INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on February 13 & 16, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, John F. Kennedy Behavioral Health Center 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on the review of the "Staffing Requirements Facility Summary Reports" completed by each facility in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
The findings include:
The "Staffing Requirements Facility Summary Reports" for each of the two facility's that make up the Project were reviewed from February 13, 2012 through February 16, 2012. The "Staffing Requirements Facility Summary Reports" completed by the facility on 2/13/2012 and signed on 2/13/2012, listed a combined total of 14 counselors who are providing drug and alcohol counseling. The total number of drug and alcohol counseling hours per week provided by the counselors equates to 14 FTE counselors within the project, and therefore the project is required to have at least one full-time clinical supervisor and one part-time clinical supervisor or lead counselor. The "Staffing Requirements Facility Summary Reports" did not identify a full-time clinical supervisor at either of the Project's two facilities.
The facility director confirmed the findings.
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Plan of Correction
Effective 2/16/2012, a full-time clinical supervisor was assigned to this facility. The project director will ensure that a full-time supervisor will be maintained for every 8 FTEs. If the position becomes vacant, the project direct appointment a temporary clinical supervisor until the position is filled. The HR director is responsible for implementing this corrective action. |
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.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and an interview with the facility director, the facility failed to ensure that all staff persons and volunteers received a minimum of 6 hours 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.
The findings include:
On February 13, 2012 the Staffing Requirements Facility Summary Report was reviewed.
Three employees were required to have documentation of the required HIV/AIDS and TB/STD training. The facility failed to provide documentation of the required HIV/AIDS training for employee # 9, 10, and 11.
Employee # 9 was hired October 2007.
Employee # 9 is a psychiatrist.
HIV/AIDS training was to be completed within the first 2 years of employment, by October 2009.
At the time of review on 2/13/12, the facility failed to document completion of 6 hours HIV/AIDS training for employee # 9.
Employee # 10 was hired September 1977.
Employee # 10 is the medical director.
HIV/AIDS training was to be completed within the first 2 years of employment, by September 1979.
At the time of review on 2/13/12, the facility failed to document completion of 6 hours HIV/AIDS training for employee # 10.
Employee # 11 was hired August 2006.
Employee # 11 is a psychiatrist.
HIV/AIDS training was to be completed within the first 2 years of employment, by August 2008.
At the time of review on 2/13/12, the facility failed to document completion of 6 hours HIV/AIDS training for employee # 11.
The facility director confirmed the findings.
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Plan of Correction
By 5/8/2012, all three staff members will fulfill training requirements for HIV/AIDS and TB/STD. The facility director is responsible for arranging training and ensuring that this standard is met. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document fire extinguisher training upon staff employment in one of eight records reviewed.
The findings include:
On February 13, 2012, eight personnel records requiring documentation that staff had been instructed in the use of a fire extinguisher upon employment were reviewed. The facility failed to document the completion of fire extinguisher training upon staff employment in one of eight records reviewed, record #1.
Employee # 1 was hired April 1985 and the training was required to be documented upon employment. The training was not documented at the time of review on February 13, 2012.
The human resource director confirmed the findings.
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Plan of Correction
On 2/16/2012, the employee hired in April 1985 received instruction in the use of the fire extinquisher. This instruction has been documented by the facility. The facility director is responsible for ensuring that all new employees receive this training within seven days of their employment. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
The findings include:
On February 13, 2012, eight personnel records requiring documentation that staff had training for emergencies upon employment were reviewed. The facility failed to document the completion of training for emergencies upon staff employment in one of eight records reviewed, record #1.
Employee # 1 was hired April 1985 and the training was required to be documented prior to working any shift. The training was not documented at the time of review on February 13, 2012.
The human resource director confirmed the findings.
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Plan of Correction
On 3/14/2012, the employee hired in April 1985 was trained to perform assigned tasks during emergencies. This training has been documented in facility records. The HR director will review all personnel files and will ensure that no employee will go to the unit without having satisfied this requirement. |
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 and a review of the facility's policy and procedure manual, the facility failed to document a psychosocial evaluation per policy.
The findings include:
The facility's policy titled "Intake and Admission" states:
A Psychosocial Evaluation will be completed by the therapist within 30 days of intake/admission. The evaluation will provide a composite picture of the client in relationship to his/her psychosocial history to identify possible relationships, conditions and underlying causes leading to the client ' s current situation.
Psychosocial evaluations include but not limited to:
A clear description of the client's presenting and underlying problems, client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment, client assets, strengths or other factors that can contribute to the resolution of identified problems, the potential or available client support systems, negative factors that might affect treatment, the client's preferred coping mechanisms, conclusions regarding the client's appearance, behavior and reactions during the intake process, conclusions regarding the client's attitude toward and ability to participate in the treatment process.
On February 16, 2012, twelve client records requiring documentation of a psychosocial evaluation were reviewed. The facility failed to document an evaluative psychosocial per policy in eleven of twelve records reviewed, # 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, and 12.
Client # 1 was admitted to the program on 10/31/11.
The psychosocial evaluation was documented on 11/22/11.
However, the facility failed to document an evaluative psychosocial assessment.
The clinician failed to provide an assessment regarding the client's assets/strengths, support systems, coping mechanisms, and negative factors.
In addition, the evaluation failed to include the client's attitude toward treatment.
Client # 2 was admitted to the program on 10/25/11.
The psychosocial evaluation was due on 11/24/11 but was documented late on 12/31/11.
The facility failed to document an evaluative psychosocial assessment.
The clinician failed to provide an assessment regarding the client's assets/strengths, support systems, coping mechanisms, and negative factors.
In addition, the evaluation failed to include the client's attitude toward treatment.
Client # 3 was admitted to the program on 11/23/11.
The psychosocial evaluation was documented on 12/6/11.
However, the facility failed to document an evaluative psychosocial assessment.
The clinician failed to provide an assessment regarding the client's assets/strengths, support systems, coping mechanisms, and negative factors.
In addition, the evaluation failed to include the client's attitude toward treatment.
Client # 4 was admitted to the program on 9/21/11.
The psychosocial evaluation was documented on 9/28/11.
However, the facility failed to document an evaluative psychosocial assessment.
The clinician failed to provide an assessment regarding the client's assets/strengths, support systems, coping mechanisms, and negative factors.
In addition, the evaluation failed to include the client's attitude toward treatment.
Client # 5 was admitted to the program on 8/17/11.
The psychosocial evaluation was documented on 9/8/11.
However, the facility failed to document an evaluative psychosocial assessment.
The clinician failed to provide an assessment regarding the client's assets/strengths, support systems, coping mechanisms, and negative factors.
Client # 6 was admitted to the program on 10/25/11.
The psychosocial evaluation was documented on 11/13/11.
However, the facility failed to document an evaluative psychosocial assessment.
The clinician failed to provide an assessment regarding the client's assets/strengths, support systems, coping mechanisms, and negative factors.
Client # 7 was admitted to the program on 8/12/11.
The psychosocial evaluation was documented on 8/26/11.
However, the facility failed to document an evaluative psychosocial assessment.
The clinician failed to provide an assessment regarding the client's assets/strengths, support systems, and negative factors.
Client # 9 was admitted to the program on 10/18/11.
The psychosocial evaluation was to be documented within 30 days of intake/admission.
The psychosocial evaluation did not have a completion date.
In addition, the facility failed to document an evaluative psychosocial assessment which included an assessment regarding the client's assets/strengths, support systems, coping mechanisms, and negative factors.
Client # 10 was admitted to the program on 10/21/11.
The psychosocial evaluation was to be documented within 30 days of intake/admission.
The psychosocial evaluation did not have a completion date.
In addition, the facility failed to document an evaluative psychosocial assessment which included an assessment regarding the client's assets/strengths, support systems, coping mechanisms, and negative factors.
Client # 11 was admitted to the program on 9/19/11.
The psychosocial evaluation was to be documented within 30 days of intake/admission.
The psychosocial evaluation did not have a completion date.
In addition, the facility failed to document an evaluative psychosocial assessment which included an assessment regarding the client's assets/strengths, support systems, coping mechanisms, and negative factors.
Client # 12 was admitted to the program on 10/14/11.
The psychosocial evaluation was to be documented within 30 days of intake/admission.
The psychosocial evaluation did not have a completion date.
The facility director did not dispute the findings.
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Plan of Correction
By 4/30/2012, the facility director will conduct 2 staff trainings to improve documentation of psychosocial evaluations. This training will focus on client assets/strengths, support systems, negative factors, coping mechanisms, and probmems/needs. In addition, the psychosocial evaluation format will be revised to include documention of client's attitude towards treatment. A completion date will be added to all pages of the document. Training will also address timeliness of documentation and documentration of an evaluative psychosocial assessment. The clinical supervisor will ensure compliance with this standrd. |
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 and a review of the facility's policy and procedure manual, the facility failed to document a treatment plan update per policy.
The facility's policy titled "Treatment/Rehabilitation Services" states:
Treatment Plan Updates will be completed by the therapist at least every 60 days.
On February 16, 2012, nine client records requiring documentation of treatment and rehabilitation plan updates were reviewed. The facility failed to document treatment and rehabilitation plan updates per policy in four of nine records reviewed, # 1, 2, 4, and 5.
Client # 1 was admitted to the program on 10/31/11.
The comprehensive treatment plan was documented on 11/22/11.
The treatment plan update was documented on 1/20/12; however, the treatment plan update failed to provide a report on the client's progress with the goals identified on the treatment plan.
Client # 2 was admitted to the program on 10/25/11.
The comprehensive treatment plan due on 11/24/11, was documented on 12/13/11.
The treatment plan update was documented on 2/13/12; however, the treatment plan update failed to provide a report on the client's progress with the goals identified on the treatment plan.
Client # 4 was admitted to the program on 9/21/11.
The comprehensive treatment plan was documented on 9/28/11.
Treatment plan updates were documented on 11/18/11 and 1/24/12.
The treatment plan update, documented late on 1/24/12, failed to provide a report on the client's progress with the goals identified on the treatment plan.
Client # 5 was admitted to the program on 8/17/11.
The comprehensive treatment plan was documented on 9/8/11.
The treatment plan update was documented on 11/8/11, however, the treatment plan update failed to provide a report on the client's progress with the goals identified on the treatment plan.
The facility director did not dispute the findings.
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Plan of Correction
By 4/30/2012, the facility director will conduct one staff training to improve timely documentation of treatment plan updates. This training will also assist staff to improve documentation of the client's progress with the goals identified on the treatment plan. The clinical supervisor will monitor client treatment plans on a weekly basis to ensure this deficiency does not recur. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to document a complete client record which included an aftercare plan.
The findings include:
The facility's policy titled "Aftercare" states:
Aftercare plans are for clients who have successfully completed treatment. The plan is discussed and mutually constructed in the final session(s) of the treatment process.
On February 16, 2012, one client record requiring documentation of an aftercare plan was reviewed. The facility failed to document an after care plan in one of one record reviewed, specifically # 7.
Client # 7 was admitted to the program on 8/12/11 and successfully discharged on 12/1/11.
The facility was required to document an aftercare plan by the client's final sessions in treatment. There was no documented aftercare plan in client record # 7 at the time of review on 2/16/11.
The facility director did not dispute the findings.
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Plan of Correction
By 4/30/2012, the facility director will conduct one staff training on the completion of Aftercare plans for all clients who complete treatment by the client's final sessions in treatment. The clinical supervisor will be responsible for monitoring client records, prior to discharge, to ensure compliance. |
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.
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Observations
Based on a review of client records and a review of the facility's policy and procedure manual, the facility failed to document a complete client record which included a discharge summary.
The facility's policy titled "Discharge Summary" states:
It is the policy of the Center to complete a discharge summary for all clients who terminate treatment/services. The primary therapist will complete the discharge summary within one week after discharge. This summary will be a stand alone document reflecting the following aspects of treatment.
1. reason for admission
2. services provided
3. summary of response to treatment
4. status at discharge
5. recommendations
On February 16, 2012, four client records requiring documentation of a discharge summary were reviewed. The facility failed to document a discharge summary per policy in four of four records reviewed, # 5, 6, 7, and 8.
Client # 5 was admitted to the program on 8/17/11 and discharged on 12/9/11.
The discharge summary should have been documented by 12/16/11. There was no documented discharge summary in client record # 5 at the time of review on 2/16/11.
Client # 6 was admitted to the program on 10/25/11 and discharged on 1/25/12.
The discharge summary should have been documented by 2/1/12.
There was no documented discharge summary in client record # 6 at the time of review on 2/16/11.
Client # 7 was admitted to the program on 8/12/11 and discharged on 12/1/11.
The discharge summary should have been documented by 12/8/11.
There was no documented discharge summary in client record # 7 at the time of review on 2/16/11.
Client # 8 was admitted to the program on 9/14/11 and discharged on 12/9/11.
The discharge summary should have been documented by 12/16/11.
There was no documented discharge summary in client record # 8 at the time of review on 2/16/11.
The facility director did not dispute the findings.
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Plan of Correction
Effective 4/2/2012, the discharge summary will be revised to be a stand alone document and it will contain all required elements. The facility director will also conduct a staff training on proper completion of the revised form. The clinical supervisor will review all client dischages summaries to ensure compliance with this standard. |