INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the on-site licensure renewal inspection that was conducted September 29, 2008 to October 1, 2008. The follow-up inspection was conducted on April 27, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Northwestern Human Service of PA, Susquehanna 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 May 20, 2009 .
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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 staff interview on April 27, 2009, the facility failed to appoint an appropriate staff member to the position of project director.
The findings include:
A follow-up licensing inspection was conducted on April 27, 2009. The staff person identified as the project director at the time of the inspection did not have the responsibility or authority to execute contracts, establish wage scales or approve personnel policies. The staff person identified as the project director at the time of the inspection did not report directly to the governing body.
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Plan of Correction
POC # 0021
Based on a review of our corporate structure it has been determined that the Executive Vice President for the Central and Western Region be appointed Project Director for all Drug and Alcohol Programs governed by the NHS of PA Board. We have contacted the Executive Vice President of the Central Western Region and he has agreed to accept the responsibility of this position. His qualifications include the following: BS in the Administration of Justice from Penn State and a Masters' in Public Administration from Shippensburg University. He has worked as an administrator in human services for at least five years. On May 22, 2009 a letter was drafted requesting this change and has been submitted to the NHS of PA Board for approval. Susquehanna Center's Human Resource Director along with the Program Director will ensure that the Project Director's personal file is available for review to verify his experience and credentials at Susquehanna Center in Shamokin.
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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 record reviewed.
The findings include:
Training records for the 2007-2008 training year for employee #2, a counselor assistant, documented only 27 hours of training. Since the 2008-2009 training year was not complete on the date of the follow-up inspection, this finding remains deficient until the current training year can be reviewed for compliance.
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Plan of Correction
This citation was carried over from the previous inspection that occurred on 10/01/2008. The plan of correction for this citation was approved on 10/29/2008. All counselor assistants have been informed by the Program Director, Michael Pawlicki, that they are required to obtain 40 approved credit of training during their first year of employment and 30 credit hours of training each year after the initial training year. All Counselors and Counselor Assistants have also been instructed to provide a copy of the training certificates and evaluation of the trainings to the Program Director. The Program Director maintains a Training Manual in which all staff training certificates are kept. The numbers of training hours obtained by each staff member are monitored by the program director throughout the training 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 a physical plant investigation on April 27, 2009 at 10:00AM, the facility failed to ensure privacy so that counseling sessions cannot be heard outside the counseling room.
The findings include:
A physical plant inspection was conducted on April 27, 2009 at approximately 10:00AM. White noise machines were in place in the waiting room and in counseling room #5; however, there were no white noise machines seen in counseling rooms #4 and 6. The licensing specialist was able to hear parts of the conversation in counseling room #6. The licensing specialist was able to hear parts of the conversation in counseling room #5 because either the white noise machine was not turned on, or it was not strategically placed near the door.
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Plan of Correction
POC # P189
We have determined that sound suppression or sound covering (e.g., music) equipment needs to be located in the hallway connecting the therapy session rooms to ensure client confidentiality. The appropriate equipment will be purchased and installed on or before June 15th, 2009. The Program Director, Michael Pawlicki, is responsible for the completion of this POC by the previously mentioned target date. The effectiveness of this system will be evaluated by the program director and it will continue to be monitored on an ongoing basis by the program director and the counselors that use these offices.
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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 client records on April 27, 2009, the facility failed to document a personal history in six of eight client records.
The findings include:
Eight client records were reviewed on April 27, 2009. A personal history was required in eight client records. The family history did not document historical information regarding family dynamics in client records #1, 3, 4, 7 and 8. Information documented simply listed the family members the client resided with and current family relationships. The employment history only listed one job and did not document dates of employment or reason for leaving in client record #3. The employment history in client record #1 did not list names of former employers, dates of employment or reasons for leaving. The educational history in client records #3 and 4 did not document why the client never finished high school or whether drugs/alcohol caused problems while in school. The sexual history does not document the age of first experience, whether drugs/alcohol were involved, or whether drugs/alcohol has caused any dysfunction in client records #1, 2, 3, 4, 5, 7 and 8. The personal history in client record #6 was blank.
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Plan of Correction
POC # 1865
We are currently in the process of developing a more comprehensive Biopsychosocial Assessment. We obtained a copy of the Biopsychosocial North'd County is currently using in their Central Intake Project. Each counselor was given a copy of this Biopsychosocial and is to provide the Program Director with feedback regarding this assessment tool. We will be using this Biopsychosocial in its current form until it is edited by the Program Director. Once the new Biopsychosocial is edited it will be submit to the NHS of PA Board for approval. All Counselors and Counselor Assistants will receive in-house training regarding the completion of the Biopsychosocial. This training will be provided by the Program Director. The target date for completion of the new Biopsychosocial and the training on it use is June 30th, 2009. Ongoing chart audits will be performed each month by the Project Director to ensure the completion of the Biopsychosocial as required by licensing regulations.
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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 client records on April 27, 2009, the facility failed to document a psychosocial evaluation in eight of eight client records.
The findings include:
Eight client records were reviewed on April 27, 2009. A psychosocial evaluation was required in eight client records. The psychosocial evaluation was not documented in client record #6. The composite picture of the client was incomplete in client records #1, 2, 3, 4, 5, 7 and 8. The client's presenting and underlying problems was client reported rather than evaluative in client records #3, 4 and 5. The client's assets and strengths were client reported rather than evaluative in client records #3 and 4. Coping mechanisms were client reported rather than evaluative in client records #1 and 3. Negative factors that might inhibit treatment were client reported rather than evaluative in client record #1. Negative factors that might inhibit treatment were not documented in client record #5. The psychosocial evaluation failed to include a clinical evaluation in client records #1, 2, 3, 4, 5, 7, 8 and 9.
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Plan of Correction
POC # 1871
We are currently in the process of developing a more comprehensive Biopsychosocial Assessment. We obtained a copy of the Biopsychosocial North'd County is currently using in their Central Intake Project. Each counselor was given a copy of this Biopsychosocial and is to provide the Program Director with feedback regarding this assessment tool. We will be using this Biopsychosocial in its current form until it is edited by the Program Director. Once the new Biopsychosocial is edited it will be submit to the NHS of PA Board for approval. All Counselors and Counselor Assistants will receive in-house training regarding the completion of the Biopsychosocial. This training will be provided by the Program Director. The target date for completion of the new Biopsychosocial and the training on it use is June 30th, 2009. Ongoing chart audits will be performed each month by the Project Director to ensure the completion of the Biopsychosocial as required by licensing regulations.
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