INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 2-3, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cen-Clear Child Care Services, 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 and a plan of correction is due on July 3, 2009.
|
Plan of Correction
|
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.
|
Observations
Based on a review of employee personnel records during the annual on-site licensing inspection of June 2-3, 2009, the facility failed to hire counselors who met one of the qualifications for the position of counselor, as required under this Chapter, in three of five personnel records.
The findings included:
A total of seven employee records were reviewed. Five of these were staff who are engaged in the provision of counseling services. Three employees on staff identified as counselors did not meet at least one of the qualifications as specified in this chapter. Specifically employees # 4, 5 and 6 . None of the three had a degree that was related to human services.
Employee # 4 had documentation of a Bachelor's degree in criminology and no documentation of clinical experience. Employee # 5- had documentation of a Bachelor's degree in education (social studies) and no documentation of clinical experience. Employee # 6 - had documentation of a Bachelor's degree in Political Science and a Master's degree in Industrial /Labor relations and no documentation of clinical experience.
|
Plan of Correction
CCS have made employee #4 and #5 Counselor Assistants status who will be supervised by the Facility Director and one other Full Time Masters Level Counselor. They both have 4 yr degrees in related fields and will both will receive direct supervision for a period of 3 months and close supervision for an additional 6 months. They willl alsohave clinical supervision access on a daily basis. In addition, employee #6 has resinged from the agency and new qualified staff will be hired to replace him. Both of the COunselor assistants have been enrolled or are in process of pursuing thier CAC certification. Proof of enrollment in a CAC program will be documented in their personal file. |
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.
|
Observations
Based on a review of agency the agency policy manual and staff training records during the annual onsite licensing inspection of June 2-3, 2009, the facility failed to follow agency policy regarding the safe physical management of clients who were acting out.
The findings included:
The agency policy and procedure manual contains a policy which addresses safe physical management. The policy indicates that all staff will be trained in this technique. When staff training files were reviewed no documentation was on file to indicate that any of the staff presently employed, specifically employees # 1, 2, 3, 4, 5, 6, and 7, had been trained in this technique.
|
Plan of Correction
All staff were registered to complete this training on June 30, 2009. In addition, CCS has deleted this required training from the DA policy and procedure manual as a required training by all staff. |
704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on the review of employee personnel and training records and the agency self report staffing form during the annual onsite licensing inspection of June 2-3, 2009, the facility failed to maintain client to counselor caseloads at or below 35:1.
The findings included:
The agency employs five clinical staff. Three of the clinical staff, employees # 4, 5 and 6, did not meet one of the requirements specified at 28 Pa. Code subsection 704.7(b), hence their clients were not assigned to the caseloads of qualified staff. This resulted in uncovered caseloads of 21:0; 24:0; and 11:0.
|
Plan of Correction
Counselor Assistant #4 has submitted to CCS supporting documentation that she is acquiring her CAC. In addition, a qualified Bachelor Level Counselor has been hired to cover the other caseload of Counselor #6. Counselor Assistant #5 is in process of getting enrolled in CAC program. Accommadations with other staff will be covering caseloads. In addition, many active clients were discharged since the review. At this time, we are within the required ratio's |
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
|
Observations
Based on the physical plant inspection conducted on June 2-3, 2009, the facility failed to ensure that garbage and rubbish were disposed of in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings included:
A physical plant inspection was conducted during the onsite licensing inspection on June 3, 2009. Bags of trash were piled in the entranceway awaiting pick up by the waste disposal service later in the week.
|
Plan of Correction
A stainless steel garbage can has been set outside to secure waste. Dept Assistant will be responsible to make sure that all trash is bagged and placed in the waste disposal cans. |
709.22(e)(2) 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:
(2) A financial statement of income and expenses.
|
Observations
Based on a review of the annual report during the annual onsite licensing inspection of June 2-3, 2009, the facility failed to document an annual report which included a statement of income and expenses.
The findings include:
The 2007-08 annual report was documented as required but did not include the statement of income and expenses for the agency. This documentation must be included in the annual report each year.
|
Plan of Correction
The expenditures for the DA division of CCS will be added to the 2008-2009 annual board report. We were sited at last review for this but our annual report is not due until August of each year which does not reflect the corrections til this August of 09. |
709.22(e)(3) 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:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
|
Observations
Based on a review of the annual report during the annual onsite licensing inspection of June 2-3, 2009, the facility failed to document an annual report which included a statement disclosing the names of officers, directors and principal shareholders..
The findings included:
The 2007-08 annual report was documented as required but a statement disclosing the names of officers, directors and principal shareholders was not included in the documentation as required.
|
Plan of Correction
Same as the previous obervation. CCS's annual board report that will reflect the additions of board members names, stake holders and directors will be added in the 2008-2009 annual board report due August 09. The Executive Assistant is responsible for the corrections and additions to the annual board report. |
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.
|
Observations
Based on a review of client records during the annual onsite licensing inspection of June 2-3, 2009, the facility failed to document consents to release information which included the specific information to be disclosed to the identified recipient, in nine of nine client records.
The findings included:
Nine client records were reviewed during the onsite licensing inspection. Each was required to have completed consent forms for releases to all persons or agencies receiving client related information. Eight client records contained consents to release information to family members or significant others which did not identify what information was permitted to be released on the form. Client records # 1, 2, 3, 4, 5, 6, 7 and 8 were the records identified with this issue.
|
Plan of Correction
Release of information form has been altered to address state requirements. Developed a new release of information form to include specific information, purpose and to whom to disclose. Facility Director is responsible to train all staff on the completion and accuracy of the form. Review of completeness will be responsibility of Facility Director as well. Paperwork will be part of FD QA review as part of supervision. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
|
Observations
Based on a review of client records and an interview with the Project and Facility Directors during the onsite licensing inspection of June 2-3, 2009, the facility failed to document consents to release information which included a purpose for the specific information to be released on each release of information form signed by the clients in nine of nine client records.
The findings included:
Nine client records were reviewed during the annual onsite licensing inspection. Each record must document the purpose for releasing the specific information identified on the consent to release information forms. Facility forms used to authorize releases of information did not identify the purpose for the release of the specific information listed on the forms found in eight of nine client records, specifically client records # 1, 2, 3, 4, 5, 6, 7 and 8.
The forms which are identified below were problematic in that the purpose section of the form, rather than identifying why it was necessary to release the specific information listed on the form, was, in effect, used to identify additional information which would be released - such as; assessment outcomes, significant history, significant client contacts, treatment plans and relevant consultations with service providers. The agency forms D&A 11,12, 60, 64 and 81 were developed to release information to government agencies, including county probation officers and third party payers. In addition to not identifying a purpose for the need to release identified information, the information that would be released that was listed in the purpose section exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b).
An interview with the Project and Facility Directors during the exit summary on June 3 , 2009, verified that the areas identified in the purpose section of the form were intended to authorize disclosure of the additional information. The form, as constructed, did not constitute an informed consent because the manner in which the form was utilized by staff to release information documented in the purpose section of the form rather than actually identifying a purpose for the release of the information identified in the specific information part of the form, confused and confounded rather than informed.
|
Plan of Correction
As stated in previous plan of correction, the release of information form has been revised to reflect the recommendations from the reviewer. Completeness and accuracy will be monitored by the Facility Director in superivision and QA chart reviews. In addition, the Facility Director will be meeting with all counselors reviewing the current active caseload and make adjustments accordingly to their deficient areas. All forms will be updated in active charts to show these corrections. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on a review of client records during the onsite licensing inspection of June 2-3, 2009, the facility failed to document a complete drug and alcohol history in each client record.
The findings included:
Nine client records were reviewed during the annual onsite licensing inspection. Eight of those client records were required to include documentation of complete histories. Seven client records, # 1, 4, 5, 6, 7, 8 and 9, did not identify the lengths and patterns of use for each drug used by the client, and failed to address the clients' perception of the impact of use/abuse of substances on their lives.
Prior treatment episodes were not documented in client record # 5. Family drug and alcohol abuse issues were not addressed in client records # 1 and 2.
|
Plan of Correction
Facility Director has revised histories to include, patterns, lenght of use and perceptions of DA usage. Review of completed and clinical perceptions, documentation of counselors will be monitored by the Facility Director for accuracy and completeness. This will be done during QA chart reviews and supervision by the supervisor or Facility Director. In addition, the current caseloads charts will be updated with complete, revised forms to reflect this correction and reviewed by the Facility Director. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on a review of client records during the onsite licensing inspection of June 2-3, 2009, the facility failed to document a complete personal history in nine of nine client records.
The findings included:
Nine client records were reviewed during the onsite inspection. Eight of the records were required to have personal histories. Family dynamics relative to interrelationships were not addressed as a part of the family history in client records # 1, 3, 4, 5, 6, 7, 8 and 9, causing incomplete family histories.
Work histories were not completed in client records # 1, 3, 6, 7 and 8. The form is designed to list only the most current and previous job held rather than requiring a work history.
Client record # 7 did not document a legal history even though the record documented that the client was under the supervision of a probation officer.
|
Plan of Correction
Psychosocial will be completed by the second session. PsychoSOcial must be completed in its entirety and will be reviewed by the Facility Director. No areas will be left blank and an NA will be noted. Additional areas for narrative comments have been added to capture a better history of the family relationship patterns, work history, legal issues, etc. In addition, the current active clients charts will be updated utilizing the new forms to reflect these corrections and reviewed in supervision. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records during the onsite licensing inspection of June 2-3, 2009, the facility failed to document complete psychosocial evaluations in eight of nine client records.
The findings included:
Nine client records were reviewed during the onsite licensing inspection. Eight of these were required to have complete psychosocial evaluations. Eight client records did not include documentation of the required components of the psychosocial evaluation. Specifically,
client records # 4, 5, 6, 7, 8 and 9 did not include documentation of a complete description of the client's presenting and underlying problems.
Client records # 5, 6, 7 and 9 did not include documentation of the client's preferred coping mechanisms.
Client records # 6 & 7 did not include documentation of negative factors that might impact treatment and the recovery effort.
Client records # 1, 3, 4, 5, 6, 7, 8 and 9 did not include a complete evaluation of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
|
Plan of Correction
Psychosocial history has been revised to incorporate these areas. Review of all psychosocials will be conducted by Facility Director for accuracy and completion. In addition, all staff will be retrained by the FD in completing the psychosocial in its entirety. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on the review of the client records during the onsite licensing inspection of June 2-3, 2009, the facility failed to document a preliminary treatment plan based upon information derived from the initial interview in six of nine client records.
The findings included:
Nine client records were reviewed. Preliminary treatment plans were not documented based on the information derived from the initial interview, while the facility policy incorrectly allows for the preliminary treatment plan to be formulated by the third session. Specifics from client records are noted below:
Client record # 2 - no preliminary treatment plan formulated - client admitted 5/12/09, last session documented 5/20/09. There was no documentation of the preliminary treatment plan as of June 3, 2009.
Client record # 3 - The preliminary treatment plan was not documented until the third treatment session.
Client record # 5 - The preliminary treatment plan was not documented until the fifth session.
Client record # 7 - The preliminary treatment plan was not documented until the third session
Client record # 8 - The preliminary treatment plan was not documented until the third session
Client record # 9 - The preliminary treatment plan was not documented until the third session.
|
Plan of Correction
CCS policy has been changed to reflect that preliminary treatment plans needs to be completed and reviewed by the Facility Director/Supervisor by the third session for all clients and placed in chart. Tracking for the delinquent plans will be responsibility of the dept assistant to inform the Facility Director for disciplinary action. |
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.
|
Observations
Based on the review of the client records during the onsite licensing inspection of June 2-3, 2009, the facility failed to document treatment plan updates which addressed the clients' progress on the stated goals of the treatment plan in five of nine client records.
The findings included:
Nine client records were reviewed during the onsite licensing inspection. Five of the client records in the sample required treatment plan updates every sixty days . Client record # 3 had a comprehensive treatment plan which was formulated on 3/03/09. At the time of the inspection on June 3, 2009, there was no documentation of the treatment plan update.
Client records # 1, 4, 5 and 8 documented treatment plan updates which did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
|
Plan of Correction
Treatment goals and progress notes will reflect treatment plans. Facility Director will review treatment plans/updates for measurable, obtainable, realistic goals and interventions. Treatment plan updates will occur every 60 days and be tracked by the dept. assistant. Chart reviews, documentaion will occur biweekly for deficiencies in this area. |
709.93(a)(5) LICENSURE Client records
709.93. 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.
|
Observations
Based on a review of client records during the onsite licensing inspection of June 2-3, 2009, the facility failed to document progress notes which included data, assessment and plans relative to treatment in six of nine client records.
The findings included:
Nine client records were reviewed during the annual onsite licensing inspection of June 2-3, 2009. Client records # 1, 3, 4, 5, 7 and 8 did not document progress notes which were consistent with the stated goals of the treatment plans. Nor did the progress notes include a plan component which reflected the counselor's required actions in light of the evaluation and indicate the direction of treatment. The progress notes did not include plans for the next sessions.
|
Plan of Correction
QA chart reviews of progress notes, tx plans, updates reflect the documented direction of treatment. Facility Director/supervisor will review these documentations and direct counselors in treatment as according to the client's needs. Developed a new progress note to reflect the DAP format with other MCO requirements. |
709.93(a)(8) LICENSURE Client records
709.93. 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.
|
Observations
Based on a review of client records during the onsite licensing inspection of June 2-3, 2009, the facility failed to document case consultations which included the disposition of the case in five of five client records.
The findings included:
Nine client records were reviewed during the inspection. Five client records were required to have documentation of case consultations. At least two clinical staff must be involved in order to initiate a case consultation. Consultations documented in client record # 1 ( 9/17/08 and 12/17/08) were conducted by only one clinical staff person.
Client records # 1, 3, 4, 5 and 8 did not include documentation of the disposition of the cases reviewed.
|
Plan of Correction
Facility Director will contact Project Director if there is no other clinical staff available for consultation reviews. Consultations will occur with two qualified staff and reviewed by the Project Director and Facility Director for accuracy and timely completion. Tracking system has been intiated to monitor timelines when consults are due this is monitored by the dept. assistant and forwarded to FD. |
709.93(a)(11) LICENSURE Client records
709.93. 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.
|
Observations
Based on a review of the client records during the annual onsite licensing inspection of June 2-3, 2009, the facility failed to document attempts to follow up on client who had been discharged, in accordance with stated agency policy, which states contacts would be once per week for one month, once every two weeks for two months and once every month for three months. Follow up was not documented in accordance with facility policy in 2 of 3 client records.
The findings included:
Three closed client records were reviewed at the time of the inspection . Two of these client records were required to have documentation of follow up . No follow up was documented in client record # 3. One follow up contact was noted in client record # 4, within two weeks of discharge, but there was no other documentation of attempts to follow up on the clients.
|
Plan of Correction
The Project Director changed the CCS DA follow up policy/procedure to reflect that one follow up will occur with disharged clients within one week of discharge. Dept Assistant will be tracking these follow ups on a weekly basis. If follow up does not occur in required guidelines the Facility Director will be informed to address this in supervision and will follow up to ensure the procedure is followed. In |