INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD New Start II 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 July 21, 2008.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of personnel and training records, the facility failed to document an individual training needs assessment in four of five records reviewed, #2, 3, 4 and 5.
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Plan of Correction
The Director will revise the policy 709.26C (1)to incorporate the individual needs assessment into the annual training plan. The Clinical Supervisor will ensure that each staff persons training needs assessment is completed by Decemeber 31 of the each year and placed in their personnel file. |
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 training and administrative records, the facility failed to document an annual evaluation of the overall training plan for the 2007 calendar training year.
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Plan of Correction
The Director, staff #2 completed the annual training evaluation and placed it in the manual. The Director will ensure that future plans are completed by December 31st and placed in the facility manual. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel and training records, one counselor was required to have the minimum of 25 training hours for the 2007 training year. The facility failed to document the 25 hours of training in one of one record reviewed, #5. The counselor only had 10 hours of training for the 2007 training year.
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Plan of Correction
Staff #5 completed the requirements and sent away for his outside of RHD certificates. His personnel file was updated to reflect his in-house training of clinical documentation which was reviewed by the program director.the clinical supervisor will monitor and ensure that the reauired number of training hours are documentated by 9/1/2008. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted on June 26, 2008 at 2:00 PM, the facility failed to maintain the maximum hot water temperature of 120 degrees Fahrenheit. The hot water temperature was measured at 130 degrees Fahrenheit.
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Plan of Correction
The facility skills trainer/cook will check the water temperture daily and record it in the logbook with the freezer and refrigerator tempertures. If the hot water temperature is above 120 degrees Fahrenheit then the skills trainer will inform the Residential Supervisor who will turn the hot water regulator down. The Director will check the log book monthly to ensure continued compliance. This will be effective 7/1/2008. |
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 conducted on June 26, 2008 at 2:00 PM, the facility failed to maintain client records in a locked storage container. The client records were maintained in a metal filing cabinet in the rear building on the facility grounds. During the inspection, the building was left unattended and the door to the building was left open. The filing cabinets were left unlocked.
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Plan of Correction
The clinical supervisor will ensure that the records are kept in a locked file cabinet at all times. The clinical supervisor, director and program manager will have access to the keys and a notice will be posted on each cabinet to keep it locked when leaving the room and/or the area. The standard will be in compliance by 8/15/2008. |
709.28 (c)(1) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent in two of four records, reviewed, #1 and 2. The names of the emergency contacts to whom the disclosure was to be made were missing.
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Plan of Correction
The Clinical Supervisor will ensure that all consents are completely filled out with all required information. Specifically, the Clinical Supervisor met with the Client # 1 and # 2 on 6/27/08 to fill in the name of the emergency contact. To ensure on-going compliance with the standard the clinical supervisor will review the records monthly.
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709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of the administrative records and project policies and procedures, the facility failed to conduct quarterly inspections. The last inspection was conducted in February 2008. There was no inspection for May 2008.
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Plan of Correction
The Clinical Supervisor completed the medication inspection as scheduled but had failed to file it. It was reviewed by the Director and put in the log and filed on 6/26/08. The procedure to ensure future and on-going compliance is for the clinical supervisor to continue to conduct quarterly inspections of the medication storage area. The next one is due August 2008.
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709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of medication administration records, the facility failed to document medication administration records for three of four client records reviewed, #3, 4 and 5. The licensing specialist was informed that the medication records were maintained somewhere within the facility, but the program staff were unable to present those records at the time of the inspection.
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Plan of Correction
The Director and clinical supervisor will ensure that the medication administration records for all clients are maintained in the closed client charts/records. The residential team leader will remove the medication administration records monthly and submit them to the clinical supervisor who will ensure that they are placed in the appropriate client file. The clinical supervisor will conduct training on medication maintenance for all team leaders on 7/22/08. The standard will be in compliance on 8/1/2008. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of five client records, four were required to have complete psychosocial evaluations. The facility failed to document complete psychosocial evaluations in four of four records reviewed, #1, 2, 3 and 4. Psychosocial evaluations did not include an assessment of the client's assets/strengths, support systems and negative factors that may inhibit treatment.
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Plan of Correction
The Clinical Supervisor will conduct training for all clinical staff on writing psychosocial evaluations and assessments with an emphasis on assets, strengths, support systems and negative factors that are a barrier to TX. The training will take place over two Fridays starting 8/1/2008. The goal will be completed 8/8/2008. The clinical supervisor will monitor compliance each time a psychosocial is submitted.
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709.52(a)(1) LICENSURE Short/Long term TX Goals
709.52. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document complete treatment plans in three of five records reviewed, #2, 4 and 5. Treatment plans did not include goals stated in terms of measurable criteria
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Plan of Correction
The clinical supervisor will conduct training for all clinical staff on treatment planning and goal-setting. This training will be conducted on 8/26/2008. The facility will be in compliance thereafter by monthly monitoring of all treatment plans prior to signing by the clincal supervisor. |
709.52(a)(3) LICENSURE Support service type
709.52. 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 the proposed types of support services in four of five records reviewed, #1, 2, 4 and 5
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Plan of Correction
The program director and clinincal supervisor will revise the master treatment plan to outline the support services in a format that identifies the service and list the times a client will attend those services. This standard will be in compliance 8/4/2008. It will be monitored by the clinical supervisor monthly. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of five client records, four were required to have treatment plan updates. The facility failed to document complete treatment plan updates in one of four records reviewed, #2. The treatment plan updates did not provide an assessment of the client's progress in relationship to the stated goals of the prior treatment plan. The treatment plan updates did not indicate if the goals needed to be revised or restated and if the action steps needed to be modified. Additionally, the information in two treatment plan updates in client record #4 were identical with regards to the goals and action steps achieved, those not achieved and the overall assessment of the client's progress.
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Plan of Correction
The clinical supervisor will conduct 1:1 training during supervision for the therapists at the facility. The training will review the treatment plan update and include instructions on completion of the forms. This supervision training will be conducted on 7/29/2008. The clinical supervisor will monitor on-going compliance bi weekly.
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