, the facility failed to document that the clinical supervisor completed a core curriculum in clinical supervision. The clinical supervisor, hired in 10/07, did not have documentation of 2 years of prior experience as a supervisor in the provision of clinical services.
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Plan of Correction
Clinical Supervisor will complete core curriculum when it is offered (in June, according to BDAP.
The Project Director will be responsible for ensuring that the Program Coordinator completes the curriculum. |
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
Based on a review of personnel records on April 9, 2008, the facility failed to document that two counselors met the qualifications for the position of counselor, #5 and #6.
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Plan of Correction
One of the two counselors referenced has produced his Bachelor's degree diploma, and this was sent on to DAPL. The second counselor is now a Counselor Assistant.
The Program Coordinator forwarded the diploma to DAPL; She will also provide weekly supervision for the Counselor Assistant, and will arrange observation of his work.
The Ptogram Director will ensure that all new hires produce the appropriate documentation of their credentials before beginning work. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of training records on 4/9/08, the facility failed to document complete training plans in six of seven records reviewed, #2, 3, 4, 5, 6 and 7. Individual training plans did not identify specific subject areas.
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Plan of Correction
All current staff will develop revised training plans, which will identify specific topics, and time frames. All new hires will have the training Plans developed with the same criteria.
The Program Coordinator will be responsible for developing the revised Training Plans by the time fram stated above. |
704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of administrative documents on April 9, 2008, the facility failed to document client to counselor ratios did not exceed 35:1. The overall client to counselor ratio was 160:1. The hours for two counselors could not be included in the calculation since they did not meeting the qualifications for their positions. The FTE ratio for counselor #5 was 40:1. The FTE ratio for counselor #6 was 62:1.
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Plan of Correction
As referenced above, one of our Counselors has produced his Bachelor's degree, and the Program Coordinator has forwarded that to DAPL. This should bring out client ration to within acceptable limits.
The Program Director will ensure that all new hired document their credentials before beginning work. |
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
Based on a review of the fire drill record on April 10, 2008, the facility failed to document that alternate exit routes were used during fire drills from August 2007 through March 2008.
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Plan of Correction
All future fire drill records will document the alternate exits that were used in the drill.
The Program Director will ensure that this happens during ther monthly fire drills. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documents on April 9, 2008, the facility failed to document time frames other than "ongoing" for the 2008 project goals and objectives.
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Plan of Correction
Future HBHS Project Goals and Objectives will indicate specific time frames for completion.
The Project Director will be responsible for developing this properly. |
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 on April 9, 2008, the facility failed to document that the audit for the 2006/2007 fiscal year was completed within the required time frame. The audit was due December 31, 2007. It was dated March 24, 2008.
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Plan of Correction
Holcomb Behavioral Health Systems ' annual Fiscal Audit is done at the behest of Chimes, Inc., our parent company.
The Program Director will reemphasise with the audit firm the importance of
completing the audit by the end of the calendar year. |
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
Based on a review of client records on April 10, 2008, the facility failed to obtain an informed and voluntary consent from the client in one of five records reviewed, #2. The specific information to be disclosed on the consent to release information form to Magellan exceeded that allowed under the limitations imposed by 4 Pa. Code 255.5. The specific information to be disclosed included psychological evaluation, psychiatric evaluation and treatment/aftercare plan.
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Plan of Correction
Program Coordinator, Intake Counselor, and assistant Counselor all are schedule for Confidentiality Training
6-9-08, at Mirmont. The Program Director will be responsible for ensuring completion of this training.
The specific Consent form referenced in the citation was updated correctly.
The Clinical Supervisor will be responsible for ensuring that all future releases are filled out appropriately. This issue will be addressed during ongoing supervision. |
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 client records on April 10, 2008, the facility failed to document complete psychosocial evaluations in five of five client records reviewed, #1, 2, 3, 4 and 5. 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 treatment.
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Plan of Correction
Clinical Supervisor provided training to staff to ensure that all future assessments include a clinical assessment of the client's assets/strengths, support systems, and negative factors that may impede treatment.
The Clinical Coordinator will review this issue periodically in supervision. |
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 client records on April 10, 2008, the facility failed to document treatment plan goals stated in terms of measurable criteria in five of five client records reviewed, #1, 2, 3, 4 and 5.
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Plan of Correction
Clinical Supervisor provided Training on effective documentation in writing Treatment Plans, with an emphasis on creating measurable goals.
This issue will be addressed in an ongoing manner in Clinical Supervision, and ongoing trainings; The Clinical Supervisor will review Treatment Plans weekly to ensure compliance. |
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 client records on April 10, 2008, the facility failed to document a complete treatment plan update in two of three records reviewed, #1 and 3. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the treatment plan.
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Plan of Correction
The Clinical Supervisor will monitor treatment plans weekly to ensure compliance. Training has been provided by the Clinical Supervisor to instruct staff to include assessment of progress in each Treatment Plan update; this issue will also be addressed in ongoing supervision. |