INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5 through September 6, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Women's Institute for Family Health 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 October 8, 2007.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of the staff development policy and procedure on 9/5/07, the facility failed to document time frames for the completion of the assessment of staff training needs and the annual evaluation of the overall training plan.
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Plan of Correction
The Project Director will develop an assessment of staff training needs and and an evaluaion of the agency's overall training plan by October 15, 2007. The training plan will include specific time frames for completion of staff training and also protocols for an evaluation of the training plan.The time frame for the completion of the assessment of staff training needs is seven days of the date of hire of each employee.An annual assessment of training needs for the entire staff of WIFH will be completed by the15th day of January of each calendar year.An annual training plan for the agency and an individualized training plan for each staff person will be developed by the 31st day of January of each calendar year by the Project Director |
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of administrative documentation and staff interview on 9/5/07, the facility failed to document an assessment of staff training needs for the 2007 training year.
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Plan of Correction
The Project Director will develop an assessment of staff training needs for the 2007 training year by October 15, 2007. Included in the employee orientation will be an acknowledgement that the employee did receive a training assessment. The employee will sign and date this acknowledgement and it will be retained in the employee's personnel record. Each employee will be provided with a training assessment within 7 days of hire and the Project Director will forward a copy of all training assessments to the Board of Directors during scheduled board. The meetings. The annual training assessment of each staff person will be completed by the Project Director by the 15th day of January of each calendar year. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of administrative documentation and staff interview on 9/5/07, the facility failed to document an overall training plan for 2007 training year.
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Plan of Correction
The Project Director will develop a comprenhensive training plan to address the overall training needs of the program by October 15, 2007. The Project Director will submit to the Board of Directors a comprehensive training plan to address the overall needs of the program during the first meeting of each program year. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative documentation and staff interview on 9/5/07, the facility failed to document an annual evaluation of the 2006 training plan.
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Plan of Correction
The Project Director shall develop an evaluation of the agency's overall training plan and the Board of Directors will review the outcome of the evaluation. The evaluation will be completed and presented to the board for review by the Project Director during the last meeting of the board for fiscal year ending 2007 on December 18, 2007 |
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 employee records on 9/5/07, the facility failed to document an individual training plan with input from both the employee and supervisor in two of two records reviewed, #1 and 2. Individual training plans were not dated, nor signed.
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Plan of Correction
The Project Director will develop an individual training plan for each staff person within the first 30 days of employment with the agency. The Project Director will develop each training plan in consultation with the employee and the employee's personnel record shall contain documentation to attest to his/her input in the development of the training plan. The documentation shall include a dated signature of the employee. The training plan shall include a time line for completion. The Board of Directors will develop and approve the training plan for the Project Director and the plan shall include documenta during the first meeting of the program year. The plan will include the Project Director's input in the development of the plan, time line for completion and a dated signature for the plan shall be retained in the Project Director's personnel file. The Project Director's training plan for the 2007 year will be completed by October 15, 2007. An individual training plan will be completed for each employee by the 15th of January of each calendar year |
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 employee records on 9/5/07, the facility failed to document HIV/AIDS and TB/STD training in one of one record reviewed, #1.
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Plan of Correction
The Project Director shall receive HIV/AIDS and TB/STD or obtain documented proof of having received this training by January 16, 2008. The Project Director will contact the local health department to ascertain if records of her previous training in HIV/AIDS is available. If it is not, the Project Director will attend a HIV/AIDS training class and will schedule all new hires for HIV/AIDS training with an approved provider at the time of hire if the new hire does not have documentation of having this training. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill record on 9/6/07, the facility failed to document whether the fire alarm or smoke detector was operative on each entry in the record.
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Plan of Correction
The Project Director will document whether the fire alarm or smoke detector was operative at the time of the fire drill and the outcome shall be documented on the fire drill record at the time of each drill |
709.22(e) 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:
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Observations
Based on a review of administrative documentation and staff interview on 9/6/07, the facility failed to document that the annual report was made available to the public.
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Plan of Correction
The Project Director shall place an advertisement in at least one local newspaper announcing the yearly annual meeting of the agency at least 2 weeks prior to the date of each annual meeting. The next annual meeting will be held January 2008. A meeting notice will be placed in the newspaper by the Project Director two weeks before the date of the next annual meeting and every annual meeting thereafter. The agency does have an annual report that includes a financial statement and preceding year activities for 2006. An annual report for 2007 will be held December 2007 and will include a financial statement, the names of officers and preceding year activities. The annual report will be advertised in at least one local paper and the Project Director will retain a copy of the advertisement in a permanent file to serve as proof of meeting this requirement. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation and staff interview on 9/5/07, the facility failed to document an annual audit.
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Plan of Correction
The agency's fiscal year operates on the calendar year from January to December. The Project Director will retain the services of an auditor for the fiscal year December 31, 2007. An audit will be completed by June 2008 as well as annually every year thereafter within six months of the close of each fiscal year. |
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
Based on a review of personnel records, the facility failed to document verification of training experience in one of three employee records reviewed, #3.
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Plan of Correction
The Project Director will ensure that every personnel file has proof of education and/or required experience for every employee, new hire or every person promoted to new position |
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 comply with the restriction imposed at 4 Pa. Code, Subsection 255.5 (b). Clients signed a HIPAA release form that exceeded the specific information allowed to be released in five of five records reviewed, # 1, 2, 3, 4 and 5.
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Plan of Correction
The Project Director will ammend the agency's HIPPA notice to reflect policy provided for in 4 PA Code 255.5 that limits information to be discussed for drug and alcohol clients; these regulations take precedence over HIPPA and shall be reflected in agency literature on privacy practices. To be completed by the Project Director by 10/15/2007 |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document whether a client was offered a copy of the consent in five of five records reviewed, #1, 2, 3, 4 and 5.
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Plan of Correction
Effective immediately the consent to release information forms will be revised by the Project Director to include a statement checked by the client indicating that she/he was offered a copy of the consent to release information. The statement will read, I accept/I reject a copy of this consent to release information form. The client will cirlce whether or not she/he accepted a copy. The Facility Director will conduct chart reviews to assure that the Counselor is having the client indicate whether or not she/he was offered a copy of the consent |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records and staff interview on 9/6/07, the facility failed to document that client's were informed of his/her rights in four of five client records reviewed, #1, 2, 3 and 5.
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Plan of Correction
The Project Director shall develop a protocol to document client receipt of the agency statement on client rights. The client shall through dated signature acknowledge receipt of the agency's policy on client rights and documentation shall be retained in the client record. To be completed by 10/15/2007 |
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
Based on a review of client records on 9/6/07, the facility failed to include lengths and patterns of abuse in four of five client records reviewed, #1, 2, 4 and 5. Additionally, the facility failed to provide a complete history of substances abused in two of five client records reviewed, #1 and 2.
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Plan of Correction
The Project Director shall revise the agency history form to include a section that will record lengths and patterns of substance abuse. The Project Director shall conduct a review of all client records on a regular basis to monitor completion of records and assure that all sections of the history and assessment tools are completed in its entirety. Corrective actions will be completed by October 15, 2007 |
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
Based on a review of client records on 9/6/07, the facility failed to provide complete personal history in five of five records reviewed, #1, 2, 3, 4 and 5. The educational history was incomplete in four of five client records reviewed, #2, 3, 4 and 5. The employment and legal history was incomplete in five of five client records reviewed, #1, 2, 3, 4 and 5.
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Plan of Correction
The Project Director shall review client records on a regular basis to assure that all sections of the history and assessment tools are completed in its entirety. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records on 9/6/07, the facility failed to document consent to treatment forms signed by clients in two of five client records reviewed, #1 and 3.
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Plan of Correction
The Project Director shall review client records on a regular basis to assure that all treatment forms including consent forms contain proper signatures as required. The Project Director shall assure that all treatment forms are signed by clients and staff where required. |
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 client records on 9/6/07, the facility failed to document psychosocial evaluations in five of five client records reviewed, #1, 2, 3, 4 and 5. An interview with the director confirmed that the psychosocial evaluations were not completed.
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Plan of Correction
The Project Director shall implement a policy that requires the psychosocial evaluation be completed in coordination with the intake process. A psychosocial evaluation will be completed on each client that is admitted to the program and shall be included in the intake process. The psysocial evaluation form will be added as part of the total assessment packet that includes the history and other data collection instruments. The Project Director will conduct an agency in service with current and new hires on the completion of all forms and will obtain signed and dated acknowledgement of recieving and understanding how to use and complete all forms including the psychosocial evaluation within the appropriate time frame. The Project Director will review all client files within two weeks of admission to assure that the psychosocial evaluation is completed for each client. |
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 client records on 9/6/07, the facility failed to document treatment goals stated in terms of measurable criteria in four of five client records reviewed, #2, 3, 4 and 5.
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Plan of Correction
The Project Director shall implement procedures to assure that treatment goals are stated in measurable terms. Treatment plans will be developed after the psychosocial evaluation in coordination with the client and reflected in the client record. The Project Director will conduct an agency in service with all current and new hires to provide instruciton of developing treatment goals. All staff will acknowledge receipt of this instruction through dated signature. The Project Director will inspect files on a bi-weekly basis to assure that treatment plans are stated in measurable goals and completed as required. |
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 on 9/6/07 and staff interview on 9/6/07, the facility failed to document a complete record in five of five records reviewed, #1,2, 3, 4 and 5. Portions of the biopsychosocial history were completed by the client and the counselor failed to go over this with the client and complete the missing portions.
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Plan of Correction
The Project Director shall conduct regular review of client records to assure that assessment, history and treatment plans are fully completed and all required information is properly recorded in the client file. Counseling staff will recieve training by 10/31/2007 as provided by the Project Director on how to properly complete history, assessment and treatment forms. A follow-up training session on the correct completion of forms will be conducted on or about January 5, 2008. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records on 9/6/07, the facility failed to document a discharge summary in one of two closed client records reviewed, #4.
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Plan of Correction
The Project Director shall review client records on a regular basis to assure that forms are completed in its entirety. The Project Director will provide a staff training on the completion of program forms by October 31, 2007. A follow-up training will be conducted on or about January 5, 2008 on the completion of forms. |
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.
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Observations
Based on a review of client records on 9/6/07, the facility failed to document follow up information in one of one client records reviewed, #4.
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Plan of Correction
The Project Director shall conduct a regular review of client records to assure that forms are completed in its entirety. The Project Director shall provide a training for program staff on the completion of program forms by October 31, 2007. A follow-up training on the completion of forms will be conducted on or about January 5, 2008 |