INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on November 7-8, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Parkside Recovery 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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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on observation, at the time of the project ' s site visit, the facility failed to provide the Department licensing representatives with the plan documenting the qualifications and training of staff.
The findings include:
On November 2, 2011 at approximately 9:00 AM, the Department licensing representatives requested the Staffing Requirements Facility Summary Report. The facility did not present the completed Staffing Requirements Facility Summary Report until November 2, 2011 at approximately 2:15 PM.
The findings were confirmed by the project director on November 2, 2011.
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Plan of Correction
Effective 11/08/2011, the facility will collaborate with internal resources to ensure completion of the Staffing Requirements Facility Summary Report prior to the on-site inspection. This will be monitored by the Executive Director and the Program Director |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the review of personnel records, the facility failed to document a minimum of 12 clock hours of training annually for the project director.
The findings include:
On November 8, 2011, the project director ' s personnel record was reviewed for documentation of 12 clock hours of training for the 2010 training year. The project director ' s personnel record contained documentation of only 6 hours of completed training during the 2010 training year.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
Effective 11/08/2011 all completed education certificates and training evaluation forms will be submitted to the Human Resources Department immediately upon completion. All training hours are tracked by the Director of Training and provided to each Program Director to ensure compliance. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors.
The findings include:
An inspection of the facility ' s physical plant was conducted on November 8, 2011 between approximately 12:30 PM and 1:30 PM. At the time of inspection, the grounds of the facility were not in good repair.
The walls and fixtures in the main lobby men ' s and women ' s client bathrooms were covered with graffiti and needed painting.
Ceiling tiles throughout the entire building on both the lower and main floors were water-stained as a result of a roof leak.
The carpet in office # 101 was stained and needed to be cleaned.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
Effective 11/08/2011 the bathroom walls were repainted, the carpets were steam cleaned and the ongoing service plans for cleaning and facilities management were reviewed to ensure regularly scheduled and as need cleaning and repairs will occur. The landlord was notified of the ceiling tile concerns for regular maintenance checks. The Facilities manager will monitor the grounds with regularly scheduled rounds. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate all bathrooms by exhaust fan or window.
The findings include:
An inspection of the facility ' s physical plant was conducted on November 8, 2011 between approximately 12:30 PM and 1:30 PM. At the time of inspection, the exhaust fans were not working in the men ' s and women ' s employee bathrooms on the main floor.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
The ceiling fan was repaired on the same day of the facility walk through and confirmed on 11/08/2011 as functioning properly. The Facilities manager will continue to monitor this during regular rounding. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on the review of administrative documents, the project director failed to present the policy manual to the governing body at least annually for approval.
The facility ' s policy manual and board of directors meeting minutes were reviewed on November 8, 2011. The facility ' s policy manual was not signed-off by the governing body, and the board of directors meeting minutes did state whether the policy manual had been reviewed and approved by the governing body.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
Effective 11/4/2011 the project director submitted the policy manual to the governing body for approval. This will occur at the annual report board meeting ongoing to maintain compliance |
709.26(a)(4) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(4) Employe benefits.
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Observations
Based on the review of the facility ' s policy manual, the facility failed to develop personnel policy to address employee benefits.
The findings include:
The facility ' s policy manual was reviewed on November 8, 2011. The facility ' s policy manual did not address employee benefits (eligibility, cost to employee, continuity after separation, etc.).
The policy manual mentioned a " fringe benefit program " , but the details of this program were not included in the policy manual.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
Effective 11/04/2011 the policy was updated to include the details of the fringe benefits program. This was confirmed by the project director prior to 11/08/2011. |
709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based on the review of personnel records, the facility failed to document salary information.
The findings include:
Twelve personnel records were reviewed on November 8, 2011 for documentation of salary information. The facility failed to document starting salary and all salary increases/decreases in ten out of twelve records reviewed, specifically, personnel records #, 1, 2, 3, 4, 5, 6, 7, 10, 11 and 12.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
Effective 11/08/2011 all in starting salary and all salary increases/decreases will be filed in the personnel files and monitored by the appropriate human resources personnel. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a physical plant inspection, the facility failed to secure all client records within locked storage containers.
The findings include:
An inspection of the facility ' s physical plant was conducted on November 8, 2011 between approximately 12:30 PM and 1:30 PM. Client identifying information was stored unlocked in a vacant office.
Additionally, the closed records storage room was being used to store a microwave and an old computer monitor.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
Effective 11/08/2011 all client identifying information was stored in a locked storage container in a locked room dedicated to records storage. All items unrelated to record storage were removed from the locked storage room. The security supervisor will ensure ongoing compliance via regular rounding. |
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 the review of client records, the facility failed to document a psychosocial evaluation to include a composite picture of the individual in relationship to the collected historical information.
The findings include:
On November 7-8, 2011, psychosocial evaluations in fourteen client records were reviewed. The facility did not document a psychosocial evaluation to include a composite picture of the individual in relation to the collected historical information in . in fourteen of fourteen records reviewed, specifically, client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14 and 16.
Client # 1 was admitted on 3/30/10. The psychosocial evaluation in client record # 1 dated 4/15/11 did not include the client ' s assets and strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client ' s appearance and behavior during the initial interview.
Client # 2 was admitted on 9/6/11. The psychosocial evaluation in client record # 2 dated 9/26/11 did not include the client ' s assets and strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client ' s appearance and behavior during the initial interview.
Client # 3 was admitted on 2/2/11. The psychosocial evaluation in client record # 3 dated 2/24/11 did not include the client ' s assets and strengths, support systems, coping mechanisms and negative factors.
Client # 4 was admitted on 2/8/11. The psychosocial evaluation in client record # 4 dated 2/22/11 did not include the client ' s assets and strengths, support systems and negative factors, and conclusions regarding the client ' s appearance and behavior during the initial interview.
Client # 5 was admitted on 5/11/11, but client # 5 ' s record did not contain a psychosocial evaluation.
Client # 6 was admitted on 3/17/11. The psychosocial evaluation in client record # 6 dated 3/29/11 was illegible, so it was not possible to rate this evaluation.
Client # 7 was admitted on 2/7/11. The psychosocial evaluation in client record # 7 dated 2/15/11 was illegible, so it was not possible to rate this evaluation.
Client # 8 was admitted on 3/2/11. The psychosocial evaluation in client record # 8 dated 3/21/11 did not include the client ' s assets and strengths, support systems, coping mechanisms, negative factors, conclusions regarding the client ' s appearance and behavior during the initial interview, and conclusions regarding the client ' s attitude toward and ability to participate in the treatment process.
Client # 9 was admitted on 2/24/11. The psychosocial evaluation in client record # 9 dated 3/16/11 did not include the client ' s needs or problems, assets and strengths, support systems, coping mechanisms, and negative factors.
Client # 10 was admitted on 5/23/11. The psychosocial evaluation in client record # 10 dated 6/10/11 did not include the client ' s assets and strengths, support systems, coping mechanisms, and negative factors.
Client # 11 was admitted on 2/8/11. The psychosocial evaluation in client record # 11 dated 3/8/11 did not include the client ' s assets and strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client ' s attitude toward and ability to participate in the treatment process.
Client # 13 was admitted on 2/3/11. The psychosocial evaluation in client record # 13 dated 2/21/11 did not include the client ' s assets and strengths, support systems, coping mechanisms, and negative factors.
Client # 14 was admitted on 2/17/11. The psychosocial evaluation in client record # 14 dated 2/28/11 did not include the client ' s assets and strengths, support systems, coping mechanisms, and negative factors.
Client # 16 was admitted on 3/24/11. The psychosocial evaluation in client record # 16 dated 4/12/11 did not include the client ' s assets and strengths, support systems, coping mechanisms, and negative factors.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
The Clinical Supervisors will conduct a training with all counselors on how to properly evaluate a client regarding the information provided during the psychosocial interview process. The training will include specifically how to evaluate the client ' s assets and strengths, support systems, coping mechanisms, negative factors, conclusions regarding the client ' s appearance and behavior during the initial interview, and conclusions regarding the client ' s attitude toward and ability to participate in the treatment process. The training will also include the importance of legibility of the documentation. Supervisors will also follow up the training during weekly supervision with counselors.
The Clinical Supervisors and Program Director will be responsible to ensure this deficiency does not re-occur.
Completion and Training Date: 12-19-11
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations.
The findings include:
On November 7-8, 2011, eleven client records requiring documentation of case consultations were reviewed. The facility did not document a case consultation at least quarterly in in six of eleven client records, specifically, client records # 1, 4, 6, 7, 8 and 16.
Client # 1 was admitted on 3/30/11. The first case consultation was documented on 6/3/11, but the second case consultation was not documented 90 days later. The second case consultation was not documented until 11/3/11.
Client # 4 was admitted on 2/8/11, but the first case consultation was not documented 90 days later. The first case consultation was not documented until 5/20/11.
Client #6 was admitted on 3/17/11. The first case consultation was documented on 6/1/11, but the second case consultation was not documented 90 days later. The second case consultation was not documented until 10/1/11.
Client #6 was admitted on 3/17/11. The first case consultation was documented on 6/1/11, but the second case consultation was not documented 90 days later. The second case consultation was not documented until 10/1/11.
Client # 7 was admitted on 2/8/11. The case consultations in client # 7s records were not documented every ninety days. The first case consultation was not documented until 5/23/11, and the second case consultation was not documented until 10/18/11.
Client #8 was admitted on 3/2/11. The first case consultation was documented on 6/1/11, but the second case consultation was not documented 90 days later. The second case consultation was not documented until 6/21/11.
Client #16 was admitted on 3/24/11. The first case consultation was documented on 6/6/11, but the second case consultation was not documented 90 days later. The second case consultation was not documented until 10/18/11.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
Program Directors and Clinical Supervisors developed a document tracker to specifically track all case conferences which are due. The tracker will be assessed weekly to ensure that all case conferences due during the upcoming week will be done. The clinical supervisors will meet with the Program Director weekly who will be responsible to ensure this deficiency does not re-occur.
Completion: December 19, 2011
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information.
The findings include:
On November 7-8, 2011, five client records requiring follow-up information were reviewed, specifically records # 9, 11, 12, 13 and 15. The facility did not document follow-up information within 30 days, as per facility policy, in two of five records reviewed, specifically client records # 9 and 11.
The facility ' s follow-up policy states: Supervisory staff mails a follow-up questionnaire to the client within 30 days.
Client # 9 was admitted on 2/24/11 and discharged on 6/21/11, but client # 9 ' s record did not contain documentation of a follow-up questionnaire mailed to the client.
Client # 11 was admitted on 2/24/11 and discharged on 6/21/11, but client # 11 ' s record did not contain documentation of a follow-up questionnaire mailed to the client.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
The clinical supervisors will turn in all discharge packets to a clinical supervisor who will monitor that the follow up has been done and the needed confirmation of such is noted is noted on the discharge packet to ensure this deficiency does not re-occur. The Program Director will be responsible to ensure documentation of all follow ups are completed
during weekly meetings with the noted supervisor.
Competed: December 12, 2011
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709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to display the hours of operation conspicuously to the general public.
The findings include:
An inspection of the facility ' s physical plant was conducted on November 8, 2011 between approximately 12:30 PM and 1:30 PM. At the time of inspection the hours of operation were not displayed to the public.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
Effective 11/08/2011 the hours of project operation were displayed conspicuously to the general public. This will be sustained and monitored by the security supervisor during regular rounding. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to display a telephone number conspicuously to the general public for emergency purposes.
The findings include:
An inspection of the facility ' s physical plant was conducted on November 8, 2011 between approximately 12:30 PM and 1:30 PM. At the time of inspection, a telephone number for emergency purposes was not displayed to the public.
The findings were confirmed by the project director on November 8, 2011.
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Plan of Correction
Effective 11/08/2011 the telephone number for emergency purposes was displayed conspicuously to the general public. This will be sustained and monitored by the security supervisor during regular rounding. |