INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 31 - April 2, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, George Junior Republic 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 May 1, 2008.
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Plan of Correction
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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
Based on a review of the personnel records on March 31, 2008, the facility failed to ensure that one clinical staff member assigned as a counselor met the requirements for the counselor position. The employee represented by record #4 had less than one year of clinical experience and did not qualify as a counselor.
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Plan of Correction
Employee #4 will complete a Masters Degree in counseling in May, 2008. She will not participate in therapeutic activities as a counselor until she completes her Masters Degree or completes 1820 hours experience. The Facility Director will monitor for compliance.
Plan of correction is completed. |
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 client record reviews on 4-1-08, the facility failed to provide a signed consent to release information form prior to the disclosure of client identifying information. A referral was made to Children's Hospital without a consent to release information form signed by the client. Refer to client record #1. Client record #3 included another clients' psychiatric update report.
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Plan of Correction
New consent to release information forms will be developed and signed by each client prior to the disclosure of client identifying information to outside referral sources. The Medical Director and Facility Director will monitor to insure this procedure is followed prior to the services.
Plan of correction is completed. |
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
Based on medication policy and procedure reviewed on 4-2-08, the facility failed to provide a procedure indicating the verbal order would be signed by the prescribing physician within 24 hours. The current procedure states the physician will sign the order within two weeks.
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Plan of Correction
This procedure indicating the verbal order will be signed by the prescribing physician within 24 hours was revised in August, 2007, but was not included in the manual reviewed. This policy was in the main Medical Policy Manual at the Infirmary. The Facility Director will update the Manual reviewed to ensure the revised policy is in place. The Medical Director and Facility Director will monitor compliance.
Plan of Correction is completed. |
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 client record review on April 1, 2008, the facility failed to provide a review of the progress made on the previous treatment plan goals and objectives. This was noted in three of three client records, specifically client records # 1, 2 and 3.
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Plan of Correction
The treatment goals will be reviewed with each counselor by the Facility Director to ensure that the progress from the goals of the previous treatment plan is included in the updated treatment plan. The Facility Director will monitor the goals for compliance.
Plan of correction will completed by 4/30/08. |
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
Based on client record reviews on April 1, 2008, the facility failed to provide a complete record of service. The documentation of individual counseling sessions is missing and the services documented are out of chronological order. This was noted in three of three client records reviewed. Refer to client records #1, 2 and 3.
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Plan of Correction
The Facility Director will review the record of Service Logs with the Counselor/Parents and Social Workers to ensure that all therapeutic services are included on the Record of Service in chronological order. Files will be reviewed on a Monthly basis by the Facility Director and clerical staff for compliance.
Plan of correction will be completed April 30, 2008. |