INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 14-15, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northwestern Services 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 November 13, 2009.
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Plan of Correction
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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 the review of employee records, the facility failed to ensure that each counselor met the requirement of one year of clinical experience prior to employment in the counselor position.
The findings included:
Employee # 4 was hired 12/1/08. This employee file had documentation of an approved degree, however, based on the documentation in her resume, she lacked one year of clinical experience. The experience referenced in her resume indicated that she had worked in human services for over a year but that her duties were focused in an educational/support role rather than engaging in clinical duties which included formulating treatment plans, providing individual and group therapy, writing clinical assessments, etc.
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Plan of Correction
POC # 0037
Employee # 4 was removed from the position of Counselor and reassigned to the position of Counselor Assistant. Employee # 4 has started supervision under the program director and this will continue until she has completed a year of clinical experience. In future hiring practices the program director will review resumes' with other experienced clinical staff to help determine an applicant has the appropriate experience along with the appropriate degree to be designated as a counsel or if their designation would be Counselor Assistant. If there is any remaining ambiguity regarding the applicant or employee's designation the program director will seek further clarification with the Department of Health.
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on the review of the agency manuals and administrative materials, the facility failed to document a confidentiality policy which complied with state law and federal regulation regarding "duty to warn" situations.
The findings included:
The facility's policy and procedure, section 11 pages 2C and 3C was reviewed as part of the facility policy on the confidentiality of client identifying information. The language in the written policy did not comply with the requirements at 71 P. S. Subsection 1690.108(b) and 42 CFR Part II, Subpart E, subsection 2.63(a)(1). Section 11, page 2C stated: Confidentiality may be violated when a real and immediate danger exists to the client and/or others. Such information may be released only to appropriate professional and legal authorities."
Section 11 page 3C stated: "...information disclosed without the consent of the client will be limited to the following :..." then listed the five types of information which are specified at 4 Pa. Code 255.5(b). The federal regulations require that a facility obtain a court order prior to releasing information to warn a third party. The state law requires that a consent to release information be obtained from the client prior to releasing such information.
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Plan of Correction
POC # 0271
The written policy regarding confidentiality has been reviewed and the language regarding duty to warn others has been removed. This statement has been replaced with a direct quote from PA Code § 255.5 (a), (9) regarding emergency medical situations. In addition a copy of PA Code § 255.5 has been placed in the Policy and Procedure Book for reference. The entire written policy regarding confidentiality is being revised by the program director and it will be completed on or before November 30, 2009.
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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 the review of client records , the facility failed to obtain an informed an voluntary consent for each release of information in each client file. Incomplete consents to release information were documented in four of eleven client records.
The findings included:
Eleven client records were reviewed during the inspection . Incomplete consents to release information were documented in 4 of 11 client records.
Client record # 3 - client admitted 9/13/09. An emergency contact consent was completed on 9/10/09 for emergency contacts with family members . The specific information to be released was not identified on the form.
Client record # 4 - client admitted 6/5/09. On 6/5/09 a consent was signed by the client to release information to the Probation Officer. The purpose for the release of information was not identified.
Client record # 5- the client was admitted on 9/24/09. Consents to release information to a third party payer and the Office of Medical Assistance were completed but failed to include the dated signatures of the client and the witness.
Client record # 7 - Client admitted 2/26/09. A consent to release information form was signed on 3/2/09 by the client, but there was no documentation of a signature of the witness.
A consent to release information to the Office of Medical Assistance was signed on 2/26/09, but the form did not include documentation of the specific information to be released. A consent to release information to the client's sister was signed on 2/26/09, but the form did not include documentation of the specific information to be released.
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Plan of Correction
POC #0277
On Nov. 4th, 2009 the Program Director, employee #2, conducted a Staff Meeting/Training regarding the various citations we received during this last inspection. The training part of the meeting mainly focused on the proper completion of Release of Information Forms. The regarding this citation was the result of carelessness by the counselors. They all know what to do but they are simply not taking the time to ensure the release of information forms are completed properly. This information was communicated to all the counseling staff. Future chart audits which are conducted by the program director will focus on the accurate completion of Release of Information Forms.
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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 the review of 11 client records during the inspection, the facility failed to document psychosocial evaluations in each client record which provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in six of eleven client records.
The findings included:
Eleven client records were reviewed on October 15, 2009.
A composite picture was not documented in client records # 1, 2, 4, 8, 9 and 10.
Coping mechanism were not documented in client records # 1, 2, 3 and 9.
The counselors' evaluations of the clients' assets and strengths were not documented in client records # 4, 9 and 11.
The counselor's clinical impressions did not include a picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in client records # 1, 2, 4, 7, 10 and 11.
There was no documentation of a psychosocial evaluation in client record # 5. The client was admitted on 9/24/09. Facility policy required that the psychosocial assessment be completed at the first session with the client. At the time of the inspection on 10/15/09, this client had attended four sessions and no psychosocial evaluation was documented.
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Plan of Correction
POC #1871
We recently started using a new Biopsychosocial assessment document and further training is needed for completion of the composite picture of the client. The Program Director will provide further training regarding the Biopsychosocial with emphasis on the integrated summary. The program Director will also make some changes in the Integrated Summary Paperwork and it will be completed on or before December 11, 2009. Trainings will be provided by the Program Director throughout the month of December and continue as needed. Chart audits will be conducted by the Program Director on a monthly basis to ensure the Biopsychosocial are completed and in compliance with the regulations. In addition, a policy change will be sent to the NHS Board of PA regarding the time frame for completion of the psychosocial assessment. The current policy states that it is to be completed during the first session which is not possible due to the length of this document. The request will be to change this to the forth session, however, the completion of a Preliminary Treatment Plan, that is at the end of the Biopsychosocial Assessment will still be required by the second counseling session.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the agency failed to document aftercare plans for each successfully discharged client in one of two client records.
The findings included:
Three closed client records were reviewed on October 15, 2009. Two of the three client records were successful discharges and were required to have documentation of aftercare plans.
Client record # 7 included documentation that the client was admitted to treatment on 2/26/09. The client's last counseling session occurred on 5/21/09 and the client was discharged successfully on 5/21/09. There was no documentation of an aftercare plan as of 10/15/09. Facility policy and procedure states that the aftercare plan is to be completed at the time of discharge.
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Plan of Correction
POC # 1907
On Nov. 4th, 2009 the Program Director, employee #2, conducted a Staff Meeting/Training regarding the various citations we received during this last inspection. After Care Plans were discussed during this meeting and there was some confusion among the counselors regarding clients that completed D&A treatment but were not yet being discharged from the Academy. It was explained that an aftercare plan still need to be completed. Addition mandatory training on After Care Planning is scheduled for December 2nd, 2009 at the Shamokin Office. In addition, all closed charts will be checked by our Administrative Assistant/Billing Coordinator for aftercare plans if it was a completion of treatment.
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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 the review of client records , the facility failed to document attempts to follow up on clients who have been discharged from the facility in accordance with written facility policy in three of three client records.
The findings included:
Three closed client records were reviewed on October 15, 2009. Written facility policy required that a letter be sent one time at 30 days for each client who is discharged without a referral elsewhere for services. In the case of clients referred elsewhere at discharge, seven day follow up is required.
Client record # 7 had an admission date of 2/26/09 and a discharge date of 5/21/09. There was no documentation of an attempt to follow up on the client as of 10/15/09.
Client record # 8 had an admission date of 2/16/09 and a discharge date of 7/8/09. There was no documentation of an attempt to follow up on the client as of 10/15/09.
Client record # 10 had an admission date of 1/17/09 and a discharge date of 8/13/09. There was no documentation of an attempt to follow up on the client as of 10/15/09.
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Plan of Correction
POC #1911
Our Administrative Assistant/Billing Coordinator was the only person responsible for follow-up letters after a client is discharged and she has simply been overwhelmed with the amount paperwork she has to do. Our Administrative Assistant will continue to send out the follow-up letters for clients seen at the Shamokin Office but she will no longer be responsible for clients seen at the Academy. This responsibility will fall to the counselors that see Academy Clients with oversight by the program director. In addition, the Program Director will include closed charts in the monthly audits.
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