INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 9, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights II, 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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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
One staffing record was reviewed for the Project Director and Facility Director positions on January 9, 2017.
Employee # 1 was initially hired by the project on 1/1/16, and was promoted to both the Project Director and Facility Director positions on 8/16/16. The qualifications documented in the employee's record indicated that the employee completed a Bachelor's degree in Social Work. The resume documented in the employee's record indicated that the employee's prior work experience in human services did not include 3 years of experience in the area of Project Planning. Therefore, Employee # 1 did not meet the qualifications for the positions of Project Director and Facility Director.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Immediately following the site visit on January 9 by DDAP's licensing specialist, there was an active search for a qualified Project Director. As of February 6, 2017, there is a Project Director in place that possess all qualifications for the position. The previous acting Project Director was made a Clinical Supervisor on the same date the replacement Project Director started at the project. The newly hired Project Director is a highly qualified individual with a Master's degree in Human Services and also holds a CADC. This person also has prior experience as both a Program Director at Pyramid Healthcare Methadone Clinic for one year and as Clinical Supervisor/Program Supervisor at Children's home of York from 1998-2013; she meets all the requirements of Project Director listed under Chapter 704. This person will be functioning in a combined role of Project Director/Facility Director and will be responsible for overseeing both office locations without a facility director; her official title within the organization will be Project Director. |
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
One staffing record was reviewed for the Project Director and Facility Director positions on January 9, 2017.
Employee # 1 was initially hired by the project on 1/1/16, and was promoted to both the Project Director and Facility Director positions on 8/16/16. The qualifications documented in the employee's record indicated that the employee completed a Bachelor's degree in Social Work. The resume documented in the employee's record indicated that the employee's prior work experience in human services did not include 3 years of experience in the area of Project Planning. Therefore, Employee # 1 did not meet the qualifications for the positions of Project Director and Facility Director.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The qualification specifically regarding the requirement of having 3 years of program planning experience was misinterpreted by the Board of Directors, therefore permitting Employee #1 to be promoted into the position of project director. Effective immediately, the Chairman of the Board will ensure all applicants for the position of Project/Facility Director have clear documentation of 3 years experience in all components listed in the qualifications. Employee #1 was made a Clinical Supervisor on February 6 when a fully qualified individual started as Project Director. The Project Director will be responsible for the supervision of both office locations and function in a combined role of Project Director and Facility Director so both positions are being fulfilled. The Chairman of the Board and the Board of Directors were made aware of the issue in a special board meeting to discuss the specific qualifications of Project/Facility Director. This special board meeting was held on January 10, subsequent to the verbal exit survey by DDAP's licensing specialist on January 9. This special meeting of the Board was documented and includes notes of what was discussed. |
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
Four staffing records were reviewed for the Counselor position on January 9, 2017.
Employee # 5 was hired as a counselor on 11/7/16. The qualifications documented in the employee's record indicated that the employee completed a Bachelor's degree in Psychology. The resume documented in the employee's record indicated that the employee acquired 3 months of clinical experience prior to starting employment at the facility. Therefore, Employee # 5 did not meet the qualifications for the position of Counselor.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director is responsible for the screening and selecting of all potential counselor's resumes for interviews and job placement. Effective 1/23/17, the Project Director may still conduct the first interview and select applicants to be scheduled for a second interview, however, a member of the senior executive staff must be present with the Project Director at the second interview to review the applicant's prior experience and other qualifications. The Employee Hiring for Clinical Staff policy was amended by the Board of Directors on January 23, 2017, to reflect this change. Employee #5 referenced in this citation is no longer employed by this project as of January 25, 2017, as a result of poor job performance and not due to their qualifications. If future questions present or surface regarding an applicant's qualifications, either the Project Director or a member of the senior executive staff will contact DDAP's Division of Licensure to assure that the candidate meets the basic requirements for the Counselor position. |
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.
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Observations
Fifteen client records were reviewed on January 9, 2017. The facility failed to obtain an informed and voluntary consent where consent was required in client record # 2.
Client # 2 was admitted into treatment on 8/30/16 and was still active at the time of the inspection. The facility documented in the client's record that a letter reporting the client's urinalysis drug screen results was sent to an attorney on 12/2/16. The documented consent to release information to the attorney, signed and dated on 10/6/16, did not authorize the release of the client's urinalysis drug screen results.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff were made aware of this citation and breach in their staff meetings. Effective immediately, the primary clinicians are responsible for ensuring that proper consent is documented when a client requests for information to be released. The primary clinician will be responsible for monitoring each release to make sure all subject matter specifically requested to be released is outlined clearly and documented on the release. The project director went over in staff meeting the necessity of consents and the responsibility of making sure the specific subject matter to be released is clearly documented before sending any information to a third party. The primary clinicians will be responsible for the continuous monitoring of consents and confirming that they are correlated with client needs whenever the client needs any information released to a third party. The Project Director will be responsible for reviewing all consents for proper content at least one time monthly as a quality assurance measure. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Six records for Partial Hospitalization activities were reviewed on January 9, 2017. The facility failed to document the type and frequency of treatment services on the individual treatment and rehabilitation plan in client records # 10 and 11.
Client # 10 was admitted into treatment on 11/16/16 and was still active in treatment. The individual treatment and rehabilitation plan completed for the client on 11/29/16 did not specify the type and frequency of counseling services.
Client # 11 was admitted into treatment on 12/5/16 and was still active in treatment. The individual treatment and rehabilitation plan completed for the client on 12/19/16 did not specify the type and frequency of counseling services.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director was responsible for the re-development of all treatment plans used by the project to reflect the type and frequency of treatment. All treatment plans used by the project were updated on January 10, 2017 by the Project Director following a verbal exit survey by DDAP's licensing specialist on January 9, 2017. An announcement was made in staff meeting in the Lemoyne office on January 11, 2017 and noted in the staff meeting minutes that all treatment plans now include the type AND frequency of treatment and must be filled out to reflect both. The Project Director and Clinical Supervisor will be responsible for overseeing and implementing the updated treatment plans. The Project Director and Clinical Supervisor will be making sure the updated treatment forms are being used by monthly quality assurance checks they will perform and follow up documentation to record these quality assurance checks. |