INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 29 -30, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer 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 December 24, 2010.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy and procedure manual and an interview with the clinical supervisor and the Quality Assurance/Compliance Coordinator, the facility documented an overall plan for addressing training needs, as required by regulation, but did not indicate a completion date.
The findings include:
On November 29, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, a training plan will be completed by June 30. The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. The facility documented an overall training plan for the July 1, 2010 - June 30, 2011 training year, but the plan was not signed and did not include a date of completion.
This was discussed with the clinical supervisor and the Quality Assurance/Compliance Coordinator on November 29, 2010. The clinical supervisor and the Quality Assurance/Compliance Coordinator confirmed that a plan for addressing training needs of staff was not dated, and therefore it could not be determined if the plan was completed in accordance with facility policy and procedure.
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Plan of Correction
A signature line with date has been added to the templet to remind the person completing the form to sign and date it after completion. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the policy and procedure manual and an interview with the clinical supervisor and the Quality Assurance/Compliance Coordinator, the facility failed to document an annual evaluation of the overall training plan which included a date of completion.
The findings include:
On November 29, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, an annual evaluation of the training plan will be completed by July 31 of each training year. The regulation requires an annual evaluation of the overall training plan to be completed as a component of a staff development program. The facility documented the completion of an annual evaluation of the overall training plan for the July 1, 2009 - June 30, 2010 training year, but the annual evaluation was not signed and did not include a date of completion.
This was discussed with the clinical supervisor and the Quality Assurance/Compliance Coordinator on November 29, 2010. The clinical supervisor and the Quality Assurance/Compliance Coordinator confirmed that an annual evaluation of the overall training plan was not dated, and therefore it could not be determined if the annual evaluation was completed in accordance with facility policy and procedure.
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Plan of Correction
A signature line and date has been added to the templet to prompt the person completing the evaluation to add a signature and date of completion. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative polices and procedures and an interview with the Quality Assurance/Compliance Coordinator, the facility failed to document the project director completed an annual update of the written manual delineating project polices and procedures.
The findings include:
The administrative policies and procedures were reviewed on November 29, 2010. The project director failed to document the annual update of the written project policies and procedures, as required by regulation.
This was discussed with the Quality Assurance/Compliance Coordinator and the clinical supervisor on November 29, 2010. The facility director documented a review of the project polices and procedures via a dated signature, but the project director failed to document a review.
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Plan of Correction
A new sign of page to the policy and procedure manual has been created with the appropriate information included. Immediate signature will be procured and the new page used beginning &/2011. |
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, the facility failed to document a treatment plan update in one of two client records.
The findings include:
Nine client records were reviewed on November 30, 2010. Two client records were required to have a treatment plan update. Per the facility policy, treatment plan updates are required to be completed within 60 days of the comprehensive treatment plan. The facility failed to document a treatment plan update in client record #10.
Client record #10 - The client was admitted on June 24, 2010, and was discharged on November 17, 2010. The comprehensive treatment plan was completed on August 19, 2010. A treatment plan update was due by October 19, 2010 but was not documented. The facility failed to document the completion of a treatment plan update as of the date of this inspection on November 30, 2010.
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Plan of Correction
The missing updates were specific to 2 therapists. The need to complete updates, timelines and need to complete updates timely even if the client is not available was reviewed individually with these two clients and a brief reminder was given in the team meeting. |