INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 21, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights, 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position in one of one personnel record.
The findings include:
Personnel records were reviewed on September 21, 2012. Two personnel records were reviewed for the clinical supervisor position. One personnel record required the documentation of monthly meetings between the clinical supervisor and their supervisor for the first six months of employment in that position. The facility failed to document monthly supervision meetings in personnel record # 3.
Employee # 3 was hired at the project on October 28, 2003 and was promoted to the position of clinical supervisor on April 19, 2012. Monthly supervision meetings were required to take place in April, May, June, July, and August of 2012. There was no documentation of monthly supervision meetings in the personnel record of employee # 3.
An interview with the project director and clinical supervisors took place on September 21, 2012 at which time it was confirmed that there was no documentation of monthly supervision meetings.
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Plan of Correction
The Clinical Director meets with the Clinical Coordinator on a bi-weekly basis. These Supervision sessions will now be documented on a form the Clinical Director has developed specifically for that purpose. These meetings results forms will be maintained chronologically by the Clinical Director.
As per New Insights policy, the Executive Director will make sure that any new clinical staff member, who qualifies as a new supervisor, will have documented sessions with their supervisor on a regular basis for the first six months of employment in that position. This plan of action will be initiated on 9/26/2012. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facilities staff schedule work hours and the Fist Aid and CPR certification cards, the facility failed to provide a sufficient number of staff persons trained in CPR and First Aid during the project's hours of operation.
The findings include:
The CPR certification cards and First Aid certification cards were reviewed on September 21, 2012. The facility's hours of operation are; Monday through Thursday 9 am - 9 PM, Friday 9 am - 5 PM and Saturday 9 am - 1 PM. There were times where only one staff member had a current CPR certification on varied shifts and one time period that the facility did not have any coverage.
Monday - Lack of sufficient coverage 5 PM to 9 PM
Tuesday- Lack of sufficient coverage from 5 PM to 9 PM
Wednesday - Lack of sufficient coverage 5 PM to 6:30 PM and no coverage from 6:30 PM to 9 PM
An interview with project director on September 21, 2012 confirmed the findings. This is a repeat citation from the May 16-17, 2012 licensing inspection.
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Plan of Correction
The Executive Director made adjustments to the staff schedule that will go into effect on October 1, 2012. This staff schedule change will provide for a minimum of two (2) employees on duty during all hours of operation.
The Executive Director will assure that adequate coverage will remain intact by completing the CPR/First Aid coverage grid on a quarterly basis. This will take in to account any possible changes in employee work schedules or personnel changes.
This standard will be in full compliance by October 1, 2012. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included the counselors evaluation of the client's assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in four of five client records. Additionally, the counselor failed to evaluate and document their conclusions and impressions of the client in three of five records.
The findings include:
Twelve client records were reviewed on September 21, 2012. Five of the sixteen records reviewed were from the partial hospitalization outpatient activity. A psychosocial evaluation was required in all partial hospitalization client records. The facility failed to document a psychosocial evaluation that included the counselor's evaluation of the client's assets/strengths, support systems, coping mechanisms and negative factors, specifically records # 2, 3, 4, and 5. The counselor also failed to document their conclusions and impressions of the client's evaluation in client records # 2, 3, and 4.
Client # 2 was admitted on July 25, 2012. The psychosocial evaluation was documented on August 1, 2012. The counselor failed to document an evaluation that included the client's assets/strengths, support systems, coping mechanisms and negative factors. The counselor did not document their conclusions and impressions of the client's evaluation.
Client # 3 was admitted on August 22, 2012. The psychosocial evaluation was documented on August 31, 2012. The counselor failed to document an evaluation that included the client's assets/strengths, support systems, coping mechanisms and negative factors. The counselor did not document their conclusions and impressions of the client's evaluation.
Client # 4 was admitted on August 2, 2012. The psychosocial evaluation was documented on August 7, 2012. The counselor failed to document an evaluation that included the client's assets/strengths, support systems, coping mechanisms and negative factors. The counselor did not document their conclusions and impressions of the client's evaluation.
Client # 5 was admitted on July 13, 2012. The psychosocial evaluation was documented on July 24, 2012. The counselor failed to document an evaluation that included the client's assets/strengths, support systems, and coping mechanisms.
This finding was discussed with the project director and clinical supervisor and was not disputed.
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Plan of Correction
The Clinical Coordinator will review with the clinical staff in the staff meeting on 10/24/2012 that all composite pictures/psycho-social evaluation of the client must include the counselor's evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, and the counselor's conclusions and impressions of the client. Examples will be provided. The Clinical Coordinator will review all composite views of clients for required content for compliance for 3 months. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The findings include:
The letters of agreement were reviewed on September 21, 2012. There was no documentation of a 24- hour emergency medical coverage agreement.
The project director was interviewed on September 21, 2012. It was confirmed at that time that no documentation of a 24- hour emergency medical coverage was available.
This is a repeat citation from the May 16-17, 2012 licensing inspection.
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Plan of Correction
The Executive Director revised the Letter of Agreement with the local Hospital for the provision of emergency medical and psychiatric care for the Lemoyne facility. The Letter of Agreement agrees to provide twenty-four (24) hour coverage and does not require a renewal period.
The Clinical Director has a meeting arranged with the Director of Emergency Services on October 17, 2012, to obtain his signature. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of administrative polices and procedures, the facility failed to complete the 2010-2011 audit by the end of the project's fiscal year, as required by the regulation.
The findings include:
The administrative polices and procedures were reviewed on September 21, 2012. Per regulation, the project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug and alcohol abuse services. The project's fiscal audit for July 1, 2010 through June 30, 2011 was to be completed no later than December 31, 2011. The project provided a fiscal audit that was dated January 20, 2012. This was documented 20 days late.
The findings were confirmed by the project director.
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Plan of Correction
The Executive Director will request the scheduling of our Annual Audit in May of each year. An effort will be made to schedule the audit in August (or) September of that same year. This will better assure that the audit will be completed before the end of the year, December 31.
The Executive Director will have a calendar flag in May of each year as a reminder to schedule the annual audit. This action will be completed by 10/24/2012. |
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 the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in four of twelve patient records reviewed. The facility also exceeded 4 Pa. Code, Subsection 255.5(a) (6) by releasing too much information to the employer in one of twelve records reviewed.
The findings included:
Twelve client records were reviewed September 21, 2012. All records were reviewed were reviewed for release of information documentation. The facility failed to document that an informed and voluntary consent to release information was obtained in four patient records, specifically records # 2, 3, 4, and 9. Additionally, documentation was released to an employer in record # 4 that exceeded 4 Pa. Code, Subsection 255.5(a) (6).
A review of record # 2 documented a family session took place on August 17, 2012 with the client's sister and brother-in-law. The facility failed to obtain an informed and voluntary consent from the client for a brother-in-law.
A review of record # 3 documented a family session took place on August 26, 2012 with the client's father and stepmother. The facility failed to obtain an informed an voluntary consent from the client for the stepmother.
A review of client record # 4 revealed information was released to the employer that exceeded 4 Pa. Code, Subsection 255.5(a)(6). The facility had the client sign a consent to release that allowed for the client's location and length of stay. Additionally, this record had a letter faxed " To Whom it May Concern" on August 20, 2012. A consent to release could not be verified for this letter due to the letter not being written to a specific person or entity.
A review of record # 9 documented couples counseling took place on August 30, 2012 with the patient's wife. The facility failed to obtain an informed and voluntary consent from the client for his wife.
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Plan of Correction
The Clinical Coordinator will review with the clinical staff in the staff meeting on 10/24/2012 that an informed and voluntary consent is required for any and all members that attend a family or couples counseling session or group. The information permitted to be released to an employer under 255.5 will also be reviewed. The Clinical Coordinator will randomly audit charts once a month to check for compliance. |