INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 3, 4, 7, and 12, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Consortium 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 December 9, 2008.
|
Plan of Correction
|
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.
|
Observations
Based on a review of fifteen personnel records, the facility failed to document a timely assessment of staff training needs in fourteen personnel records. As per facility policy, the assessment of staff training needs will be completed by July 1 of each year.
Findings:
Fifteen personnel records were reviewed on November 3, 2008 through November 5, 2008. An assessment of staff training needs was required in fourteen records. An assessment of staff training needs was missing for two of fourteen records, #1 and 2.
An assessment of staff training needs was documented as completed on 10/31/08, 11/3/08, or 11/4/08, respectively, for twelve of fourteen records, # 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, and 15.
|
Plan of Correction
0055
704.11(a)(1) LICENSURE
Training Needs Assessments:
Responsible: The Program Director will ensure through monitoring that all staff Assessments of Training Needs are completed by 07/01 of each year.
Responsible: During the period of May 1 through June 30 of each year the Program Managers, Directors and/or Supervisors of the program will be responsible to assess past year trainings of each counselor and assess the training needs of each counselor for the coming year by 06/30 of each year.
Time Frame: Annual Training Needs Assessments will be completed between 05/01 and 06/30 of each year.
Monitoring: Program Director, Director of Opiate Treatment, Supervisors will monitor completion of Training Needs Assessments during the period identified.
|
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.
|
Observations
Based on a review of fifteen personnel records, the facility failed to document a mechanism to collect feedback on completed training, provided by the facility, as well as outside trainers, in three of six records.
Findings:
Fifteen personnel records were reviewed on November 3, 2008 through November 5, 2008. Documentation of feedback on completed training was required in six records. The facility did not document feedback on completed training in two of six records, #1 and 4. The facility documented only feedback for external training in personnel record #3.
|
Plan of Correction
0059
704.11(a)(3) LICENSURE
Training Feedback
Responsible: Human Resource Director in conjunction with the Licensing/Training Director will develop a form to collect feedback on completed trainings. The form will be a combined form to collect feedback on trainings and an evaluation tool for feedback on the training and trainee.
Time Frame: The form will be developed by 01/30/09.
Monitoring: Human Resource Staff and Program Director will monitor the completed training feedback forms for submission through quarterly reports generated by the Human Resource Department.
|
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.
|
Observations
Based on a review of fifteen personnel records, the facility failed to document an individual training plan for nine of fifteen records. As per facility policy, individual training plans are to be completed by July 30 of each year.
Findings:
Fifteen personnel records were reviewed on November 3, 2008 through November 5, 2008. Individual training plans were required in fourteen personnel records. The facility failed to document an individual training plan for nine of fourteen personnel records reviewed, #1, 2, 4, 9, 10, 11, 12, and 14. The facility failed to document a training plan completed in a timely fashion in five of fourteen records. Personnel records #3, 5, 7, 8, and 15 were dated October 31, 2008 or November 3, 2008, respectively.
|
Plan of Correction
0063
704.11(b)(1) LICENSURE
Individual Training Plan:
Responsible: Program Director will ensure all staff Individual Training Plans are developed annually and completed by 07/30/ of each year.
Responsible; Program Managers, Director, and/or Supervisors will meet will all Staff between 06/01 and 07/30 of each year to discuss and develop staff Individual Training Plans.
Time Frame: Individual Training Plans for all staff will be completed by 7/30 of each year.
Monitoring: Program Director will monitor Program Managers, Director and/or Supervisors during monthly Division Meetings on completion of written Individual Training Plans for each employee by 07/30 of each year.
|
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of personnel records, the facility failed to document at least 12 clock hours of training annually for the Project Director.
Findings:
The facility failed to document any training hours for the Project Director, employee #1, for the 2007-2008 training year.
|
Plan of Correction
0075
704.11(d)(2) LICENSURE
Annual Training Requirements:
Responsible: Project Director will be responsible to show documentation of completing at least 12 hours of annual training by 06/30 of each year.
Time Frame: Appropriate training will be completed and documented by 07/30 of each year.
Monitoring: Human Resource Director along with the Board of Directors will monitor the Project Director completion and documentation of annual trainings.
|
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.
|
Observations
Based on a review of fifteen personnel records, the facility failed to document at least 25 clock hours of training annually for each counselor.
Findings:
Fifteen personnel records were reviewed on November 3, 2008 through November 5, 2008. Three of the personnel records were required to have 25 clock hours of training documented. The facility failed to document at least 25 clock hours of training for the 2007-2008 training year in three of three records, #9, 10, and 12. Employee #9 had 12.5 hours documented. Employee #10 had one hour documented. Employee #12 had 11.5 hours documented.
|
Plan of Correction
0083
704.11(f)(2) LICENSURE
Trng Hours Req-Coun:
Responsible: Program Director will ensure each counselor completes at least 25 clock hours of training annually.
Responsible: Program Managers, Director, and /or Supervisors will be responsible to monitor and ensure each counselor completes and show documentation of completion (certificate) of at least 25 clock hours of training annually.
Time Frame: Documentation of 25 clock hours of training will be submitted to supervisors and Human Resource Department by 06/30 of each year.
Monitoring: Program Managers, Director, Supervisors along with Human Resource Department will monitor quarterly reports of annual trainings completed for each year
|
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that each bathroom was ventilated by an exhaust fan or window.
Findings:
A physical plant inspection of the facility was conducted on November 7, 2008. The exhaust fans in the male and female staff bathrooms on the first and second floor, rear, were found to be inoperable.
|
Plan of Correction
P201
705.24 (5) LICENSURE
Bathrooms.:
Responsible: The Community and Facilities Director as of 11/26/08 made repairs to the exhaust fans in the male and female staff bathrooms on the first and second floors and they are operable
Time Frame: Exhaust Fans are operable as of 11/26/08
Monitoring: Facilities Management will monitor the ongoing operation of the exhaust fans in bathrooms.
|
705.28 (b) (2) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(2) Place the smoke detector in a common area or hallway. All detection devices shall be interconnected.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that all smoke detection devices were interconnected.
Findings:
A physical plant inspection of the facility was conducted on November 7, 2008. The facility has smoke detectors in place on the first and second floor, however, these devices are not interconnected.
This is a repeat citation from the 2007 licensing inspection.
|
Plan of Correction
P253
705.28 (b) (2) LICENSURE
Fire Safety:
Responsible: The Community and Facilities Director will contract with Macrae Electrical Associates to inspect and repair all smoke detectors to ensure they are interconnected by 01/30/09
Time Frame: Smoke Detectors to be interconnected by 01/30/09
Monitoring: The Community and Facilities Director and Facilities staff will monitor ongoing operation of smoke detectors.
|
709.22(e)(3) 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:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
|
Observations
Based on a review of administrative records, the facility failed to include a statement disclosing the names of officers, directors, and shareholders, where applicable in the annual report.
Findings:
Based on a review of administrative records on November 3, 2008, the facility failed to include a listing of the Board of Directors with the annual report.
This is a repeat citation from the 2007 licensing inspection.
|
Plan of Correction
0141
709.22(e)(3) LICENSURE
Governing Body:
Responsible: Board of Directors, Project Director will ensure the inclusion of a listing of the Board of Directors with the Annual Report by 07/01 of each year.
Time Frame: Listing of Board of Directors will be included with the Annual Report by 07/01 of each year.
Monitoring: Licensing/Training Director along with Project Director will monitor inclusion of listing.
|
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
|
Observations
Based on a review of fifteen personnel records, the facility failed to demonstrate efforts toward informing staff of employee rights.
Findings:
Fifteen personnel records were reviewed on November 3, 2008 through November 5, 2008. Demonstration of the project ' s efforts to inform the staff of employee rights was required in fourteen personnel records. The facility failed to document demonstration of the project ' s efforts toward informing staff of employee rights in fourteen of fourteen records, # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, and 15.
|
Plan of Correction
0233
709.26(e) LICENSURE
Personnel Management:
Responsible: Human Resource Director along with Licensing/Training Director will develop written policy on employee rights and demonstrate how staff will be informed such
Time Frame: Policy and Procedure for informing staff of employee rights will be completed by 03/31/09.
Monitoring: Project Director and human Resource Director will monitor staff being informed of
Employee rights.
|
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:
|
Observations
Based on a review of nineteen client records, the facility failed include within the informed and voluntary consent forms the right for clients to verbally revoke the consent.
Findings:
Nineteen client records were reviewed between November 7, 2008 and November 12, 2008. Informed and voluntary consent forms were required in thirteen records. The " Consent for Release of Information " form only indicated the client could revoke the consent in writing in thirteen of thirteen client records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 14, and 15.
|
Plan of Correction
0277
709.28(c) LICENSURE
Confidentiality:
Responsible: Program Director will revise the informed and voluntary consents from the client for the disclosure of information to contain wording that allows the client to verbally revoke the consent as well as revoking the consent in writing.
Responsible: Program Director will submit request to Policy Committee for a change in language on consents forms. Policy Committee will present change to Board of Directors for approval.
Time Frame: The revision of the consent forms will be completed by 03/30/09
Monitoring: The Program Director along with Licensing/Training Director
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of nineteen client records, the facility failed to document a complete psychosocial evaluation for each client.
Findings:
Nineteen client records were reviewed between November 7, 2008 and November 12, 2008. Psychosocial evaluations were required in thirteen records. The facility failed to document a complete psychosocial evaluation in thirteen of thirteen client records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 14, and 15.
The facility failed to document a clinical assessment of the client ' s assets/strengths in thirteen of thirteen records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 14, and 15.
The facility failed to document a clinical assessment of the client ' s potential support systems in ten of thirteen records. Client record #1 did not include any documentation of a clinical assessment of the client ' s support systems. Client records # 2, 3, 4, 5, 8, 10, 11, 14, and 15 were missing a clinical assessment of the client ' s support systems.
The facility failed to document a clinical assessment of the negative factors that may impact the client during treatment in seven of thirteen records, #1, 2, 3, 4, 10, 11, and 15.
The facility failed to document a clinical assessment of the client ' s attitude toward treatment in six of thirteen records. Client record #2 did not include any documentation of a clinical assessment of the client ' s attitude toward treatment. Client records #1, 3, 4, 10, and 11 were missing a clinical assessment of the client ' s attitude toward treatment.
The facility failed to document a clinical assessment of the counselor ' s conclusions/impressions in six of thirteen records. Client record #2 did not include any documentation of a clinical assessment of the counselor ' s conclusions/impressions of the client. Client records #1, 3, 4, 10, and 11 were missing a clinical assessment of the counselor ' s conclusions/impressions of the client.
|
Plan of Correction
Plan of Correction
1871
709.91(b)(6) LICENSURE
Intake and admission:
Responsible: The Program Director will submit to the Policy Committee a request for revision of the Biopsychosocial Assessment Procedure CP 135 #1 to state "The Biopsychosocial Assessment will be completed 30 days from admission. The Policy Committee will present this change request to the Project Director and Board of Directors for approval.
Monitor: Licensing/Training Director, Program Director, Program Managers, and Supervisors will be responsible for training staff on comprehensive completion of the psychosocial evaluation document. Training will focus on clinical assessment of assets/strengths, support systems,
Clinical assessment of negative factors that may impact the client during treatment, attitude towards treatment and the counselors conclusions/impressions of the client.
Time Frame: Supervisors will review in their weekly supervision with the counselors the Psychosocial Evaluation to ensure that assets/strengths are included in the evaluation.
|
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of nineteen client records, the facility failed to document a case consultation on a quarterly basis for five client records.
Findings:
Nineteen client records were review between November 7, 2008 and November 12, 2008. Case consultation notes were required in twelve client records. The facility failed to document a case consultation note on a quarterly basis for five client records, #1, 6, 7, 9, and 15.
In client record #15, the case consultation was due on May 5, 2008 but was not documented as completed by the facility as of the ending date of this licensing inspection.
In client record #1, the case consultations were due August 5, 2008 and November 5, 2008 but were not documented as completed by the facility as of the ending date of this licensing inspection.
In client record #6, the case consultation was due October 14, 2008, but was not documented as completed by the facility as of the ending date of this licensing inspection.
In client record #7, the case consultation was due on August 6, 2008, but was documented as completed on September 26, 2008 as of the ending date of this licensing inspection.
In client record #9, the case consultation was due on August 14, 2008, but was documented as completed on August 28, 2008 as of the ending date of this licensing inspection.
|
Plan of Correction
Plan of Correction:
1905
709.93(a)(8) LICENSURE
Client records:
Responsible: Program Director, Director of Opiate Treatment, Program Managers and Supervisors will ensure Case Consultations are documented on a quarterly basis in all client records. Training will be provided by Supervisors on completion of Case Consultations.
Time Frame: Training on completion of Case Consultations will be done during first 30 days of employment, during individual supervision sessions and as needed. Training will ongoing as needed beginning 01/09.
Monitoring: Program Director, Director of Opiate Treatment and Supervisors. Supervisors will review with the counselors in their weekly supervisions to ensure that the Case Consultations have been completed within the time frames stated.
|
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.
|
Observations
Based on a review of nineteen client records, the facility failed to document follow-up on those clients that were discharged for ten client records.
Findings:
Nineteen client records were reviewed between November 7, 2008 and November 12, 2008. Follow-up was required for ten client records. The facility failed to document follow-up for eight of ten client records, #10, 13, 14, 15, 16, 17, 18, and 19.
|
Plan of Correction
Plan of Correction:
1911
709.93(a)(11) LICENSURE
Client records:
Responsible: Supervisors will be responsible to monitor counselors on completion of client Follow-up information. When a client is discharged and referred to an outside resource the counselor with written consent attempt to determine from the resource the disposition of the referral. When clients are not referred the counselor will send a letter for follow up on the ex-client's progress or status.
Time Frame: Follow-up letter will be utilized beginning 01/09
Monitoring: The Supervisors will meet with each counselor during their weekly or bi-weekly supervision and will review at least five client charts to monitor documentation of counselor's follow-up with discharge clients
|