INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 21, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation, 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:
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Plan of Correction
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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 client records, the facility failed to document an individual training plan and/or document an individual training plan that includes potential resources for training which meet the requirements for the employee's position and which relate to the employee's skill level and interest.The findings include:On December 12, 2012, ten records requiring documentation of an individual training plan were reviewed. The facility did not document an individual training plan that included potential resources for employees in six of ten records reviewed, specifically, personnel records # 1, 3, 4, 6, 7, 9, and 10. The facility also did not document an individual training plan in one of ten records reviewed, specifically, personnel record # 8Employee # 1 is the project director and was hired for his current position on April 24, 2006. An individual training plan was completed on January 31, 2012; however, the individual training plan did not include potential resources for employee # 1.Employee # 3 is a clinical supervisor and was hired for his current position on September 1, 2009. An individual training plan was completed on February 28, 2012; however, the individual training plan did not include potential resources for employee # 3.Employee # 4 is a clinical supervisor and was hired for her current position on July 12, 2004. An individual training plan was completed on March 5, 2012; however, the individual training plan did not include potential resources for employee # 4. Employee # 6 is a counselor and was hired on March 10, 2005. An individual training plan was completed on February 7, 2012; however, the individual training plan did not include potential resources for employee # 6.Employee # 7 is a counselor and was hired for her current position on February 17, 2012. An individual training plan was completed on February 13, 2012; however, the individual training plan did not include potential resources for employee # 7. Employee # 8 is a counselor and was hired for her current position on August 30, 2000. The individual training plan was due at the time of employee # 8's annual performance evaluation on February 16, 2012. However, personnel record # 8 did not include documentation of an individual training plan as of December 12, 2012.Employee # 9 is a counselor and was hired on February 1, 2000. An individual training plan was completed on February 15, 2012; however, the individual training plan did not include potential resources for employee # 9. Employee # 10 is a counselor and was hired for her current position on January 9, 2012. An individual training plan was completed on July 6, 2012; however, the individual training plan did not include potential resources for employee # 10. The findings were confirmed during an interview with one of the clinical supervisors on December 12, 2012 at approximately 3:00 P.M.
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Plan of Correction
The project director will be responsible for implementing a plan for staff to include resources to their annual individual training plan. In addition, the clinical supervisors will ensure that everyone complete the individual training plan section of their evaluation. Directions for the training plan have been already changed to include resources for 2013 evaluations. There are also added directions within the document that ask that resources be included. The project director will ensure that resources are included on an ongoing basis. Completed 1/4/13. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills at least once a month. The findings include:Fire drill records were reviewed on December 21, 2012. The records were reviewed from the period covering January 2012 to December 2012. The facility did not have documentation of an unannounced fire drill in two of twelve months reviewed, specifically, July 2012 and August 2012. The findings were confirmed during an interview with the project director on December 21, 2012 at approximately 10:00 A.M.This is a repeat citation. The facility was cited on December 13, 2011 for noncompliance with this standard.
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Plan of Correction
The project director and clinical supervisors will ensure that all programs have monthly fire drills regardless if clients are present or not. The policy has already been changed and the fire log sheet directions state that fire drills must be conducted in all months including summer months. This is implemented as of 1/4/13 and the project director will ensure ongoing compliance. |
709.82(e)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on a review of letters of agreement and an interview with the project director, the project failed to demonstrate the ability to assist clients in obtaining dental supportive services when necessary. The findings include:On December 12, 2012, the Licensing Specialist asked to see documentation that the facility assists clients in obtaining dental supportive services when necessary. Documentation that the facility assists clients in obtaining dental supportive services when necessary was not presented for review. The findings were confirmed during an interview with the project director on December 12, 2012 at approximately 10:30 A.M.
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Plan of Correction
The project director will ensure that documentation of dental relationships exist through client files or through Business Associate Agreements. The project director will begin to collect this documentation by 2/28/13 and ensure that ongoing relationships are established. The project director will ensure these agreements are current. |
709.82(e)(3) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on a review of letters of agreement and an interview with the project director, the project failed to demonstrate the ability to assist clients in obtaining legal supportive services when necessary. The findings include:On December 12, 2012, the Licensing Specialist asked to see documentation that the facility assists clients in obtaining legal supportive services when necessary. Documentation that the facility assists clients in obtaining legal supportive services when necessary was not presented for review. The findings were confirmed during an interview with the project director on December 12, 2012 at approximately 10:30 A.M.
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Plan of Correction
The project director will ensure that documentation of legal services and relationships exist through client files or through Business Associate Agreements. The project director will begin to collect this documentation by 2/28/13 and ensure that ongoing relationships are established. The project director will ensure these agreements are current.
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709.82(e)(4) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(4) Economic.
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Observations
Based on a review of letters of agreement and an interview with the project director, the project failed to demonstrate the ability to assist clients in obtaining economic supportive services when necessary. The findings include:On December 12, 2012, the Licensing Specialist asked to see documentation that the facility assists clients in obtaining economic supportive services when necessary. Documentation that the facility assists clients in obtaining economic supportive services when necessary was not presented for review. The findings were confirmed during an interview with the project director on December 12, 2012 at approximately 10:30 A.M.
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Plan of Correction
The project director will ensure that documentation of economic supportive services and relationships exist through client files or through Business Associate Agreements. The project director will begin to collect this documentation by 2/28/13 and ensure that ongoing relationships are established. The project director will ensure these agreements are current. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to adopt a written plan for the coordination of client treatment and rehabilitation services which include policies and procedures that include time frames for completing the preliminary treatment and rehabilitation plan and the individual treatment and rehabilitation plan.The findings include:The facility's policy and procedure for preliminary treatment and rehabilitation plan of partial hospitalization titled: "709.81 Intake and Admission," states:"A preliminary treatment plan should be based on the aftercare plan of the primary treatment facility, if the client has been in residential treatment, and information from the initial interview, histories and other available data. The plan also identify critical problems and strategies for their resolution."The facility's policy and procedure for individual treatment and rehabilitation plan of partial hospitalization titled: "709.82 Treatment and Rehabilitation Services," states:"(a)An individual treatment plan is developed with each client and shall include:(1)Short and long-term goals for treatment as formulated by both staff and client. We pay special attention to the treatment plans developed by a primary treatment facility, particularly the aftercare plan. Goals are realistic and stated in terms of measurable criteria."The facility's policy and procedure for preliminary treatment and rehabilitation plan of outpatient activities titled: "709.91 Intake and Admission," states:"A preliminary treatment plan should be based on the aftercare plan of the primary treatment facility, if the client has been in residential treatment, and information from the initial interview, histories and other available data. The plan also identify critical problems and strategies for their resolution."The facility's policy and procedure for individual treatment and rehabilitation plan of outpatient activities titled: "709.92 Treatment and Rehabilitation Services," states:"(a)An individual treatment plan is developed with each client and shall include:(1)Short and long-term goals for treatment as formulated by both staff and client. We pay special attention to the treatment plans developed by a primary treatment facility, particularly the aftercare plan. Goals are realistic and stated in terms of measurable criteria."On December 11, 2012 and December 12, 2012, the facility's policy and procedures manual was reviewed for a written plan for the coordination of client treatment and rehabilitation services. The facility's policies and procedures on the preliminary treatment and rehabilitation plan and the individual treatment and rehabilitation plan for partial hospitalization and outpatient activities did not include time frames for completing the preliminary treatment and rehabilitation plan and the individual treatment and rehabilitation plan.The findings were confirmed during an interview with the project director on December 12, 2012 at approximately 10:30 A.M.
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Plan of Correction
The project director will be responsible to specify time frames for the preliminary, individual and rehabilitation plans within the policy and procedure manual. These additions to the policies will be created and supported by the board of directors by 3/1/13. The project director will ensure the revised policy and procedure will be implemented and remain in place at the facility. |
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 ensure that the client is notified of his/her right to revoke client consent to release information verbally or in writing in five of five client records.The findings include:On December 21, 2012, five records requiring documentation of consent to release information were reviewed. The facility's consent to release form had verbiage that only gave the client the right to revoke in writing in five of five client records reviewed, specifically, client records # 1, 2, 3, 4, and 5.Client record #1 contained an informed and voluntary consent dated 5/23/12 to a government agency, an informed and voluntary consent dated 5/23/12 to her parents, and an informed and voluntary consent dated 5/23/12 to an insurance company. The forms used as the informed and voluntary consents did not give the client the right to revoke in writing or verbally. Client record #2 contained an informed and voluntary consent dated 6/22/12 to a government agency and an informed and voluntary consent dated 6/22/12 to his parents. The forms used as the informed and voluntary consents did not give the client the right to revoke in writing or verbally. Client record #3 contained an informed and voluntary consent dated 7/3/12 to a government agency, an informed and voluntary consent dated 7/3/12 to his parents, and an informed and voluntary consent dated 7/3/12 to an insurance company. The forms used as the informed and voluntary consents did not give the client the right to revoke in writing or verbally. Client record #4 contained an informed and voluntary consent dated 7/24/12 to a government agency and an informed and voluntary consent dated 7/24/12 to his parents. The forms used as the informed and voluntary consents did not give the client the right to revoke in writing or verbally. Client record #5 contained an informed and voluntary consent dated 8/16/12 to a government agency, an informed and voluntary consent dated 8/16/12 to his mother, and an informed and voluntary consent dated 8/16/12 to an insurance company. The forms used as the informed and voluntary consents did not give the client the right to revoke in writing or verbally. The findings were confirmed during an interview with one of the clinical supervisors on December 21, 2012 at approximately 3:00 P.M.
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Plan of Correction
The project director will change the release information forms to include the provision for clients to revoke consent verbally as well as through written means. The project director will change the forms and implement with clients by 2/1/13. The project director and clinical supervisors will ensure ongoing compliance. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a date of completion for a preliminary treatment and rehabilitation plan.The findings include:The facility's policy and procedure on the preliminary treatment and rehabilitation plan does not include a time frame for completing the preliminary treatment plan. However, during an interview with on the clinical supervisors on December 20, 2012, the clinical supervisor stated the facility's standard practice is to allow the counselors to complete the preliminary treatment and rehabilitation plan within seven days of the client's date of admission. On December 21, 2012, five client records requiring documentation of a preliminary treatment and rehabilitation plan were reviewed. The facility did not document a date of completion for a preliminary treatment and rehabilitation plan in five of five client records reviewed, specifically, client records # 1, 2, 3, 4, and 5. Client # 1 was admitted May 18, 2012. The preliminary treatment and rehabilitation plan was due May 25, 2012. The preliminary treatment and rehabilitation plan was completed. However, the preliminary treatment and rehabilitation plan did not include documentation of a date of completion and client record # 1 did not include documentation of when the preliminary treatment and rehabilitation plan was completed as of December 21, 2012. Client # 2 was admitted June 22, 2012. The preliminary treatment and rehabilitation plan was due June 29, 2012. The preliminary treatment and rehabilitation plan was completed. However, the preliminary treatment and rehabilitation plan did not include documentation of a date of completion and client record # 2 did not include documentation of when the preliminary treatment and rehabilitation plan was completed as of December 21, 2012. Client # 3 was admitted June 29, 2012. The preliminary treatment and rehabilitation plan was due July 6, 2012. The preliminary treatment and rehabilitation plan was completed. However, the preliminary treatment and rehabilitation plan did not include documentation of a date of completion and client record # 3 did not include documentation of when the preliminary treatment and rehabilitation plan was completed as of December 21, 2012. Client # 4 was admitted July 20, 2012. The preliminary treatment and rehabilitation plan was due July 27, 2012. The preliminary treatment and rehabilitation plan was completed. However, the preliminary treatment and rehabilitation plan did not include documentation of a date of completion and client record # 4 did not include documentation of when the preliminary treatment and rehabilitation plan was completed as of December 21, 2012. Client # 5 was admitted August 15, 2012. The preliminary treatment and rehabilitation plan was due August 22, 2012. The preliminary treatment and rehabilitation plan was completed. However, the preliminary treatment and rehabilitation plan did not include documentation of a date of completion and client record # 5 did not include documentation of when the preliminary treatment and rehabilitation plan was completed as of December 21, 2012. The findings were disputed during an interview with one of the clinical supervisors on December 21, 2012 at approximately 3:00 P.M., but the clinical supervisor was unable to produce documentation demonstrating the dates of completion of the preliminary treatment plans.
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Plan of Correction
The project director will ensure that preliminary treatment and rehabilitation plans will be signed and dated at completion of the document to match the time frame defined by the policy and procedure manual. The clinical supervisors will supervise the counselors to implement this change starting 1/15/13. Both the clinical supervisors and project director will monitor and ensure implementation and compliance. All ongoing reports for current and future clients will be dated. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on an interview with the clinical supervisor and review of client records, the facility failed to comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).The findings include:The regulation at 55 Pa. Code Part III chapter 1223.52 section (a) subsection 6 (i) - (ii) specifies that "within 15 days following intake, the clinic's supervisory physician shall review and verify each patient's level of care assessment, psychosocial evaluation and initial treatment plan prior to the provision of any treatment beyond the 15 th day following intake. The clinic's supervisory physician shall verify the patient's diagnosis. The clinic's supervisory physician shall sign and date the patient's level of care assessment, psychosocial evaluation, treatment plan and diagnosis in the patient's record. Payment will not be made for services provided within or beyond the 15 th day following intake, without the clinic's supervisory physician's review and approval of the level of care assessment, psychosocial evaluation, treatment plan and determination of the patient's diagnosis. Sixty days following the date of the initial treatment plan and at the end of every 60-day period during the duration of treatment, the clinic's supervisory physician shall review and update each patient's treatment plan. Each review and update shall be dated, documented and signed in the patient's record by the clinic's supervisory physician."On December 21, 2012, one client record requiring documentation of a physician's signature on client treatment plans were reviewed. A physician did not sign the individual treatment and rehabilitation plan in one of one record reviewed, specifically, client record # 3. A physician also did not sign the individual treatment and rehabilitation plan update and subsequent individual treatment and rehabilitation plan update in one of one record reviewed, specifically, client record # 3.Client # 3 was admitted June 29, 2012. A physician was required to sign the individual treatment and rehabilitation plan, the treatment plan update, and the subsequent treatment plan update. The individual treatment and rehabilitation plan was completed July 3, 2012, the treatment plan update was completed August 29, 2012, and the subsequent treatment plan update was completed October 29, 2012. However, the individual treatment and rehabilitation plan, the treatment plan update, and subsequent treatment plan update did not include documentation of a physician's signature as of December 21, 2012.The findings were confirmed during an interview with the clinical supervisor on December 21, 2012 at approximately 3:00 P.M.
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Plan of Correction
By 2/28/13, the project director will implement a process that will ensure that a physician will review and verify each medical assistant client's assessment, psychosocial and treatment plans according to medical assistance guidelines and procedures. Once this process is in place, the project director and clinical supervisor will continue to monitor the review and verification of such records. The physician will review and sign andy current and future treatment plans and/or treatment plan updates of cients on medical assistance. |