INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Al-Assist Behavioral Health Care was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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
Based on a review of personnel records, the facility failed to document a mechanism to collect feedback on completed training in three of seven records.The findings include:Seven personnel records were reviewed on July 28, 2014. The following staff records lacked documented feedback forms after training ' s, #1, 3 and 4. The training year reviewed was January 1, 2013 through December 31, 2014. The findings were confirmed by the facility staff on July 29, 2014.
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Plan of Correction
704.11 (a)(3) LICENSURE - Training Feedback
Based on a review of the personnel records, the facility failed to document a mechanism to collect feedback on completed training in three of seven records.
CORRECTIVE ACTION:
The findings of 2014 DDAP Licensure Renewal Inspection will be disseminated and reviewed with Chief Behavioral Health Officer, Quality Assurance Manager, Drug / Alcohol Program Coordinator, Coordinator of Behavioral Health Services at the next scheduled Management Meeting. The Quality Assurance Manager will identify any drug/alcohol treatment staff that lack evaluations of their annual trainings and direct them to complete those evaluations ASAP. The Quality Assurance Manager will develop / institute procedures ensuring that all staffs external and internal training certificates include attached evaluations prior to filing them into their training / personnel records. Any training certificates lacking an accompanying evaluation will not be accepted and withheld from staffs' training record until the evaluation is submitted. The Quality Assurance Manager will randomly review personnel / training files to ensure compliance.
TIME FRAME FOR COMPLETION:
September 4, 2014
PERSONS RESPONSIBLE:
Quality Assurance Manager, Drug / Alcohol Program Coordinator, Coordinator of Behavioral Health Services
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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
Based on a review of personnel and training records, the facility failed to ensure that staff persons and/or volunteers received 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 as per the regulatory requirements in one of seven records reviewed.The findings include:Seven were reviewed on July 28, 2014 for documentation verifying the completion of the mandatory HIV/AIDS and TB/STD training's. One out of seven lacked documentation that the training's were completed as per the regulatory requirements. Employee # 6, a counselor, was hired on June 3, 2013. Employee #6 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by June 3, 2014. The training was not documented as of the date of the inspection.The findings were confirmed by the facility director on July 28, 2014.
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Plan of Correction
704.11(c)(1) LICENSURE - Mandatory Communicable Disease Training
CORRECTIVE ACTION:
The findings of the 2014 DDAP License Renewal Inspection will be disseminated and reviewed with the Quality Assurance Manager and Clinical Coordinators at the next scheduled Management Meeting. The staff member lacking the HIV / AIDS and TB training, will be directed by the Quality Assurance Manager to schedule this training ASAP. All newly hired staff will be directed to schedule and obtain HIV / AIDS and TB training during their orientation period, and demonstrate proof of the scheduled training prior to its completion. Additionally, the Clinical Coordinator will review each Counselor's training hours during weekly supervision sessions to further ensure that the above trainings are completed within the first year of their employment.
TIME FRAME FOR COMPLETION:
August 15, 2014 - Ongoing Monitoring
PERSONS RESPONSIBLE:
Quality Assurance Manager / Drug/Alcohol Program Coordinator / Coordinator of Behavioral Health Services
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in two of seven personnel records.The findings include:Seven personnel records were reviewed on July 28, 2014. Five personnel record pertained to counselors who are required to obtain 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel records # 3 and 4. Training year reviewed was January 1, 2013 through December 31, 2013.Employee # 3 was hired on September 21, 2009. Employee # 3 had only 7.5 clock hours of training documented for the 2013 training year. Employee #4 was hired on June 20, 2010. Employee #4 had only 1.5 clock hours of training documented for the 2013 training year.The findings were confirmed by the facility staff on July 29, 2014.
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Plan of Correction
704.11(f)(2) LICENSURE -Training Hours Required for Counselors
CORRECTIVE ACTION:
The 2014 DDAP Licensing Renewal Inspection findings will be disseminated and reviewed with the Chief Behavioral Health Officer, Drug Alcohol Program Coordinator, Coordinator of Behavioral Health, and Quality Assurance Manager at the next scheduled Management Meeting. The Drug / Alcohol Coordinator, Quality Assurance Manager and Clinical Supervisors will ensure that all counseling staffs' Annual Training Plans include, at least, 25 clock hours of training relative to drug/alcohol treatment, and will monitor the completion of these mandatory training hours during weekly and/or bi-weekly supervision meetings. All staffs will receive written notice from the Quality Assurance Manager that failure to complete 25 clock hours of annual training will result in disciplinary action, and possible non-credentialed status with restricted counseling privileges.
TIME FRAME FOR COMPLETION:
September 1, 2014 - Ongoing Monitoring
PERSONS RESPONSIBLE:
Drug/Alcohol Program Coordinator, Quality Assurance Manager, Coordinator of Behavioral Health
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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 a review of client records, the facility failed to obtain informed and voluntary consents in eight of ten records reviewed.The findings include:Ten client records were reviewed on July 28, 2014. The facility failed to document informed and voluntary consents in eight client records, specifically records, #1, 2, 3, 4, 5, 8, 9 and 10.Client record #1 - contained a consent to release information form dated 10/2/13 to an insurance agency that exceeded 4 PA Code 255.5 by allowing the facility to release the following information: billing &/or insurance information, intake/admission information, medication prescribed, medical history/physical history and discharge summary/plan. Additionally, staff didn't sign the consent to release form. Client record #2 contained a consent to release information form dated 5/7/14 to a government agency that exceeded 4 PA Code 255.5 by allowing the facility to release the following information: billing &/or insurance information, intake/admission information, medication prescribed, medical history/physical history and discharge summary/plan. Client record #3 contained a consent to release information form dated 5/14/14 to an insurance agency that exceeded 4 PA Code 255.5 by allowing the facility to release the following information: billing &/or insurance information, intake/admission information, plan of care/review and psychiatric evaluation. Client record #4 contained a consent to release information form dated 12/10/13 to an insurance agency that exceeded 4 PA Code 255.5 by allowing the facility to release the following information: billing &/or insurance information, intake/admission information, plan care/review, psychiatric evaluation, lab results, psychological assessment, strength assessment, progress notes, psychological evaluation/report, screening assessment, medication prescribed, medical history/physical history and discharge summary/plan. Client record #5 contained a consent to release information form dated 4/16/14 to an insurance agency that exceeded 4 PA Code 255.5 by allowing the facility to release the following information: billing &/or insurance information, intake/admission information, medication prescribed, plan care/review, psychiatric evaluation, psychosocial assessment, progress notes and psychological evaluation/report.Client record #8 contained a consent to release information form dated 5/9/14 to an insurance agency that exceeded 4 PA Code 255.5 by allowing the facility to release the following information: billing &/or insurance information, plan of care/review, psychiatric evaluation and medication prescribed. Client record #9 contained a consent to release information form dated 12/27/13 to an insurance agency that exceeded 4 PA Code 255.5 by allowing the facility to release the following information: billing &/or insurance information, intake/admission information, plan care/review, psychiatric evaluation, lab results, psychological assessment, strength assessment, progress notes, psychological evaluation/report, screening assessment, medication prescribed and medical history/physical history. Client record #10 contained a consent to release information form dated 3/28/14 to an insurance agency that exceeded 4 PA Code 255.5 by allowing the facility to release the following information: billing &/or insurance information, intake/admission information, plan of care/review, psychiatric evaluation and medication prescribed.The findings were confirmed by the facility director took place on July 28, 2014.
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Plan of Correction
709.28(c) LICENSURE - Confidentiality
CORRECTIVE ACTION:
The 2013 DDAP Licensing Renewal Inspection findings will be disseminated and reviewed with the Chief Behavioral Health Officer, Quality Assurance Manager, Coordinator of Behavioral Health, and Drug/Alcohol Program Coordinator at the next scheduled Management Meeting. The Chief Behavioral Health Officer and Quality Assurance Manager will outline specific changes to be made to the EHR Consent to Release Confidential Information Form that will ensure compliance with regulations protecting the confidentiality of clients. These changes will be conveyed to EHR AVATAR Technical Support for immediate correction. The Chief Behavioral Health Officer and Quality Assurance Manager will review the corrected (revised) Consent to Release Confidential Information Form to ensure that the Consent to Release Confidential Information Form does not contain any information which exceeds 4 PA Code 255.5.
The Quality Assurance Manager and Quality Assurance Clerks will provide one (1) hour training to Drug/Alcohol Counselors specifically on completing the Consent to Release Confidential Information Form. Additionally, the Drug/Alcohol Program Coordinator, Clinical Supervisors, Quality Assurance Manager and Clerks will monitor client records weekly to ensure that all Consent to Release Confidential Information Forms are completed in accordance with 4 PA Code 255.5 regulations.
TIME FRAME FOR COMPLETION:
September 1, 2014- Ongoing Monitoring
PERSONS RESPONSIBLE:
Chief Behavioral Health Officer, Drug/Alcohol Program Coordinator, Quality Assurance Manager, and Coordinator of Behavioral Health Services.
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709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to have a complete record in three of ten records reviewed.The findings include:Ten client records were reviewed on July 28, 2014. Three client records were incomplete record, #1, 2 and 6.Client #1 was admitted on October 2, 2013. Client #1's case consultations were completed on January 2, 2014, April 24, 2014 and July 2, 2014. The facility failed to document who all participated in the case consultation dated July 2, 2014. The only person documented as being a part of the July 2, 2014 case consultation was client #1's counselor. Client #2 was admitted on November 2, 2013. Client #2's case consultations were completed on May 27, 2014 and June 6, 2014. The facility failed to document who all participated in the case consultations. The only person documented as being a part of the case consultations was client #2's counselor. Client #7 was admitted on March 25, 2014 and discharged on July 10, 2014. The facility failed to document a case consultation as of the date of client #7's discharge date.The findings were confirmed by the facility staff on July 28, 2014.
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Plan of Correction
709.93(a) Licensure ? Client Records
CORRECTIVE ACTION:
The DDAP Licensing Renewal Inspection findings will be disseminated and reviewed by the Clinical Management Team. The Chief Behavioral Health Officer and Quality Assurance Manager will consult with the EHR AVATAR Technical Support to request immediate correction to the signature program's routing mechanism to allow for more than one (1) signature on the Case Consultation Form. All clinical staff will receive an email informing them of the routing mechanism start-up date, which will allow primary counselors to obtain the electronic signatures of all case consultation participants. During the interim period, staff participating in case consultations will sign the "printed out" version of the form, which will be scanned into the client's record. Additionally, the Clinical Supervisors and Drug/Alcohol Program Manager will conduct weekly / bi-weekly record reviews to ensure that case consultations are completed and signed by all staff participating in the activity.
TIME FRAME FOR COMPLETION:
September 19, 2014 ? Ongoing Monitoring
PERSONS RESPONSIBLE:
Chief Behavioral Health Officer, Quality Assurance Manager, Drug/ Alcohol Program Coordinator, Coordinator of Behavioral Health Services
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