INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from September 29, 2008 to October 1, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northwestern Human Services of PA, Shomokin, 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 November 4, 2008.
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Plan of Correction
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704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records and training records, the facility failed to meet the annual training requirements for a counselor assistant in one of one personnel records where required.
FINDING:
Training records for the 2007-2008 training year for employee # 2, a counselor assistant, documented only 27 hours of training.
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Plan of Correction
POC 0085
During the previous inspection that occurred May 13th and 14th 2008 we were cited because employee #2 (#8 in that inspection) was inappropriately promoted from a counselor assistant to a counselor. This was corrected by returning employee #2 to the status of counselor assistant. This occurred on May 23rd and at that time she was also informed that she would, once again, be required to obtain 30 credit hours of training per year. Therefore, employee #2 is aware of the training requirements of her position. All staff training hours will be monitored by the program director during the License year.
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the physical plant inspection during the inspection from 9/29-10//2008, the facility failed to ensure complete privacy during all counseling sessions.
FINDING:
Counseling sessions were heard by Division staff during the licensing inspection through closed counseling office doors. During one counseling session in particular held on 10/1/08 every word that the client said was audible. The facility failed to ensure the privacy of counseling sessions.
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Plan of Correction
POC P189
Sound suppression or sound masking equipment will be installed by December 19th 2008 or sooner. The program or project director will consult with NHS's IT Dept regarding this matter.
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709.24(a) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
Based on the review of administrative documentation and the agency policy and procedure manual during the onsite licensing inspection from 9/29 to 10/1/2008, the facility failed to document governing body approval of a "Treatment and Rehabilitation Management Plan" for the coordination of services.
FINDING:
No documentation was presented to demonstrate that the governing body, Northwestern Human Service of PA, Susquehanna Center Board of Directors, adopted the appropriate policies and procedures to address treatment and rehabilitation management.
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Plan of Correction
The entire Policy and Procedure manual was reviewed and approved by the NHS of PA Board of Directors, our governing body at their quarterly board meeting October 20, 2008. Our "Treatment and Rehabilitation Management Plan" is included in this manual. Documentation of this review will be included in our Policy and Procedure manual. |
709.26(a) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
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Observations
Based on the review of administrative documentation and the agency policy and procedure manual during the onsite licensing inspection from 9/29 to 10/1/2008, the facility failed to document governing body approval of written project personnel policies and procedures.
FINDING:
No documentation was presented to demonstrate that the governing body, Northwestern Human Service of PA, Susquehanna Center Board of Directors, adopted the appropriate policies and procedures to address personnel issues.
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Plan of Correction
The entire Policy and Procedure manual was reviewed and approved by the NHS of PA Board of Directors, our governing body at their quarterly board meeting October 20, 2008. Our policies and procedures for personnel issues are included in this manual. Documentation of this review will be included in our Policy and Procedure manual. |
709.26(b) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
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Observations
Based on the review of administrative documentation and the agency policy and procedure manual during the onsite licensing inspection from 9/29 to 10/1/2008, the facility failed to document governing body approval of personnel management policies.
FINDING:
No documentation was presented to demonstrate that the governing body, Northwestern Human Service of PA, Susquehanna Center Board of Directors, adopted the appropriate policies and procedures to address coordination of personnel management.
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Plan of Correction
The entire Policy and Procedure manual was reviewed and approved by the NHS of PA Board of Directors, our governing body at their quarterly board meeting October 20, 2008. Our policies and procedures addressing coordination of personnel management are included in this manual. Documentation of this review will be included in our Policy and Procedure manual. |
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.
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Observations
Based on the review of twelve client records during the onsite licensing inspection of 9/29 to 10/1/2008, the facility failed to consistently document the purpose of disclosure on each signed consent to release information form in four of twelve client records where required.
FINDING:
The purpose for the disclosure of client identifying information was missing on one or more signed consents to release information forms in client records # 2, 3, 4 and 11.
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Plan of Correction
The Program Director will continue to schedule mandatory chart paperwork trainings. There has been a marked improvement in the chart paperwork but it is obvious more work needs to be done. The monthly chart audits will continue to focus on Release of Information Forms so problems can be identified and corrected. |
709.28(c)(5) 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:
(5) Dated signature of witness.
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Observations
Based on the review of twelve client records during the onsite licensing inspection of 9/29 to 10/1/2008, the facility failed to consistently document a dated signature of a witness on each signed consent to release information form on forms documented in three of twelve client records where required.
FINDING:
A dated witness signature was missing from one or more signed consents to release information in client records # 1, 4 and 11.
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Plan of Correction
POC 0285
Mandatory chart paperwork training will be conducted by the Program Director on or before the first week of November. In addition to conducting chart paperwork trainings we have changed the format of the Release of Information (ROI) form to avoid misinterpretation of the required witness signature. The ROI form now contains a line for "staff signature" in addition to the additional witness signature line.
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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 twelve client records during the onsite licensing inspection held 9/29 to 10/1-08, the facility failed to document complete personal histories seven of twelve client records where required.
FINDING:
The family history portion of the personal history was incomplete in client records # 2, 3, 4, 6, 7, 10 and 11. The employment history was incomplete in client records # 1 and 2. The education history was incomplete in client records # 1, 2 and 7. The sexual history was incomplete in client records # 1, 4, 5, 9, 10 and 11.
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Plan of Correction
POC 1865
Mandatory chart paperwork training will be conducted by the Program Director on or before the first week of November. This training will specifically address the lack of detail being recorded in the psychosocial histories. In addition, chart audits conducted for Performance Quality Improvement (PQI) will focus on this issue.
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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 twelve client records during the licensing inspection from 9/29 to 10/1-08, the facility failed to document complete psychosocial evaluations in twelve of twelve client records where required.
FINDING:
The composite picture of the client was incomplete in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10. 11 and 12. Coping mechanisms were not identified in client records # 1, 2, 3, 4, 5, 6, 7, 11 and 12. There were little or no evaluative relating to the clients' presenting and underlying problems in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 , 11 and 12.
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Plan of Correction
POC 1871
Mandatory chart paperwork training will be conducted be the Program Director on or before the first week of November. This training will specifically address the lack of detail being recorded in the psychosocial histories and the composition of evaluations relating to the client's presenting and underlying problems. In addition, chart audits conducted for Performance Quality Improvement (PQI) will focus on these issues.
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of twelve client records during the onsite licensing inspection held 9/29 to 10/1-08, the facility failed to document complete records of service in five of twelve client records where required.
FINDING:
The duration of the treatment service was not included on the records of service in client records # 1, 4, 6, 9 and 12.
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Plan of Correction
POC 1895
The mandatory chart paperwork training will address the recording of service duration on the service flow sheet. In addition to the training the service flow sheet has been changed to include a column designated for duration of services.
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709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
Based on a review of twelve client records during the onsite licensing inspection held 9/29 to 10/1-08, the facility failed to document client related correspondence in five of ten client records where required.
FINDING:
Client related correspondence was missing or incomplete in the following client records: # 6, 7, 8, 9, 12.
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Plan of Correction
POC 1903
The Program Director will conduct a mandatory chart paperwork training on or before the first week of November. The training will address the missing and/or incomplete client related correspondence. All charts will contain ROI forms, authorizations for treatment and any related correspondence from all client related providers. During the inspection it was noted that much of our online correspondence with CCBH to obtain authorization was not being added to the client chart. This information is now being printed along with the authorization and it is filed in the chart under the correspondence section. The mandatory training will also address the correct placement of this paperwork in the charts. Following the last inspection the Program Director reviewed the charts that resulted in this citation and noted that many of the charts had the appropriate paperwork but it was misfiled and therefore it was not readily accessible.
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