INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 26-28, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System at Cove Forge 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 22, 2010.
|
Plan of Correction
|
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.
|
Observations
Based on the review of the staffing self report form submitted by the facility, and an ongoing dialogue with the administrative staff during the inspection, the facility failed to document the required mandatory communicable disease training for each employee within the required timeframes specified for each position.
The findings included:
The facility self report form tracked the completion of the required mandatory communicable disease training for 170 employees who work in a support capacity. Support staff are required to have documented evidence of the required six hours of training in HIV/AIDS and four hours of training in STD/TB within two years of the date of hire. Seventy nine of these employees were hired less than two years ago and were not yet required to have this training. Of the remaining 91 employees, 23 did not have the required training within two years of their hire date.
Employee #1 was hired on 5/9/05 and did not receive the mandatory STD/TB training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 2 was hired on 4/14/03 and did not receive the mandatory STD/TB training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 3 was hired on 5/9/05 and did not receive the mandatory STD/TB training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 4 was hired on 4/14/03 and did not receive the mandatory STD/TB training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 5 was hired on 4/16/07 and did not receive the mandatory STD/TB training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee #6 was hired on 4/7/07 and did not receive the mandatory STD/TB or HIV/AIDS training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 7 was hired on 2/4/08 and did not receive the mandatory STD/TB training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 8 was hired on 5/1/02 and did not receive the mandatory STD/TB training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 9 was hired on 1/28/08 and did not receive the mandatory STD/TB training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee #10 was hired on 4/9/07 and did not receive the mandatory STD/TB training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee #11 was hired on 2/13/06 and did not receive the mandatory STD/TB training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee #12 was hired on 2/13/95 and did not receive the mandatory STD/TB training or HIV/AIDS as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee #13 was hired on 3/12/08 and did not receive the mandatory STD/TB training or HIV/AIDS as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 14 was hired on 11/26/07 and did not receive the mandatory STD/TB training or HIV/AIDS as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 15 was hired on 7/1/06 and did not receive the mandatory STD/TB training or HIV/AIDS as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 16 was hired on 4/8/05 and did not receive the mandatory STD/TB or HIV/AIDS training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 17 was hired on 8/6/07 and did not receive the mandatory STD/TB or HIV/AIDS training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 18 was hired on 1/8/07 and did not receive the mandatory STD/TB or HIV/AIDS training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee #19 was hired on 2/13/00 and did not receive the mandatory STD/TB or HIV/AIDS training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 20 was hired on 1/8/07 and did not receive the mandatory STD/TB or HIV/AIDS training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 21 was hired on 4/4/06 and did not receive the mandatory STD/TB or HIV/AIDS training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 22 was hired on 12/23/07 and did not receive the mandatory STD/TB or HIV/AIDS training as recorded on the self report staffing form issued by the Division prior to the inspection.
Employee # 23 was hired on 2/21/08 and did not receive the mandatory STD/TB or HIV/AIDS training as recorded on the self report staffing form issued by the Division prior to the inspection.
|
Plan of Correction
Cove Forge Staff Development will schedule mandatory communicable disease training. Each employee will attend training within the required time frames specified for each position.
Employees #1 - #23 will receive applicable HIV/AIDS and STD/TB training scheduled by Staff Development on June 8, 2010 (HIV/AIDS) and on June 10, 2010 (STD/TB). Program Managers and Direct Supervisors will be responsible for ensuring that the employees attend. All 23 employees will be compliant and training will be documented.
Employee
# 1 STD/TB,
# 2 STD/TB,
# 3 STD/TB,
# 4 STD/TB,
# 5 STD/TB,
# 6 STD/TB & HIV/AIDS,
# 7 STD/TB,
# 8 STD/TB,
# 9 STD/TB,
# 10 STD/TB,
# 11 STD/TB,
# 12 STD/TB & HIV/AIDS,
# 13 STD/TB & HIV/AIDS,
# 14 STD/TB & HIV/AIDS
# 15 STD/TB & HIV/AIDS,
# 16 STD/TB & HIV/AIDS,
# 17 STD/TB & HIV/AIDS,
# 18 STD/TB & HIV/AIDS,
#19 STD/TB & HIV/AIDS,
# 20 STD/TB & HIV/AIDS,
# 21 STD/TB & HIV/AIDS,
# 22 STD/TB and HIV/AIDS,
# 23 STD/TB & HIV/AIDS
Responsible Staff:
Program Managers and Direct Supervisors.
|
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in three of three client records which addressed the client's coping mechanisms and the counselors' assessments/evaluations of the clients assets/strengths.
The findings included:
Three client records were reviewed at the partial hospitalization level of care. Three of three of the psychosocial evaluations in the records reviewed missed one or more of the required components.
Client record # 6 was admitted to the partial hospitalization level of care from the inpatient residential level of care on 4/12/10. The psychosocial evaluation in the client record included documentation that the client's strengths/assets were discussed from the client's viewpoint but did not include the counselor's assessment/evaluation.
Client record # 7 was admitted to the partial hospitalization level of care from the inpatient residential level of care on 4/9/10. The psychosocial evaluation failed to include documentation of the client's coping/defense mechanisms. Documentation in the psychosocial evaluation revealed that the client's strengths/assets were discussed from the client's viewpoint but did not include the counselor's assessment/evaluation.
Client record # 10 was admitted to the partial hospitalization level of care from the inpatient residential level of care on 4/23/10. The psychosocial evaluation failed to include documentation of the client's coping/defense mechanisms. The client's strengths/assets were discussed from the client's viewpoint but did not include the counselor's assessment/evaluation.
|
Plan of Correction
The Adult Program Director will meet with Assessment Counselors on June 1, 2010 to conduct training. The training will consist of reviewing the findings.
The training will also consist of identifying coping skills and defense mechanisms. Assessment skills will also be discussed.
To ensure compliance, the Adult Program Director will review
Three psychosocial assessments/evaluations on a weekly basis for one month. (Beginning week of May 17, 2010.)
Monitoring will include:
- Clients coping/defense mechanisms
- Counselor's assessment of the client's assets/strengths and not what the client is voicing.
To ensure compliance, the Adult Program Director will review three psychosocial assessments/evaluations on a bi-weekly basis for three months. (Beginning week of June 21, 2010)
Monitoring will include:
- Client's coping/defense mechanisms
- Counselor's assessment of the client's assets/strengths and not what the client is voicing.
To ensure compliance, the Adult Program Director will review six psychosocial assessments/evaluations on a monthly basis and will be on going.(Beginning September, 2010)
Monitoring will include:
- Client's coping/defense mechanisms
- Counselor's assessment of the client's assets/strengths and not what the client is voicing.
Responsible Staff:
Adult Program Director
|
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.
|
Observations
Based on the review of documentation in client records and a discussion with the UR coordinator, the facility failed to ensure that disclosures of client identifying information did not exceed the limitations imposed at 4 Pa. Code subsection 255.5(b) in 8 of 17 client records.
The findings included:
During the onsite licensing inspection of April 26 through April 28, 2010, the Utilization Review (UR) coordinator was interviewed regarding information disclosed to funding entities and how documentation of these disclosures were maintained.
In addition, 17 client records were reviewed in whole or in part. The UR coordinator indicated that there are contact sheets in a log kept by the UR office. Copies of the contact sheets kept by the UR department were provided to Division staff at the time of the inspection. Attached to each contact sheet was the actual information generated by the counselor and identified as being included in the disclosures to funding entities. The information documented on the contact sheets exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b).
UR staff indicated that even though these documents included information that exceed the limitations, the UR staff screen the information and disclose only information compliant with 4 Pa. Code 255.5(b); however, the only documentation in evidence is that which exceeds the limitations imposed by 4 Pa. Code Subsection 255.5(b).
Client record # 5 - admitted 4/13/10. Documentation of disclosure of client identifying information on the contact sheet indicated releases of information on April 14, 16, and 22. The document included details about drugs used, the amounts used and the age at which the drug was first used. The information also addressed triggers specific to the client and the client's strengths and weaknesses.
Client record # 9 - admitted 4/12/10. Documentation of disclosure of client identifying information on the contact sheet indicated releases of information on April 12 and 20. The document included details about drugs used, the amounts used and the age at which the drug was first used. The information also addressed triggers specific to the client and the client's strengths and weaknesses.
Client record # 10 - admitted 4/5/10. Documentation of disclosure of client identifying information on the contact sheet indicated releases of information were made to the funding source. The document included details about drugs used, amounts used and the age at which the drug was first used. The information also addressed triggers specific to the client and the client's strengths and weaknesses.
Client record # 11 - admitted 4/14/10. Documentation of disclosure of client identifying information on the contact sheet indicated releases of information on April 14 & 20. The document included details about drugs used, amounts used and the age at which the drug was first used. The information also addressed triggers specific to the client and the client's strengths and weaknesses. Treatment plan goals were listed and persons having custody of the client's children were noted in the document.
Client record # 13 - admitted 4/14/10 . Documentation of disclosure of client identifying information on the contact sheet indicated releases of information on April 13, 19 and 26. The document included details about drugs used, amounts used and the age at which the drug was first used. The information also addressed triggers specific to the client and the client's strengths and weaknesses.
Client record # 14 - admitted 4/12/10 . Documentation of disclosure of client identifying information on the contact sheet indicated releases of information on April 13 & 15. The document included details about drugs used, amounts used and the age at which the drug was first used. The information also addressed triggers specific to the client and the client's strengths and weaknesses.
Client record # 15 - admission date was not checked. Documentation of disclosure of client identifying information on the contact sheet indicated releases of information on April 23. The document included details about drugs used, amounts used and the age at which the drug was first used. The information also addressed triggers specific to the client and the client's strengths and weaknesses.
Client record # 16 - admission date was not checked. Documentation of disclosure of client identifying information on the contact sheet indicated releases of information on April 14, 15 and 23. The document included details about drugs used, amounts used and the age at which the drug was first used. The information also addressed triggers specific to the client and the client's strengths and weaknesses.
|
Plan of Correction
Beginning June 1, 2010 all Utilization Review staff will implement the use of the Utilization Review Clinical Checklist when giving clinical information to managed Medicaid and commercial organizations.
Training for the UR staff regarding use of this checklist will be completed by Monday, May 31, 2010. The UR staff will utilize a new checklist for each review. The checklists will be maintained in UR office. Upon discharge the Utilization Review Clinical Checklist will become a part of the medical record along with the Authorization History Form.
The UR Coordinator will monitor 25% of the checklists for the next 3 months to ensure that disclosures of client identifying information did not exceed the limitations imposed at 4 Pa. Code subsection 255.5(b). Charts will be monitored randomly thereafter.
Responsible Staff:
UR Coordinator & UR Staff
|
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in six of twelve client records which addressed the client's coping mechanisms and the counselors' assessments/evaluations of the clients assets/strengths .
The findings included:
Twelve client records were reviewed at this level of care from April 27 to April 28, 2010. In six of the twelve client records, the psychosocial evaluation failed to include an assessment/evaluation of one or more of the required components.
Client record # 3 - admitted to inpatient residential on 1/5/10 - the psychosocial evaluation included documentation which revealed that the client's strengths/assets were discussed from the client's viewpoint but did not include the counselor's assessment/evaluation. Documentation of the counselor's assessment/evaluation of the client's coping/defense mechanisms were not included in the psychosocial evaluation.
Client record # 9 - admitted to inpatient residential on 4/12/10 - the psychosocial evaluation included documentation which revealed that the client's strengths/assets were discussed from the client's viewpoint but did not include the counselor's assessment/evaluation.
Client record # 10 - admitted to inpatient residential on 4/5/10 - the psychosocial evaluation included documentation which revealed that the client's strengths/assets were discussed from the client's viewpoint but did not include the counselor's assessment/evaluation.
Client record # 12 - admitted to inpatient residential on 4/6/10 - the psychosocial evaluation included documentation which revealed that the client's strengths/assets were discussed from the client's viewpoint but did not include the counselor's assessment/evaluation.
Client record # 13 - admitted to inpatient residential on 4/14/10 - the psychosocial evaluation failed to include the counselor's assessment/evaluation of the client's coping/defense mechanisms.
Client record # 14 - admitted to inpatient residential on 4/12/10 - the psychosocial evaluation failed to include the counselor's assessment/evaluation of the client's coping/defense mechanisms.
|
Plan of Correction
The Adult Program Director will meet with Assessment Counselors on June 1, 2010 to conduct a training. The training will consist of reviewing the findings.
The training will also consist of identifying coping skills and defense mechanisms. Assessment skills will also be discussed.
To ensure compliance, the Adult Program Director will review three psychosocial assessments/evaluations on a weekly basis for one month. (Beginning week of May 17, 2010.)
Monitoring will include:
- Client's coping/defense mechanisms
- Counselor's assessment of the client's assets/strengths and not what the client is voicing.
To ensure compliance, the Adult Program Director will review three psychosocial assessments/evaluations on a bi-weekly basis for three months. (Beginning week of June 21, 2010)
Monitoring will included:
- Client's coping/defense mechanisms
- Counselor's assessment of the client's assets/strengths and not what the client is voicing.
To ensure compliance, the Adult Program Director will review six psychosocial assessments/evaluations one a monthly basis and will be on going.(Beginning September, 2010)
Monitoring will included:
- Client's coping/defense mechanisms
- Counselor's assessment of the client's assets/strengths and not what the client is voicing.
|
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
|
Observations
Based on a review of the staffing requirements facility summary report and active client list, the facility failed to notify the Department of a change in authorized maximum capacity.
The findings include:
The staffing requirements facility summary report was reviewed on April 28, 2010. The summary report, signed by the Project/Facility Director, indicated the facility had 111 current clients in the inpatient residential program. The facility is licensed by the Division for a maximum client capacity of 108.
In a discussion with the Clinical Supervisor and the Facility Director on 4/27/10 they disclosed that there was a situation that resulted in a temporary condition of being over capacity. The Director explained that the reason for the over capacity had to do with three clients in residential treatment who were scheduled to step down to another level of care but were unable to complete the program on the date anticipated.
|
Plan of Correction
Cove Forge will notify the Department of a change in authorized maximum capacity by sending a letter of explanation stating the reason for the occurrence and any temporary change made to accommodate the increase.
Cove Forge does not plan to deviate from the authorized maximum capacity.
Responsible Staff:
Tom Callahan, Project/Facility Director
|