INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19, 2008 through February 22, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penn Foundation for Mental Health, 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 March 26, 2008.
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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 a review of the staffing requirements facility summary report and the Corporate Table of Organization, the facility failed identify the President and CEO as the project director who is responsible for the overall management of the project, Penn Foundation, Inc.
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Plan of Correction
President and CEO of Penn Foundation will be named Project Director. This position reports directly to Board of Directors. |
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 a review of personnel records, the facility failed to document the educational qualifications for counselors in two of five records reviewed, #6 and 9.
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Plan of Correction
Both of the couselors will be made "counselor assistants". They will each receive the appropriate level of supervision based on their individual educational and job experience. The supervisors will document all supervision they receive. New job descriptions will be placed in the personnel record. Facility Director and clinical supervisors will be given a highlighted copy of what is required for the position of counselor and counselor assistant to aid in all future hirings. Human Resources will help oversee this procedure.
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records and supervisory notes, the facility failed to document both direct observation and close supervision in one of one record reviewed, #7. There was no documentation of direct observation during the first three months of employment or weekly supervision since October 2007 when the counselor assistant began working at the facility.
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Plan of Correction
Counselor Assistant will receive three months of direct supervision and will then receive nine months of close supervision. This will be documented by the clinical supervisor. Clinical supervisor will oversee this POC. Clinical supervisor will closely review all new hires to ensure if educational or experience qualifications are not sufficient for title of "counselor", that the new staff member is given the title of "counselor assistant" and given appropriate supervision.
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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.
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Observations
Based on a review of training records, the facility failed to document both the subject areas and potential resources for training in six of eight records reviewed, #1, 2, 3, 4, 5 and 9.
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Plan of Correction
Training plans will be modified and expanded to include subject areas and potential resources for all employees. Supervisors will be made aware of the new expectations of training plans. Facility Director will oversee this POC.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and training records, the facility failed to document 4 hours of tuberculosis, sexually transmitted diseases and other health related topics in one of nine records reviewed, #10.
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Plan of Correction
One employee did not have TB/STD training. He has since scheduled this training and will complete it this month. Facility Director will oversee this POC.
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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records and training records, the facility failed to document 12 training hours for the July 2006 to June 2007 training year in one of two records reviewed, #3. Employee #3 only earned eight training hours.
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Plan of Correction
This employee had a six hour training scheduled for June that was postponed until the beginning of July. We were counting these hours since the training was scheduled for the right fiscal year. We now know this is not acceptable and will not do this in the future. Staff will be reminded of the importance of completing all required training hours and our in-house training person will closely monitor this. Facility Director will oversee this POC.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill record, the facility failed to document that fire drills were conducted during sleeping hours every 6 months. From June 2007 to January 2008 none of the monthly fire drills occurred during residential client sleeping hours.
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Plan of Correction
Mainenance department has been made aware of the need to complete a fire drill during sleeping hours. They will put this into the schedule for fire drills to assure this happens in the next six months. Maintenance Director will oversee this POC.
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709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a complete drug and alcohol history in three of four client records reviewed, #1, 2 and 4. Drug and alcohol histories did not include the lengths and patterns of use or the client's perception of use.
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Plan of Correction
Counselors will be made aware at the next scheduled staff meeting to be certain to include lenths and patterns of use and client's perception of use in all records. Clinical supervisor will oversee and monitor records to assure that this is being included in all records.
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709.81(b)(6) LICENSURE Intake and admission
709.81. 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, the facility failed to document complete psychosocial evaluations in four of four client records reviewed, #1, 2, 3 and 4. The psychosocial evaluations were missing in two client records, #1 and 2. Psychosocial evaluations did not document an assessment of the client's assets/strengths, support systems and negative factors that may inhibit treatment in two records, #3 and 4.
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Plan of Correction
We realized during the site visit that at times our counselors were not printing out psychosocials, they were in the computer, but did not make it into the record. Counselors will be talked to at the next staff meeting on the importance of printing out the paperwork and also including support systems, assest and negative factors. Support staff will check all active clinical records to assure that they are complete and paperwork has been printed out. Clinical supervisor will oversee for completness of information.
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709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of facility policy and client records, the facility failed to document a treatment plan in two of four records reviewed, #1 and 2. The facility also failed to include the client's signature on the individual treatment plans in two of four client records reviewed, #3 and 4. The facility's policy indicated that clients were to sign their treatment plans.
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Plan of Correction
This was another example of paperwork not being printed out. Staff will be talked to about the importance of printing out all paperwork. Clinical supervisor will montitor clinical records to assure that treatment plans are placed in the records and signed by the client per our own policy and procedure.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed document a complete treatment plan update in one of two client records reviewed, #4. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the treatment plan.
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Plan of Correction
At the next staff meeting, staff will be instructed as to what is expected in a treatment plan update to assure that it is accurately assessing the client's progress in treatment. Clinical supervisor will oversee this plan of correction.
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709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document twice weekly group counseling sessions as indicted in the individual treatment plans in three of four client records reviewed, #1, 3 and 4.
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Plan of Correction
Counselors will be instructed at the next staff meeting on the importance of documenting group counseling session. These groups do occur daily, but counselors have been failing to document these sessions. Clinical supervisor will oversee clinical charts to assure that documentation is taking place.
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709.82(d)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(2) Group counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to document the twice weekly group counseling sessions in three of four client records reviewed, #1, 3 and 4.
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Plan of Correction
Counselors will be instructed at the next staff meeting on the importance of documenting group counseling session. These groups do occur daily, but counselors have been failing to document these sessions. Clinical supervisor will oversee clinical charts to assure that documentation is taking place.
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709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of administrative documents, the facility failed to document that the governing body assisted and/or was presented with the 2008 project goals and objectives.
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Plan of Correction
Project director will report annual goals and objectives to the board of directors during a scheduled board meeting. This will be documented in the board meeting minutes. Project Director will responsible for overseeing the plan of correction. |
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 a review of client records, the facility failed to document an informed and voluntary consent to release information in two of four partial hospitalization records reviewed, #1 and 3 and in three of five outpatient records, #1, 3 and 4. A consent to release form (used by the facility) from Bucks County SCA allowed for communication between the facility, Bucks County SCA, and the Department of Public Welfare.
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Plan of Correction
Bucks County requires this consent be signed in order to fund clients in our program. The Recovery Center will not use this consent in the clinical record, instead we will have them sign our own internal release of information that is within what is allowed by DOH. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of consent forms, the facility failed to document an informed and voluntary consent to release information form in two of four partial hospitalization records reviewed, #1 and 3 and in three of five outpatient records, #1, 3 and 4. The specific information to be disclosed to funding sources exceeded the limitations imposed at 4 Pa. Code 255.5. The consent to release information form to the Bucks County D&A Commission, Inc. and the Bucks County Department of Public Welfare (both on the same consent form) allowed for the release of the client's initial evaluation/assessment results and history. One item to be released was identified as "other" with no further clarification provided for the client.
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Plan of Correction
Bucks County requires this consent be signed in order to fund clients in our program. The Recovery Center will not use this consent in the clinical record, instead we will have them sign our own internal release of information that is within what is allowed by DOH. Staff will also be informed of the necessity of specifying what information is to be released if "other" is checked on the release form. Clinical supervisors will oversee this plan of correction.
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709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of client records, the facility failed to document that the prescribing physician signed verbal orders within 24 hours in two of two detoxification records reviewed, #1 and 2 and in three of three residential records reviewed, #2, 3 and 4.
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Plan of Correction
Nursing staff will work with our physician to sign all verbal orders within 24 hours. All nurses will be reminded of the need for verbal orders to be signed within 24 hours and will work with the phsysician to be certain this occurs. Nursing supervisor will oversee this plan of correction.
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document complete psychosocial evaluations in two of two client records reviewed, 1 and 2. The psychosocial evaluations were missing from the client records reviewed.
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Plan of Correction
Psychosocial evaluations were not printed out despite being done via the computer. Staff will be met with at the next staff meeting and talked to about the importance of printing out all paperwork. Support staff will oversee to assure that documentation and paperwork is placed in all clinical records. Clinical supervisor will oversee this POC.
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709.63(a)(6) LICENSURE Aftercare plan
709.63. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document complete aftercare plans in one of one record reviewed, #1. The aftercare plan was missing in the record reviewed.
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Plan of Correction
Aftercare plan was not completed. Staff will be talked to at the next staff meeting about the importance of completing aftercare plans on all clients. Clinical supervisor will oversee this to assure that aftercare plans are completed on all clients.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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, the facility failed to document complete psychosocial evaluations in three of four records reviewed, #1, 2 and 4. The psychosocial evaluations did not include the counselor's assessment of the client's assets/strengths and negative factors that may inhibit treatment in three records, #1, 2 and 4. Psychosocial evaluations did not document the client's support systems in two records, #2 and 4.
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Plan of Correction
Counselors will be talked to at the next staff meeting on the importance of including support systems, assest and negative factors. Support staff will check all active clinical records to assure that they are complete and paperwork has been printed out. We will look into including a section specifically dedicated to this information, to be certain counselors cannot exclude it from the evaluation. Clinical supervisor will oversee for completness of information.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document individual treatment plans within the first three days of treatment as per the project's policies in three of four client records reviewed, #1, 2 and 3. The treatment plan in #1 was due no later than 1/18/08 but was not completed until 2/13/08. The treatment plan in #2 was due no later than 1/28/08 but was not completed until 2/13/08. The treatment plan in #3 was due no later than 12/3/07 but was not completed until 12/12/07.
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Plan of Correction
We discovered during the site visit that the person responsible for printing out treatment plans and getting them signed was not consistently doing this. Since the site visit we have already instituted a new procedure for getting treatment plans to clients and staff members to be signed. We believe having support staff be responsible for printing out completed treatment plans and giving them to the clinical supervisor will assure treatment plans are signed in a timely manner.
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709.52(a)(1) LICENSURE Short/Long term TX Goals
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document short- and long-term goals stated in terms of measurable criteria in four of four client records reviewed, #1, 2, 3 and 4.
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Plan of Correction
Staff will be inserviced about providing measurable criteria on all treatment plans. Clinical supervisor will monitor clinical records to assure that goals are stated in terms of measurable criteria.
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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, the facility failed to document complete psychosocial evaluations in five of five client records reviewed, #1, 2, 3, 4 and 5. The psychosocial evaluations failed to include the counselor's assessment of the client's assets/strengths and negative factors that may inhibit treatment in five of five records reviewed, #1, 2, 3, 4 and 5. Evaluations did not include the client's coping mechanisms in two records reviewed, #3 and 4.
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Plan of Correction
Staff will be inserviced about including client's assets/strenghts and negative factors in the psychosocial evaluation. We will look into including a section specifically dedicated to this information, to be certain counselors cannot exclude it from the evaluation. Clinical supervisor and Facility Director will oversee this plan of correction.
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709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document short- and long-term goals stated in terms if measurable criteria in four of five client records reviewed, #1, 3, 4 and 5.
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Plan of Correction
Staff will be inserviced about providing measurable criteria on all treatment plans. Clinical supervisor will monitor clinical records to assure that goals are stated in terms of measurable criteria
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document complete treatment plan updates in three of three records reviewed, #1, 3 and 4. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the prior treatment plans.
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Plan of Correction
At the next staff meeting, staff will be inserviced about what information is to be included in the treatment plan update. Staff will be informed about the need to include client's progress on the stated goal on the treatment plan update. Clinical supervisor will oversee this to assure information is included in the clinical record. |
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 a review of client records, the facility failed to document aftercare plans in three of four client records reviewed, #6, 7 and 9.
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Plan of Correction
Aftercare plans were not completed. Staff will be talked to at the next staff meeting about the importance of completing aftercare plans on all clients. Clinical supervisor will oversee this to assure that aftercare plans are completed on all clients.
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