INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 5, 2006 to July 7, 2006 and July 10, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on August 8, 2006.
28 Pa. Coce Subsection 709.14 (a)(5) Restriction on License. Authorized capacity.
The facility has a census of 282 (billing) with 223 (actual) clients in the outpatient drug free activity. This exceeds the authorized maximum capacity of 200.
|
Plan of Correction
|
704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
|
Observations
The plan documenting the qualifications and training of staff was presented to the Department licensing representative at the time of the site visit, but failed to include all clinical staff and support staff. The plan was incomplete and inaccurate.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
|
Observations
Two staff were identified as clinical supervisor and program coordinator/lead counselor. Both employees have full case loads, not allowing for any time for clinical supervision. The number of Full Time Equivalent (FTE) employees comes to 8.25. The standard requires the project to have a full time clinical supervisor and a minimum of a part time clinical supervisor/lead counselor. No staff have been appointed as full time clinical supervisors.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(a) LICENSURE Staff Development Procedure
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:
|
Observations
The procedures for the overall training plan for addressing staff training needs and the procedure for the annual evaluation of the overall training plan are missing time frames.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Feedback forms were not consistently documented for training received by employees #1, and #4.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
An individual training plan was not documented for employees #1, 12 and 13.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
One support staff (12) has not received the HIV/AIDS or STD/TB training within the 2 year time frame. Employee # 13 has not received the HIV/AIDS training within the required time frame. Employee #14 has not received the STD/TB training within the required time frame.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(d)(1) LICENSURE Training Req-Proj/Fac Directors
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
|
Observations
No training plan was documented.
There was no documentation of an individual training plan for the project/facility director.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
The facility failed to provide documentation verifying that the project director obtained 12 clock hours of training during the prior training year.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Employee # 2, 3, 4, 6, and 7 did not have documentation for the 25 clock hours of training required for the prior training year.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
Two employees exceeded the maximum caseload size of 35 clients and were at 47:1 and 51:1 respectively. The overall caseload average was either at 37:1 based on the reported active caseload size or at 47:1 based on billing reports.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
The facility failed to document the provision of fire extinguisher training for new staff and existing staff within the first 7 days of employment..
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Emergency training for new staff and previously existing employees was not documented.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(e)(2) 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:
(2) A financial statement of income and expenses.
|
Observations
A financial statement of income and expenses was not included in the annual report.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
Written procedures for preliminary treatment plans, case consults, treatment plan updates and records of service were not included in the policy and procedures. All procedures for the management of treatment/rehabilitation services for clients should be documented.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
|
Observations
The facility failed to produce an annual audit for the prior fiscal year.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(a)(1) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(1) Recruitment, selection, promotion and termination of staff.
|
Observations
A promotion policy was not included in the recruitment, selection, promotion and termination policies.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(b)(4) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(4) The implementation of Federal, State and local statutes concerning fair employment practices.
|
Observations
Documentation verifying the implementation of federal, state and local statutes concerning fair employment practices was not available during the licensing inspection.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(5)(ii) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
|
Observations
There was no documentation to verify that employee #1 was informed of his/her annual evaluation.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
The facility rents space to several practitioners who are not a part of the facility. These practitioners see the drug and alcohol treatment clients as they come and go and may even have contact with some of them, but there is no Qualified Service Organization Agreement in place with those renting space from the facility. Additionally the clientele appear to be able to easily intermix with each other. The facility has not taken the necessary steps to ensure the privacy and confidentiality of the services provided to their clientele.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
In clinical records #1, 3, 5, 6 and 12 signature lines for parents were included on the consent to release information forms. State law at 71 P.S. Subsection 1690.112 allows for minors to seek treatment on their own, without parental consent. Federal regulations at 42 CFR Part 2, Subpart B, Subsection 2.14(b) stipulates that in states where a minor can consent to treatment without the parents consent, only the minor can consent to the release of information.
The consent to release information forms used by this facility has the client giving the facility permission to 'Obtain and release' information in clinical charts #1, 3, 6, 7 and 12. This language is confusing and fails to meet the stipulation of an informed and voluntary consent required at 28 Pa. Code Subsection 709.28(c). The client would have no way of knowing what the facility would obtain, and the entity receiving such a documents would not be able to act in reliance on it and release information back to the facility.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
In clinical records # 2, 4, 5, 7, 9, 10, 11, 13, 14 and 15; the consent to release information forms failed to list the specific information that would be released. Clinical chart #13 contains a letter addressed to a school which has content that exceeds the information listed on the consent to release information form. In this instance. the release form itself was not a valid consent because of insufficient content.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
|
Observations
The purpose of the consent to release information is unclearly stated in clinical records #1, 3, 4, 9, 10 and 15. The purpose for the release of information to Mental Health providers, Doctors offices, Probation,and the Single County Authority was not clearly stated on the consent to release information form.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
|
Observations
A data collection and record keeping system is in place, the system prints two different reports of client census and treatment activities for billing, but is not able, in an efficient manner, to print out an accurate list of counselors with the corresponding names of clients making up the individual caseloads. The number for the current active clients in the caseload count is less than the number given for active clients being billed.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Personal histories in client records #2,3,5,6,7,11,12,15 and 16 did not consistently address all required areas.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
Treatment plan updates did not include a review of progress on previously stated goals in six out of sixteen client records reviewed, #1,3,9,10,11 and 12.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |