INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 2, 2006 to October 3, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on November 1, 2006.
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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
Employees # 7 and 8 do not meet the qualification requirements for the position of counselor.
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Plan of Correction
Employees #7 and #8 will be provided three (3) months of direct observation and another nine (9) months of close supervision. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
The counselor assistant does not have a related degree. The counselor assistant has only one month of documented direct observation. The counselor assistant will need to obtain an additional two months of direct observation and nine months of close supervision.
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Plan of Correction
The Counselor Assistant will be provided two (2) months of direct observation and another nine (9) months of close supervision. |
705.23 (1) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(1) Maintain space for both individual and group counseling sessions.
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Observations
Duct tape was used to repair deteriorating carpet. Ceiling tiles were missing. The counseling areas are not well maintained.
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Plan of Correction
The current facility is up for sale and the agency is actively seeking a new location. If a new location is not found by late spring, 2007 the agency will work with the landlord to replace the carpet and ceiling tiles. |
709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. 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
The drug and alcohol histories in client records # 1 and 2 failed to address the client's progression of substance use and abuse.
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Plan of Correction
The referenced client histories will be corrected and the Clinical Supervisor will provide training and supervision to all staff regarding effective writing of D&A client histories, including the progression of substance use and abuse. Clinical Supervisor will continue to monitor same. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The personal history in client record #1 was from a previous admission and had been updated, however the original personal history was incomplete, leaving this client record with an incomplete personal history. The personal history in client record #2 was not complete relative to the employment, legal and recreational histories that are required.
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Plan of Correction
The referenced client personal histories will be corrected and the Clinical Supervisor will provide training and supervision to all staff regarding effective writing of personal histories. Clinical Supervisor will continue to monitor same. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluation in client record #2 was not completed within the time frames outlined by facility policy and procedure.
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Plan of Correction
The referenced record will be corrected and the Clinical Supervisor will provide training and supervision to all staff regarding the importance and requirement of timely completion of the psychosocial evaluation. Clinical Supervisor will continue to monitor same. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
The treatment plan update failed to include the client's progress or lack of progress in relation to the stated goals of the comprehensive treatment plan in client record #2.
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Plan of Correction
The referenced record will be corrected and the Clinical Supervisor will provide training and supervision to all staff regarding the importance of writing effective and comprehensive treatment plans and updates, including the progress or lack of progress in relation to the stated goals. Clinical Supervisor will continue to monitor same. |
709.83(a)(9) LICENSURE Client records
709.83. 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) Progress notes.
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Observations
The assessment piece of the group note in client records #1 and 2 was not individualized for each client participating in the group on a consistent basis.
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Plan of Correction
The referenced records will be corrected and the Clinical Supervisor will provide training and supervision to all staff regarding the effective writing of individualized group notes for each client participating in the group. Clinical Supervisor will continue to monitor same. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
There was no documentation of reference checks in employee records #4, 6, 7 and 8.
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Plan of Correction
The HR Officer has been informed of this deficiency and instructed to routinely, without exception, conduct reference checks on all new hires and assure said documentation is filed appropriately and in a timely manner. |
709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
Documentation of degrees and/or college transcripts were missing in employee records #4, 5, 6, 7 and 8.
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Plan of Correction
Th HR Officer has been informed of this deficiency and instructed to obtain, without exception, the documentation of degrees and/or college transcripts and file same appropriately in the employee records. |
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
Employee #3 was missing a six month evaluation. Employee #4 was missing the six month and the annual evaluation. Employee #5 was missing the annual evaluation.
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Plan of Correction
The HR Officer and appropriate supervisors have been infromed of this deficiency. Missing evaluations will be completed and filed. The HR Office has been instructed to monitor this going forward and inform the Facility Director of situations of noncompliance. |
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
Consent to release information forms were not consistently complete. In client records #1 and 2 (partial hospital record) the section to indicate the client's acceptance or rejection of a copy of the consent was not documented. In client record # 2 (outpatient record) the client liability form was signed but did not include which insurance company, would receive the information. In client record #4 (outpatient) a person was listed on a release of information, but it failed to include the persons function or relationship to the client, or what agency or affiliation that person held to qualify as a recipient of the information. Client records #8 and 2 (partial hospital) contained consent to release information forms that included the language "disclose/obtain". This language was included on consent to release information forms directed to a probation officer, dentist, community service center and parenting program. The language "...obtain from" is confusing and does not contribute to an informed consent.
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Plan of Correction
The Clinical Supervisor will provide training and supervision to all staff regarding the effective and proper completion of the Consent to Release Information forms. Clinical Supervisor will continue to monitor same. |
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.
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Observations
In client records # 3, 4 and 7 the drug and alcohol histories were late per agency policy. In client records # 2, 6, and 8 the drug and alcohol histories failed to address the progression of the clients substance use and substance abuse.
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Plan of Correction
The Clinical Supervisor will provide training and supervision to all staff regarding the appropriate documentation of the progression of a clien't substance use and abuse within their D&A history. Clinical Supervisor will continue to monitor same. |
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.
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Observations
In client records #3, 7, 8 and 10 the personal histories were late.
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Plan of Correction
The Clinical Supervisor will provide training and supervision to all staff regarding the timely preparation of paperwork, including personal histories. Clinical Supervisor will continue to monitor same. |
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
In client records # 1 and 9 the psychosocial evaluations were not individualized for each client. In client records #4 and 6, psychosocial evaluations were missing. In client record #10 the psychosocial evaluation was late. In client record # 6 the psychosocial evaluation was completed before the psychosocial histories upon which the evaluation was to be based were completed.
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Plan of Correction
The Clinical Supervisor will provide training and supervision to all staff on the correct and timely completion of psychosocial evaluations. Clinical Supervisor will continue to monitor same. |
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
In client records #3 and 8 the individual treatment plans were not signed by clients. In client records #4, 5 and 7 the treatment plans were late per agency policy. In client records # 4 and 5 the frequency of treatment was not included.
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Plan of Correction
The Clinical Supervisor will provide training and supervision to all staff on the correct and timely completion of individual treatment plans. Clinical Supervisor will continue to monitor same. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Medication documentation in client records # 3 and 4 did not consistently include frequency at which the medication was to be taken.
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Plan of Correction
The Clinical Supervisor will provide training and supervision to all staff regarding the completion of medication records. Clinical Supervisor will continue to monitor same. |
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.
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Observations
Progress notes in client records # 3, 6, 7 and 8 did not consistently reflect the treatment plan goals and objectives the client and counselor were to be addressing. In client record # 9 group notes were not individualized.
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Plan of Correction
The Clinical Supervisor shall provide training and supervision to all staff on the correct and effective completion of progress notes, with particular attention to treatment plan goals and objectives. Clinical Supervisor will monitor same. |