INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 22-24, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Northern Tier Counseling, 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:
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Plan of Correction
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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
Based on a review of personnel files on October 22-24, 2019, the facility failed to follow the procedure in place to collect feedback forms on completed trainings. There were no completed feedback forms associated with the trainings for the training year September 2018 - August 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall create a new departmental policy that states that when a training is attended by a staff member within the Drug and Alcohol Department and Continuing Education Credits (CEUs) are received, a training feedback form must be completed and turned into the Human Resources (HR) Director along with the CEUs. If the training feedback form is not completed and turned in along with the CEUs, the HR Director shall not accept these CEUs into the staff member's personnel file until the feedback form is completed. In these instances, the HR Director will immediately notify the Project Director so (s)he can follow up with the specific staff member or staff member's Clinical Supervisor in individual and/or group supervisions. The new policy shall go into effect on 12/1/19 as to be reviewed by the Compliance Committee. The Project Director shall put this as a primary agenda item for Group Supervision as to convey the information to the department and address any questions or concerns by the department at that time. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) 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, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a physical site inspection on October 22-24, 2019, the facility failed to include information on the annual report disclosing the names of officers, directors and principal shareholders, when applicable. As reported in the local newspaper, the annual report was located in the facility's lobby for public viewing but was missing this required element.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director shall include the names of officers, directors and principal shareholders, when applicable, for the creation, reporting, and public viewing purposes, in regards to the Annual Report. This shall be completed in the form of an Addendum Page signed off by the President of the Board, to the latest Annual Report. This information shall be clearly labeled for ease of informational transparency in the Annual Report and shall be completed on 11/25/2019. All Annual Reports thereafter shall also follow this protocol. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records on October 22-24, 2019, the facility failed to ensure that there was appropriate documentation of written acknowledgement by the client that the client had been made aware of their rights, including facility may not discriminate based on the client's sex, in client records #'s 1, 2, 3, 4, 5, 6 and 7.
Client #1 was admitted on November 8, 2018 and discharged on April 30, 2019.
Client #2 was admitted on June 11, 2019 and discharged on September 23, 2019.
Client #3 was admitted on July 26, 2019 and was still active at the time of the inspection.
Client #4 was admitted on September 11, 2019 and was still active at the time of the inspection.
Client #5 was admitted on September 13, 2019 and was still active at the time of the inspection.
Client #6 was admitted on May 7, 2019 and was still active at the time of the inspection.
Client #7 was admitted on August 27, 2019 and discharged on October 3, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director made a change to the verbiage in the Policy on Client Rights document in the Electronic Health Record (EHR) on 10/23/2019 to include that the facility may not discriminate based on the client's sex. All new clients entering into the Drug and Alcohol Program from 10/23/19 and on will read and review this document with their counselor during the intake/admission procedures. The Counselor is responsible for the advisement of client rights as stated in the document. All clients that have admission dates prior to 10/23/19 and are still active in the Drug and Alcohol Program, including Client #3; Client #4; Client #5; and Client # 6, shall be identified using the EHRs report software and distributed to all members of the Drug and Alcohol Department by the Project Director. The topic will be addressed for informational and feedback purposes at Group Supervision by the Project Director to the departmental staff. The specific Counselor of all identified clients shall then read and review this updated document in individual sessions so that the client is made aware that the facility cannot discriminate based on the client's sex. Our goal is to start immediately and to capture all client signatures of existing clients by 1/13/20. It is to be noted that Client #1; Client #2; and Client #7 were all discharged prior to this update being made, but upon any form of re-admission into the department, will be following the same protocol as outlined above for new clients on 10/23/19 and on. |
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 on October 22-24, 2019, the facility failed to provide a complete client record, which is to include a case consultation in client record #'s 1, 2 and 7.
Client #1 was admitted on November 8, 2018 and discharged on April 30, 2019.
Client #2 was admitted on June 11, 2019 and discharged on September 23, 2019.
Client #7 was admitted on August 27, 2019 and discharged on October 3, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has added a question into the Discharge Summary on 10/23/19 that specifically asks if a Case Consultation was completed before discharge. If the Counselor selects 'Yes', then an additional question asking the date(s) of each Case Consultation shall be asked on the document. This shall serve as a written reminder to all Counselors that a Case Consultation is a requirement of the complete client record. This topic will be addressed in a Group Supervision by the Project Director as a primary agenda item for informational and feedback purposes with the departmental staff. The Project Director shall additionally double-check the accuracy of all reported Case Consultations upon the final signature of the Discharge Summary. All discrepancies caught using this double-check methodology by the Project Director will be sent to the Counselor completing the Discharge Summary for feedback and re-submission. It should be noted that Client #1; Client #2; and Client #7 were all discharged before this change could take place, but upon any form of re-admission into the Drug and Alcohol Program, will follow the same protocol as outlined above for clients 10/23/19 and on. |