INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 30 to June 2, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on June 28, 2006.
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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
The staffing compliance plan was not clearly stated. The compliance plan should clearly indicate the intent of the project 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. The governing body must sign off on this plan/statement.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
The plan documenting the qualifications and training of staff must be presented to Department licensing representatives at the time of the project's site visit. The plan presented was incomplete. A full listing of support staff was omitted. The primary care hours were not clearly identified.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Employee # 4 is designated as both the Project and the Facility director. While this individual meets the educational and experience requirements for both, his duties within the organizational structure do not meet the requirements for Project Director as specified in the licensing alert of May, 2005.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Documentation to verify that counselor/parents were qualified under this Chapter to provide D&A counseling services was not presented at the time of the licensing inspection. Available documentation in the George Junior Republic manuals and literature state that the counselor/parents are integral to the provision of treatment in the milieu therapy utilized by the project.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
The policies and procedures identifying the required components of staff development were not clearly stated. The plan must include timeframe and persons responsible for each component and should clearly identify the timeframe for the training year ( example :July 1 to June 30 ; January 1 to December 31, Etc ).
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
The training needs assessment was incomplete both in terms of following written agency policy and meeting the requirements of this Chapter. Evidence of this assessment could include questionnaires completed by all staff with data compiled, or a narrative summarizing group discussion of needs. If individual questionnaires are used, a compilation should be documented.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Training feedback documentation was incomplete. The mechanism utilized for feedback was not inclusive of all training received by staff.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
The annual evaluation of the overall training did not determine the extent to which the plan addressed the identified needs, including a determination of the extent to which implementing the plan eliminated or satisfied the identified needs of the agency.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Individual training plans were not on file for all support staff. The training plan for the current year and the previous year should be presented at the time of the licensing inspection.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
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Observations
Mandatory communicable disease training was not documented for all applicable support staff. 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.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.12(a)(3)(ii) LICENSURE NonHosp Rehab/Adol
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(ii) Projects serving adolescent clients shall have one FTE counselor for every six clients.
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Observations
Based on the incomplete information provided , it was determined that the resident to counselor ratios do not meet the requirement of one FTE counselor for every six residents during the primary care hours.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
One stained mattress was noted on a bed in Memorial cottage. Beds in Memorial cottage did not have mattress covers on them while those in all other cottages did.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Monthly fire drills were not consistently documented.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Fire drills were not consistently documented during sleeping hours in each cottage at least once every six months.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
The project failed to present documentation demonstrating that the annual report was made available to the general public. Examples of availability to the public would include but not be limited to: a brochure, pamphlet, newspaper supplement or photocopied reports, and/or a posting on an Internet web site.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The written procedures for the management of treatment and rehabilitation services were incomplete. The timeframe for completion of relevant portions of the client record such as, medical, D&A and personal histories and the development of the comprehensive treatment plan were not included in the policy.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Annual performance evaluations were missing in records # 2, 4, 6, 12 and 13.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(f)(3) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
(3) The requisite skills, knowledge and experience.
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Observations
Job descriptions of support staff did not contain the minimum educational or experiential requirements for the each of these positions.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Incomplete consent forms which contained client signatures were found in records # 1 and 2. Incomplete information was provided on consents in records # 3,4,8,9 and 10. Releases without consent were noted in records # 1,2,3, 6 and 7.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
The person , agency or organization was not clearly identified on signed consents found in records # 1, 2, 4, 8, 9 and 10.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
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Observations
Specific information was not identified on consents found in records # 1 and 2. These consents were for releases to managed care organizations which were found in the records of clients funded by these organizations.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Evidence that clients are informed of their rights as required under this section was not documented . The information provided to clients for sign off did not consistently contain all rights.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.30(1) LICENSURE Client Rights
709.30. Client rights.
(1) A person receiving care or treatment under section 7 of the act (71 P. S. 1690.107), shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The statement informing clients that they may not be denied civil rights on the basis of treatment was not inclusive of relevant language in this regulation in files reviewed or in any postings throughout the facility.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
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Observations
The procedures for clients to exercise the right to inspect their records, appeal decisions limiting access to records or to make corrections or rebuttals were not identified in the manual or materials distributed to clients.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.31(a) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(a) If a project utilizes Department funds, it shall comply with the Department's UDCS.
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Observations
The data collection system in place at the project did not allow for the efficient retrieval of required materials to complete the licensing inspection. An efficient system needs to be in place for the retrieval of needed materials and files.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
A policy establishing the practice of accepting verbal medication orders is on record in the medical manuals but no timeframe which is congruent with this requirement is noted in the language of the procedures which accompany the policy.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(c)(6) 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:
(6) Inventories.
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Observations
No inventories of stock medications were available at the time of the licensing inspection. A regular account/record of stored drugs should be kept and include the date, person performing the inventory, amount of drugs on hand, amount used, amount needed and/or amount ordered [if applicable], balance in stock, and additional comments.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Lengths and patterns of use were incomplete in records # 2, 3, 4, 5 and 9. Prior treatment was not complete in records # 1,2,4,5,6 and 10. Client's perception of use was not complete in records # 1, 2, 4, 5, 6 and 9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories were incomplete in all records reviewed in the sample.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Preliminary treatment plans were missed in all applicable files in the sample. A Preliminary Treatment Plan should be based upon information derived from the initial interview. This plan should identify critical client problems and strategies for their resolution.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Information was incomplete on treatment plans in records # 1,2,3,5,6, and 10.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Proposed support services were note clearly identified on treatment plans in records # 1, 2, 5, 6 and 10.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Treatment plan updates were missing or incomplete in records # 1, 2, 4, 5, 6 and 10. The treatment plan update should include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan. Content on a number of updates reviewed did not address progress in relation to the stated goals of the treatment plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Counseling did not appear to occur on a regular and scheduled basis based on the information documented in records reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a) LICENSURE Complete Client Record
709.53. 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:
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Observations
Client records were not complete. Records # 4 , 9 and 10 had records of service which did not match progress notes.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
Client contacts were not consistently documented in files reviewed. Contacts with counselor/ parents, adventure therapists, etc. were missing from files.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
No progress notes were recorded for adventure therapy groups, counselor parent contacts, etc. Progress notes must be signed and dated by the person making the entry. Notes were not signed in files reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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
Case consultations were not documented according to the stipulations of agency policy or the requirements of this Chapter in the records reviewed. Each client's progress should be reviewed at least quarterly at a case conference consisting of representatives from the various client service components. Where the length of treatment is less than 90 days, at least one case conference should be conducted for each client.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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:
(9) Aftercare plan, if applicable.
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Observations
Aftercare plans in files #1 and 10 did not address all required areas. An aftercare plan is a plan for clients to follow after they leave formal treatment. It is the client's individual plan for the future, including an identification of the client's personal goals and objectives. It should focus on sustaining and building on the progress achieved during treatment and should have input from all significant persons, especially the client.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Discharge summaries were missing from files # 1 and 10. Discharge summaries in files # 3 and 4 did not address all required content. Within one week after discharge, there should be entered into the client's case record a discharge summary describing the reasons for treatment, services offered, response to treatment and client's status or condition upon discharge.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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
Follow up documentation was missing from files # 4 , 6, and 10.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Files reviewed were missing verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan. Individualized work therapy goals must be formulated for each client if work therapy is used as part of the treatment regime.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
The follow up policy does not address follow up in the case of referrals. Referrals must be followed up within seven days.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |