INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 2 - 3, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Al-Assist Behavioral Health Care 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(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 records and a conversation with the facility director, the clinical supervisor failed to complete a core curriculum training in clinical supervision. The findings include: Employee # 3 was hired on July 28, 2010 for the position of clinical supervisor. Employee # 3 has approximately ten years of clinical experience and no prior clinical supervisory experience, thus employee # 3 was required to complete a core curriculum in clinical supervision.At the time of review on August 3, 2011 employee # 3 failed to complete the core curriculum training in clinical supervision.The facility director reviewed the findings in employee record # 7.
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Plan of Correction
Standard in Noncompliance
704.6(c) LINCENSURE
Core Curriculum ? Supervisor Training:
In an effort to comply with regulation 704.6(c) the written findings from August 3, 2011 were discussed between the Facility Director and the Quality Assurance Manager. The Quality Assurance Manager and Employee #3 reviewed additional training requirements and developed a training plan to comply with standard. Employee #3 is currently registered and will attend administrative clinical supervision training conducted by the Bureau of Drug and Alcohol programs on October 3, 2011 through October 7, 2011 in Pittsburg, PA. Upon completion of training, certification of completion will be photo copied and placed in employee's personnel file. All newly hired Clinical Supervisors will develop a written training plan that shall include registration and attendance to Administrative Clinical Supervision Training with BDAP. Upon completion of training a copy of certificate of completion will be placed in employees personnel file. The Quality Assurance Department will review employee personnel files semiannually to ensure proper training has been obtained.
Correction time: October 7, 2011
Monitoring on-going
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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, the Staffing Requirement Facility Summary Report, and a conversation with the facility director, the facility failed to ensure that one out of three counselors met the qualifications for the position of counselor.The findings include:On August 3, 2011 three personnel records for staff designated as counselors were reviewed for documentation of the qualifications for the position of counselor.The facility failed to ensure that one out of three counselors reviewed met the qualifications for the position of counselor, specifically employee # 7.Employee # 7 was hired as an intake worker on 3/31/08, and promoted to a counselor on 9/20/10.Employee # 7 has a qualifying Bachelor's degree; however, the reviewed documentation did not indicate 1 year of clinical experience.The facility director reviewed and confirmed the findings in employee record # 7.The facility director stated employee #7's "prior experience in the field was intake/assessor. He worked as an intake assessor from March 8 - September 19, 2011."
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Plan of Correction
In an effort to address and avoid any future non-compliance of standard 704.4(b). The Director of Behavioral Healthcare Services, Coordinator of Behavioral Healthcare Services, and Clinical Coordinator held an individual meeting with the staff member identified as not meeting the educational requirements in at least one of the paragraphs of 28 Pa. Code Subsection 704.7(b). The staff member was immediately demoted from a Counselor III to a Counselor Assistant. All future/potential hires for the Drug and Alcohol program will be scrutinized based on 28 Pa. Code Subsection 704.7(b), by both the Clinical Team and the Human Resource Department. Failure to meet the educational and experience qualifications will result in a non-hiring of the applicant. This process will be monitored by the HR Director and the Director of Behavioral Healthcare Services.
Correction Time: Completed
Ongoing Monitoring
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709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on a review of administrative documentation, and a conversation with the facility director, the facility failed to select a project director as the person officially responsible to the governing body.The findings include:On August 2, 2011 a review of administrative documentation revealed that the appointed project director, employee # 1, the medical director does not report to the governing body/Board of Directors.The facility director, employee # 2 was interviewed regarding the findings, at which time she confirmed that the project director is not officially responsible to the governing body.
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Plan of Correction
Standard in Noncompliance
709.22(d)(1) LINCENSURE Governing Body
In effort to comply with regulation 709.22(d)(1) the written findings from August 3, 2011 were discussed with the Director of Behavioral Health, Chief Executive Officer, and the Governing Body. It was decided that the Chief Executive Officer would be the person responsible to the governing body.Based on our organizational structure the Chief Executive Officer is the only positon that reports to the Board of Directors; therefore moving forward, the CEO will be the project director for our Drug and Alcohol Program.
Correction time: completed
Monitoring is on-going
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709.28(c) 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:
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Observations
Based on a review of client records, a review of clinical documents and an interview with the clinical supervisor, the facility failed to obtain an informed and voluntary consent for the disclosure of information contained in one of six client records reviewed, specifically client record # 5.The findings include:On July 3, 2011 six client records were reviewed to ensure that the facility was obtaining informed and voluntary consents to release client identifying information.Documentation in client record # 5 failed to adhere to the requirements specified at 28 Pa. Code subsection 709.28 and 42 CFR.Client # 5 was admitted to the program on 1/26/11 and discharged on 6/20/11.On 3/29/11 client # 5 signed and dated a "Consent to Release Information" form that allowed for the release of information to a government agency.The consent to release form failed to include the information that would be disclosed and the purpose for the disclosure of that information.The clinical supervisor confirmed that the consent to release form failed to adhere to the requirements specified at 28 Pa. Code subsection 709.28 and 42 CFR.
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Plan of Correction
Standard in Noncompliance
709.28(c) LINCENSURE Confidentiality:
In effort to comply with regulation 709.28(c), the written findings from August 3, 2011 were reviewed with the Clinical Coordinators and Counselor III's during clinical staff meeting to again review standard 709.28(c) and the agency's confidentiality policy and procedures. The Clinical Coordinators reviewed the designated forms for consumers in the drug and alcohol outpatient program that reference specific guidelines outlined in regulation 709.28(c). The Clinical Coordinators restated the importance of accurately documenting what information is to be released, ensuring this information does not exceed the limitation set forth in 4 Pa Code subsection 255.5(b): 1. Whether the client is or is not in treatment; 2. The prognosis of the client; 3. The nature of the project; 4. A brief description of the progress of the client; and 5. A short statement as to whether the client has relapsed into drug and alcohol and frequency of such relapse. In addition, Quality Assurance Department and Clinical Staff were instructed to do away with any old blank consent to release forms that did not indicate in writing what information was to be released. Informed and voluntary consent forms will be routinely audited by the Quality Assurance Clerks and randomly audited by the Quality Assurance Coordinator to ensure compliance. A random audit of each therapist caseload will be conducted periodically by the Clinical Coordinator to ensure that Standard 709.28(c) is being followed properly.
Correction Time: Completed
Monitoring is on-going
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document individual treatment plans to include proposed type of support service.The findings include:On August 3, 2011 six client records requiring documentation of an individual treatment plan with support services were reviewed.The facility did not document a treatment plan to include proposed types of supportive services in four of six client records reviewed, specifically records # 1, 3, 5, and 6.Client # 1 was admitted to the program on 11/29/10.A comprehensive treatment plan was documented on 12/17/10; however, the facility failed to include proposed types of supportive services.Client # 3 was admitted to the program on 4/5/11.A comprehensive treatment plan was documented on 5/9/11; however the facility failed to include proposed types of supportive services.Client # 5 was admitted to the program on 1/26/11.A comprehensive treatment plan was documented on 2/11/11; however the facility failed to include proposed types of supportive services.Client # 6 was admitted to the program on 11/29/11.A comprehensive treatment plan was documented on 12/9/10; however the facility failed to include proposed types of supportive services.
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Plan of Correction
Standard in Noncompliance
709.92(a)(3)LICENSURE Treatment and rehabilitation services
In an effort to comply with regulation 709.92(a)(3)the written findings from August 3, 2011 were discussed with all Clinical Staff during staff meeting. At which time the Clinical Coordinators reviewed Standard 709.92(a)(3) on Treatment Plan Updates which states "that the Treatment Plan shall include proposed type of support service". Clinical Staff will include proposed type of support on all treatment plans. In addition, Clinical Coordinators are to review Counselor's records weekly to ensure compliance with standard 709.92(a)(3). Feedback will be given from these reviews to help Clinical Staff better understand the intent of regulation 709.92(a)(3). Clinical Staff found non-compliant of this regulation will receive additional support from the Clinical Coordinator during weekly supervision sessions. Client records will also be randomly audited by Quality Assurance Department to ensure standard 709.92(a)(3) will be followed properly.
Correction Time: Completed
Monitoring is on-going
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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 facilities policy and procedures manual, the facility failed to document treatment and rehabilitation plan updates at least every 60 days.The findings include:The facilities policy titled "Treatment Plan Update" states:The treatment plan update shall be developed every 60 days for outpatient substance abuse clients.On August 3, 2011, five client records requiring treatment and rehabilitation plan updates were reviewed.The facility failed to document a treatment and rehabilitation plan update every 60 days as per policy in five of five client records reviewed, # 1, 2, 3, 4, and 5.Client # 1 was admitted to the program on 11/29/10.A comprehensive treatment plan was documented on 12/17/10.The treatment and rehabilitation plans were due on 2/1711, 4/17/11, and 6/17/11.At the time of review on 8/3/11 the facility documented treatment/rehab updates on 4/17/11 and 7/20/11.Client # 2 was admitted to the program on 11/17/10.A comprehensive treatment plan was documented on 11/17/10.The treatment and rehabilitation plans were due on 1/17/11, 3/17/11, 5/17/11, and 7/17/11.At the time of review on 8/3/11 the facility failed to document treatment and rehabilitation updates.Client # 3 was admitted to the program on 4/5/11.A comprehensive treatment plan was documented on 5/9/11.The treatment and rehabilitation plan was due on 7/9/11.At the time of review on 8/3/11 the facility documented a treatment/rehab update on 7/18/11.Client # 4 was admitted to the program on 10/25/10.A comprehensive treatment plan was documented on 11/16/10.The treatment and rehabilitation plan was due on 1/16/11, 3/16/11, 5/16/11, and 7/16/11.At the time of review on 8/3/11 the facility documented a treatment/rehab updates on 5/16/11 and 7/11/11.Client # 5 was admitted to the program on 1/26/11.A comprehensive treatment plan was documented on 2/11/11.The treatment and rehabilitation plans were due on 4/11/11 and 6/11/11.At the time of review on 8/3/11 the facility documented a treatment/rehab update on 4/5/11.
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Plan of Correction
Standard in Noncompliance
709.92(b)LINCENSURE Treatment and rehabilitation services
In an effort to comply with regulation 709.92(b) the written findings from August 3, 2011 were discussed with all Clinical Staff during staff meeting. At which time the Clinical Coordinators reviewed the facilities policy and procedures on Treatment Plan Updates which states "that the Treatment Plan Updates shall be developed every 60 days for outpatient substance abuse clients". Clinical Staff will continue to review client's progress with goals and update treatment plan every 60 days. In addition, Clinical Coordinators are to review Counselor's records weekly to ensure compliance with standard 709.92(b). Feedback will be given from these reviews to help Clinical Staff better understand the intent of regulation 709.92(b). Clinical Staff found non-compliant of this regulation will receive additional support from the Clinical Coordinator during weekly supervision sessions. Client records will also be randomly audited by Quality Assurance Department to ensure standard 709.92(b) will be followed properly.
Correction Time: Completed
Monitoring is on-going
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