INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 11 and February 14, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, JF Kennedy Community MH/MR 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 March 20, 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 administrative documents and staff interview, the facility failed to document that the project director is responsible for the overall management of the project and staff and reports directly to the governing body.
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Plan of Correction
Our project manual has been updated to frflect that the project director is responsible for the overall management of the project and staff reports directly to the Board. In addition, a new project director is going to be identified. |
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 employee records, the facility failed to document qualifications for two counselors, #3 and 4. A diploma was presented for each counselor, but there was no verification of the major.
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Plan of Correction
The Division Director is responsible for obtaining documentation on the qualifications of these two counselors. In the future, our Human Resources department will not process any job canditate in the absence verification of major that is visible on the diploma or clearly stated on the transcript. |
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 the review of employee records, the facility did not document TB/STD training for three of four employees reviewed, #1, 3 and 4.
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Plan of Correction
TB/STD training has been completed for the identified staff members. The Division Director is responsible for ensuring that all staff receive this training in a timely manner and for securing the certificates in our training manual. |
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on a review of administrative documents on 2/11/08, the governing body failed to document that a project director is selected as the person officially responsible to the governing body.
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Plan of Correction
The President was appointed as the project director effective immediately and will report directly to the Board. |
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 client records on 2/14/08, the facility failed to document an informed and voluntary consent in three of six client records reviewed, #3, 5 and 6. Specific information to be disclosed (drug screens) to youth court exceeded 4 Pa. Code 255.5 in one client record, #3. Specific information to be disclosed (UDS reports and the psychiatric evaluation) to treatment court exceeded 4 Pa. Code 255.5 in one client record, #5. Specific information to be disclosed (drug screens) to diversion court exceeded 4 Pa. Code 255.5 in one record reviewed, #6.
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Plan of Correction
On 3/31/08 and 4/7/08, the Division Director provided staff trainings to improve documentation of informed consent and on 4 PA code 255.5 as it relates to the release of information to criminal justice system agencies. Clinical records will be reviewed weekly by the Unit Director to ensure compliance. |
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 2/14/08, the facility failed to document complete psychosocial evaluations in six of six client records reviewed, #1, 2, 3, 4, 5 and 6. The psychosocial evaluations did not include a clinical assessment of how assets/strengths, support systems and negative factors would impact the potential for treatment.
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Plan of Correction
On 3/17/08 and 3/21/08, the Division Director provided staff with training on complete documentation of psychosocial evaluations. We discussed assessment of assets/strengths, support systems and negative factors that might impact person's potential for treatment. The Unit Director will monitor records weekly in staff supervision to ensure compliance. |
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 client records on 2/14/08, the facility failed to document a complete treatment plan update in three of six client records reviewed, #1, 2 and 3. Treatment plan updates did not include an assessment of the client's progress in relationship to the previously stated goals.
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Plan of Correction
On 3/17/08 and 3/21/08, the Division Director provided staff training to improve their completion of treatment plan updates. These trainings focused on an assessment of the person's progress in relationship to the previously stated goals. The Clinic Director will review treatment plans weekly to ensure compliance. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records on 2/14/08, the facility failed to document that counseling services were provided according to the individual treatment plan in four of six client records reviewed, #1, 2, 3 and 4. Treatment plans prescribed weekly individual sessions. The record of service in client record #1 showed the last treatment date as 11/27/07. Client #2 had only three sessions documented for November and December and just two sessions for January. Client #3 had only three sessions documented for September and January and just two sessions in December. Client #4 had documentation of three sessions for October and November and only one session for December.
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Plan of Correction
On 4/7/08, the Division Director provided staff with training on accurate completion of the record of service form. Staff understand that scheduled services listed on the treatment plan must be accurately reflected in the progress notes and record of service form. Additionally, sheduled services must be individualized for each person. the Unit Director will review charts weekly in staff supervision to ensure compliance. |