INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, GPHA Al-Assist Behavioral Health Care Center 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 September 24, 2008.
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Plan of Correction
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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
Based on a review of the facility's policy and procedures manual and administrative documentation on August 27, 2008, the facility failed to designate a project director as responsible for the overall management of the project and staff.Findings:The facility did not designate a person responsible for the overall management of the project and staff who is officially responsible to the governing body.
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Plan of Correction
Standard in Non-Compliance
704.5(a) LICENSURE
Project/Facility Director:
In an effort to address the non-compliance of standard 704.4, a project director has been identified and placed in the role of project director for the overall management of the project and staff, and who is officially responsible to the governing body.
Correction Time: Completed
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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 personnel records on August 27, 2008, the facility failed to document the qualifications for the position of counselor in one of three personnel records where required. Findings:The facility did not provide documentation of one year of clinical experience in a health or human services agency in personnel record # 5.
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Plan of Correction
Standard in Non-Compliance
704.7(b) LICENSURE
Counselor Qualifications:
In an effort to address and avoid any future non-compliance of standard 704.7(b). The Director of Behavioral Healthcare Services, Coordinator of Behavioral Healthcare Services, and Clinical Coordinator held a meeting with the staff members identified as not meeting the experience requirements in at least one of the paragraphs of 28 Pa. Code Subsection 704.7(b), informing her that she lacked the appropriate experience to meet the qualifications of a Counselor III. The staff member was informed that her status as a Counselor III will be suspended for 6-months, during which time, the Coordinator of Clinical Services will be working with her one-on-one providing her with supervision, clinical guidance, and signing off on all her clinical documentation. Upon successfully completing the 6-month evaluation period and receiving a positive assessment, she will resume her role as a counselor III with a full caseload. The suspension of her status will not impact salary or seniority and will be retroactive to October, 2008. All future/potential hires for the Drug and Alcohol program will be scrutinized based on 28 Pa. Code Subsection 704.7(b), by both the Clinical Team and the Human Resource Department. Failure to meet the educational and experience qualifications will result in a non-hiring of the applicant. This process will be monitored by the HR Director and the Director of Behavioral Healthcare Services.
Correction Time: Completed
Ongoing Monitoring
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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
Based on a review of seven personnel records on August 26, 2008, the facility failed to document a written individual training plan developed annually and appropriate to the employee's skill level and with input from both the employee and supervisor in six of seven personnel records.Findings:The facility did not document a written individual training plan in personnel records, # 2, 4, 6 and 7. The facility did not document a training plan that indicated topics and presenters in personnel records # 3 and 5.
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Plan of Correction
08 Standard in Non-Compliance
704.11(b)(1)
LICENSURE Staff Development Program.
(b)Individual Training Plan. (1)Written Individual Training Plan...
In an effort to address the non-compliance of standard 704.11(b)(1)(Individual Training Plan:[Written]). The Director of Behavioral Healthcare Services and the newly appointed Project Director held a meeting on 9/29/08 with the Clinical Coordinators to review standard 704.11 (b)(1) along with the agencies policy and procedures manual as it relates to developing an individual training plan. According to the agencies policy in support of this standard, comprehensive individual training plans are scheduled to be completed by the assigned supervisor for each staff member utilizing information gathered from the assessment of training needs and supportive of the staff's job description, staff's training/ developmental desires, and skill level during the month of November for the upcoming year. Clinical Coordinators and Supervisory staff were instructed to complete the staff developmental/ training plan for each staff member no later than Friday, November 28, 2008. The Director of Behavioral Healthcare Services will review and sign off on each developmental/training
plan ensuring that each plan accurately documents/captures the training needs of each staff and to ensure that a developmental/training plan has been completed and appropriately documented for each staff. A copy of the developmental/ training plans will be maintained in the developmental/ training plan binder. The original will be placed in each staff members' personnel file. The developmental/ training plans will be review quarterly by the Clinical Coordinators to monitor progress. Findings of the reviews will be discussed with staff during their individual supervision.
Completion Time: 11/28/08
with quarterly monitoring
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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
Based on a review of six personnel records on August 26, 2008, the facility failed to document an annual individual work performance evaluation in two of four personnel records where required.Findings:The facility did not document an individual work performance evaluation within the specified time frames as indicated in the project's policy and procedures manual for employee promotions and for new hires in personnel records # 3 and 5.
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Plan of Correction
Standard in Noncompliance
709.26(d)(5)(i) Personnel Management:
In an effort to comply with Standard 709.26(d)(5)(i) Personnel Management, the Project Director, HR Director, and Director of Behavioral Healthcare held a meeting to determine strategies to avoid late annual performance evaluations: Results of the meeting: Supervising staff will receive via email from the HR department a list of all supervised staffs' annual performance evaluation due dates. Annual performance evaluations will be submitted via email to the supervisor 45 days prior to the due date. Reminders of the upcoming performance evaluation due date for each staff will be sent via email from the HR department 30 days prior, 15 days prior, and 24 hours prior to the due date if not yet received. Notification of failure to meet the annual performance evaluation due date will be forwarded to the Project Director and Director of Behavioral Healthcare Services resulting in a written reprimand.
Correction Time: Complete
Monitoring - ongoing
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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
Based on a review of five client records on August 27, 2008, the facility failed to document informed and voluntary consent forms containing specific client information to be released in three of five client records where required.Findings:The facility did not document the specific information to be released on the consent to release information form to primary care physicians in client records # 1 and 3. Additionally a progress note indicated information was released to the Social Security Administration, but the facility did not have a consent to release information form for the Social Security Administration in client record # 4.
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Plan of Correction
Standard in Noncompliance
709.28 (c)(2) Confidentiality
In an effort to comply with regulation 709.28, the written findings from the August 27, 2008 were discussed with all staff during the general staff meeting. In addition, the Director of BHS and clinical Coordinators held a meeting with all the Clinical Staff and Medical Records Clerks to review Standard 709.28 and to review the agency's Confidentiality policy and procedures supportive of Standard 709.28(c) (2) / 4 Pa code Subsection 255.5(b), and to reiterate the importance of accurately documenting on the informed and voluntary consent form the specific information to be released/disclosed with the clear understanding that the released/disclosed information must not exceed the limitation set forth in 4 Pa Code Subsection 255.5(b): 1. whether the client is or is not in treatment; 2. The prognosis of the client; 3. The nature of the project; 4. A brief description of the progress of the client; and 5. a short statement as to whether the client has relapsed into drug and alcohol and frequency of such relapse. In addition, staff was instructed not to exceed the parameters of State and Federal Confidentiality Regulations outlined in 4 Pa Code 255.5 when completing monthly reports for the Federal / State Court systems, insurers, residential facilities, and/or hospitals. Staff was also instructed to ensure that a release of information is obtained from the Client prior to releasing information to Social Security Administration. All staff were informed during the meeting that failure to comply with the Confidentiality policy and procedures, Standard 709.28(c) (2), 4 Pa Code Subsection 255.5(b) will result in 1. (First violation) a written reprimand 2. (Second violation) suspension without pay, pending termination of employment. Informed and voluntary consent forms will be randomly audited weekly for compliance by the Client Service Coordinator and Medical Records Clerks to ensure compliance. A random audit of each therapist caseload will be conducted periodically by the Clinical Coordinator to ensure that standard 709.28 (c)(2) is being followed properly.
Correction Time: Correction Completed Monitoring On-going
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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 a review of five client records on August 27, 2008, the facility failed to document a complete psychosocial evaluation in two of five client records where required.Findings:The facility did not document an evaluation of the client's support systems, assets/strengths, negative factors that may inhibit treatment and the client's attitude towards/ability to participate in treatment in client records # 1, 2 and 4.
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Plan of Correction
Standard in Noncompliance
709.91 (b)(6) Intake and Admission
In an effort to comply with regulation 709.91 (b)(6) the written findings from the August 27, 2008 were discussed with all staff during the general staff meeting. In addition, the Director of BHS has scheduled an in-service training for Friday, November 21, 2008 to review all aspects of the intake and admission process and information required to be collected and documented including but not limited to a complete psychosocial evaluation of the client's composite picture: client's problems/needs, support systems, coping mechanisms, assets/strengths, negative factors that may inhibit treatment, attitude towards treatment, ability to participate in treatment and the counselor's impressions of the client and etc. A random audit of each therapist caseload will be conducted periodically by the Clinical Coordinators to ensure that standard 709.91 (b) (6) is being followed properly. Counselors found non-compliant of this regulation will receive additional support from the Clinical Coordinator during weekly individual supervision.
Correction Time: November 21, 2008 Monitoring On-going
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
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Observations
Based on a review of five client records on August 27, 2008, the facility failed to document complete individual treatment plans in three of five records where required.Findings:The facility did not document complete individual treatment plans within 30 days as indicated in the facility's policy and procedures manual in client records # 3, 4 and 5.
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Plan of Correction
Standard in Noncompliance
709.92(a)Treatment and Rehabilitation Services
In an effort to comply with regulation 709.92 (a) the written findings from the August 27, 2008 were discussed with all staff during the general staff meeting. During this meeting, a Treatment Plan Compliance Auditing Team was identified. The TPCAT are scheduled to randomly audit Treatment Plans The TPCAT are scheduled to randomly audit Treatment Plans, Treatment Plan Updates, and Aftercare Plans the 3rd Friday of each month beginning October 17, 2008. TPCAT will be auditing based on regulation 709.92 ... and 709.93..., and the agencies policy on treatment plan documentation. Findings from the audit will be analyzed and released to all staff via memorandum. Counselors identified as inadequate in treatment planning will receive additional support from the Clinical Coordinator. Counselors who fail to demonstrate improvement in the area of treatment planning despite additional support within 30day junctures will be terminated no more than 90 days from the initial date deemed inadequate of meeting Standard 709.92 (a) with emphasis on completing Treatment Plans in a timely manner and the agencies Treatment Plan Policies.
Correction Time: October 17, 2008 Monitoring On-going
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709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. 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 five client records on August 27, 2008, the facility failed to document complete individual treatment plans with short and long-term goals in three of five client records where required.Findings:The facility did not document treatment plan goals in terms of measurable criteria in client records # 1, 2 and 3.
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Plan of Correction
Standard in Noncompliance
709.92(a)(1) Treatment and Rehabilitation Services
In an effort to comply with regulation 709.92 (a)(1) the written findings from the August 27, 2008 were discussed with all staff during the general staff meeting. During this meeting, a Treatment Plan Compliance Auditing Team was identified. The TPCAT are scheduled to randomly audit Treatment Plans The TPCAT are scheduled to randomly audit Treatment Plans, Treatment Plan Updates, and Aftercare Plans the 3rd Friday of each month beginning October 17, 2008. TPCAT will be auditing based on regulation 709.92 ... and 709.93..., and the agencies policy on treatment plan documentation. Findings from the audit will be analyzed and released to all staff via memorandum. Counselors identified as inadequate in treatment planning will receive additional support from the Clinical Coordinator. Counselors who fail to demonstrate improvement in the area of treatment planning despite additional support within 30day junctures will be terminated no more than 90 days from the initial date deemed inadequate of meeting Standard 709.92 (a)(1) with emphasis on identifying measurable long and short term goals and the agencies Treatment Plan Policies.
Correction Time: October 17, 2008 Monitoring On-going
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of five client records on August 27, 2008, the facility failed to document a treatment plan update with an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in three of five client records where required.Findings:The facility did not document a treatment plan review and update at least every 60 days in client records # 1, 2 and 4.
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Plan of Correction
Standard in Noncompliance
709.92(b) Treatment and Rehabilitation Services
In an effort to comply with regulation 709.92 (b) the written findings from the August 26, 2008 were discussed with all staff during the general staff meeting. During this meeting, a Treatment Plan Compliance Auditing Team was identified. The TPCAT are scheduled to randomly audit Treatment Plans, Treatment Plan Updates, and Aftercare Plans the 3rd Friday of each month beginning October 17, 2008. TPCAT will be auditing based on regulation 709.92 ... and 709.93..., and the agencies policy on treatment plan update documentation. Findings from the audit will be analyzed and released to all staff via memorandum. Counselors identified as inadequate in treatment planning will receive additional support from the Clinical Coordinator. Counselors who fail to demonstrate improvement in the area of treatment planning despite additional support within 30day junctures will be terminated no more than 90 days from the initial date deemed inadequate of meeting Standard 709.92 (b) with emphasis on timely completion, and assessing the client's progress or lack of progress towards the treatment goals, and the agencies Treatment Plan Update Policies.
Correction Time: October 17, 2008 Monitoring On-going
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