INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on March 23-24, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Counseling and Adoption Services, Inc 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 April 21, 2010.
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Plan of Correction
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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.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two personnel records reviewed.
The findings include:
Four personnel records were reviewed on March 23-24, 2010. Two personnel records were reviewed as counselors. One personnel record was required to include documentation that the counselor had completed 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 2.
Employee # 2 was hired on June 1, 2000. The facility training year is from January through December. The training year for January 2009 to December 2009 was reviewed. Employee # 2 had 15 clock hours of annual training documented for 2009.
The project/facility director confirmed on March 24, 2010 that the counselor did not have the required 25 clock hours of annual training documented for the 2009 training year.
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Plan of Correction
Worker has been advised that 25 hours PER YEAR is required for the D&A program. This worker has been obtaining CEU's in accordance with his CAC Certificate, but NOT in line with licensure expectations. This worker's annual training goals will reflect the expectation of 25 hours of training PER YEAR.
The monitoring of this action will be the responsible of the Facility Director who will monitor and discuss training hours (as recorded in the training log database) with each of the D&A workers during their respective supervisory sessions to ensure that all workers in this program are meeting their expected training hours each licensure year. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the staffing requirements facility summary report form completed by the facility on March 23, 2010 and an interview with the project/facility director, the facility failed to ensure that counselor outpatient caseloads were at or below 35 active clients per one Full Time Equivalent (FTE) counselor for one of two counselors.
The findings included:
On March 23, 2010, the outpatient caseloads were reviewed on the facility summary report form. Per regulation, the caseload for counseling in outpatient programs may not exceed 35 clients per one FTE counselor. Based on the number of hours the counselor, employee # 2, worked at this facility, and the number of clients on the counselor's caseload, the counselor exceeded the maximum outpatient caseload of 35:1. The counselor had a caseload of 53:1.
The project/facility director was interviewed on March 23, 2010. The project/ facility director confirmed the counselor's caseload exceeded the 35:1 active clients.
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Plan of Correction
This worker reduce his caseload as quickly as possible, while still being clinically appropriate with his current clients, and will maintain the expected 35:1 ratio.
By May 31, 2010 the Facility Director will ensure that this worker has reduced his caseload to meet the 35:1 ratio. This will be accomplished in the following manner:
1. Review of charts to determine which clients are clinically appropriate for discharge.
2. Review of charts to determine which clients have displayed a lack of committment to treatment.
3. Refusal to accept new clients until such acceptance will not push ratio beyond 35:1 limit.
After ratio of 35:1 has been re-established with this worker, the Facility Director will monitor caseload level at each supervisory session to ensure that 35:1 ratio is maintained. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of administrative documentation and an interview with the project/facility director, the facility failed to document all components as required for the fire drill log.
The findings include:
The fire drill logs for the twelve months prior to the inspection were reviewed on March 23, 2010. The facility did not include the time of the fire drill on the fire drill logs for the months of May 2009 to March 2010.
The project/facility director confirmed on March 23, 2010 that the fire drill logs did not document the time of the fire drills.
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Plan of Correction
The fire drill log for the agency has been amended to add a column for the time of day to bring us into compliance with this regulation.
By May 1, 2010, the Agency Director will assume responsibility for changing the Fire Drill log to include the time of day for each fire drill exercise. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative policies and procedures, letters of agreement and an interview with the project/facility director, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24 hour emergency psychiatric and medical coverage.
The findings include:
The administrative policies and procedures and letters of agreement were reviewed on March 23-24, 2010. The facility provided a written agreement with a licensed physician for emergency psychiatric and medical coverage. The agreement did not document the coverage was for 24 hour emergency psychiatric and medical coverage as required.
The project/facility director confirmed on March 24, 2010 that the letter of agreement did not specify the coverage was for 24 hour emergency psychiatric and medical coverage as required.
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Plan of Correction
A letter of agreement has been forwarded for signatures to the local medical facility that provides 24-hour psychiatric and medical coverage (Millcreek Community Hospital). Based upon discussion with the staff there, there is no concern that this agreement will not be accepted by both parties.
By May 31, 2010, the Agency Director will ensure that a Letter of Agreement is on file with a medical facility to provide 24/7 psychiatric and medical coverage for our clients. |
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 policy and procedure manual and review of the facility's consent to release information form, the facility failed to develop a written procedure and consent to release information forms that complied with 4 Pa Code 255.5.
The findings include:
The policy and procedures manual and the consent to release information forms were reviewed on March 23-24, 2010. The policy regarding the confidentiality of the client identity and records states " in the event that an insurance company, health or hospital plan remains dissatisfied with the content of the information released with regards to the client in accordance herewith such insurance company, health or hospital plan may apply to the agency director for additional information with the written consent of the client and, upon approval by the agency director, said information can be released. This exceeds that which is permitted under Pa Code 255.5.
The consent to release information forms contains the statement that the information released may potentially be re released by the person/facility receiving the information. This statement in the consent to release implies that once the information is released to the other party that drug and alcohol confidentiality laws do not apply.
The client's Bill of Rights includes the language-"... the client has the right to confidential treatment of the client's personal and medical records. Information from these sources will not be released without the client's consent except in an emergency, medical situation, or as required by law, or under a third party payment contract..."
The Bill if Rights did not define "emergency". Releasing client information without the client's consent in an "emergency" exceeds the law at Act 63 - 71 P.S. Subsection 1690.108(b) and 42 CFR Part 2 Subpart D, subsection 2.51(a) which states that information about a patient may be released without the client's consent to medical authorities in an emergency medical situation where the patient's life is in immediate jeopardy.
The Bill of Rights did not define "medical situation". Releasing client information without the client's consent in a "medical situation" exceeds Act 63 - 71 P.S. Subsection 1690.108(b) and 42 CFR Part 2 Subpart D, subsection 2.51(a) which states that information about a patient may be released without the client's consent in an emergency medical situation where the patient's life is in immediate jeopardy.
The Bill if Rights did not define "as required by law". Releasing client information without the client's consent "as required by law" exceeds what is permitted under 4 Pa. Code Subsection 255.5(b).
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Plan of Correction
The policy manual has been changed to reflect the appropriate wording regarding release of information in order to comply with PA Code 255.5
The agency's Release of Information for the D&A program has also been revised to remove the wording that the information being released "may potentially be re-released by the person/facility receiving the information". Not only was this wording removed, but additional language was added reminding the recipient of the information that they were not legally permitted to re-release it.
By May 31, 2010, the Agency Director will ensure that the new Release of Information form has been implemented and that the old forms are taken out of use. Follow-up action will be the responsibility of the Facility Director who will check client files during supervisory sessions. |
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 a review of client records and an interview with the project/facility director, the facility failed to document follow up contact in one of three client records.
The findings include:
Eight client records were reviewed on March 23-24, 2010. Three of the client records reviewed required a three month follow up contact, per agency policy. The facility did not document follow up contact in client record # 8.
Client # 8 was admitted on June 6, 2009 and discharged on October 12, 2009. Follow up contact was due by January 12, 2010. There was no documentation that follow up contact had been completed.
An interview with the project/facility took place on March 24, 2010. The project/facility director confirmed that there was no documentation that follow up contact had been completed.
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Plan of Correction
This citation was discussed with the worker involved and will not occur again. Both workers in the D&A program are aware of agency and regulatory expectations regarding follow-up contacts.
The Facility Director has already spoken with the worker involved and the Follow-up contact has been completed. The Facility Director will monitor the timeliness of subsequent follow-up contacts through the D&A client database and will be discussed with workers during supervisory sessions. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on an interview with the Facility Director and the review of client census information, the facility failed to comply with the maximum approved capacity for the outpatient treatment activity.
The findings included:
During the licensing inspection conducted on March 23-24, 2010, client census material provided by the project/ facility director and an interview with the project/ facility director confirmed that the current census for active clients was at 60. The maximum approved capacity on the day of the inspection was 50.
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Plan of Correction
Both D&A counselors are reviewing their caseloads and clients who are no longer actively engaged in treatment, or who have received a therapeutically appropriate level of success, will be discharged from services. This will reduce our overall agency caseload down to 50 or fewer clients thereby complying with our agency threshold.
By May 31, 2010 the agency will be in compliance with the capacity census. This time frame is necessary in order to discharge clients in a clinically appropriate manner.
The Facility Director will take the following steps to ensure that the agency's census capacity is not exceeded again:
1. Clients that are clinically appropriate for discharge at this time will be discharged.
2. Clients that have demonstrated a lack of committment to the program will likewise be discharged.
3. The Agency Director will seek an increase in the agency's census capacity (a call to Karen Conjar in this regard has already occurred).
4. No new clients will be accepted until such time as the census capacity is at or below the acceptable level. |