INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 24 - 26, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Treatment Program 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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711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in three of eight client records.
The findings include:
Sixteen client records were reviewed on July 25 - 26, 2012. Eight client records were reviewed for type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plans. The facility failed to document the type and frequency of treatment and rehabilitation services in client records # 1, 5 and 6.
Client # 1 was admitted into treatment on February 13, 2012. The treatment plan was completed on May 17, 2012. The client is receiving individual and group counseling. The treatment plan indicated the client would participate in two therapy sessions per month. The treatment plan did not document the type of treatment and rehabilitation services.
Client # 5 was admitted into treatment on May 4, 2012. The treatment plan was completed on June 4, 2012. The client is receiving individual and group counseling. The treatment plan did not document the frequency of the group counseling sessions.
Client # 6 was admitted into treatment on March 14, 2012. The treatment plan was completed on April 27, 2012. The client is receiving individual and group counseling. The treatment plan indicated the client would participate in 150 minutes of counseling monthly. The treatment plan did not document the type of treatment and rehabilitation services.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Under the Direction of the Clinical Administrator or her designee, clinical program staff will receive training by 9/1/12 on documenting the type & frequency of treatment rehabilitation services when writing an individual treatment and rehabilitation plan. The Clinical supervisor will monitor compliance with documenting frequency and type of service by auditing 10 charts per month for 4 months, beginning with the month of September 2012 and ending with the month of December 2012. Results of the monthly chart audit will be shared with clinical staff during supervision meetings as well with program leadership. |
711.15(b) LICENSURE Subchapter B.Approval Procedures.Right to ent
711.15. Right to enter and inspect.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
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Observations
Based on the review of administrative documentation, the facility failed to allow full and free access to the records of the facility.
The findings include:
The Staffing Requirements Facility Summary Report was reviewed on July 30, 2012. The Chief Executive Officer of the program had been listed as the project director at the facilities inspected the prior week. The personnel record for this person was not available for review at the previous inspections and was to be made available for review on July 30, 2012. At the time of the July 30, 2012 inspection, the Project Director's personnel record was not available. Facility staff indicated that the program was no longer listing the Chief Executive Officer as the Project Director. The Chief Executive Officer was not listed as the project director on the staffing form reviewed on July 30, 2012. The person identified on this staffing form as the project director had been reviewed only as the facility director at the previously inspected facilities.
As a result, the job descriptions for both the Chief Executive Officer and the currently listed Project Director were requested. As of July 31, 2012, the job descriptions had not been made available for review.
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Plan of Correction
Under the direction of the Clinical Administrator or her designee, the facility will give DDAP full and free access to the relevant records of the facility and its clients. Effective 8/1/12, access to all relevant records will be provided upon request during the onsite licensing inspections by the Clinical Administrator or her designee for all future inspections. |
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 policy and procedure manual and other administrative documentation, the project failed to identify a project director who has responsibility for the overall management of the project.
The findings include:
The policy and procedure manual was reviewed on July 30, 2012. Personnel records were reviewed on July 30, 2012. The employee's job description for the person listed as the project director was requested on July 30, 2012 and again on July 31, 2012. The facility did not provide documentation that demonstrated the person listed as the project director performed the duties of the project director.
The findings were discussed with Quality Assurance personnel on July 30, 2012 who disagreed with the findings that the person listed as the project director did not perform the duties of the project director. The facility did not produce documentation to demonstrate that the person identified as the project director performed the duties of the project director.
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Plan of Correction
Under the direction of the Governing body/Executive management team, the Clinical Administrator of Addiction Medicine Services (AS) is the Project Director. AS meets the qualifications of Project Director for Western Psychiatric Institute and Clinic Addiction Medicine Services as stated in applicable DDAP regulations and legal authority requirements for program director position.
- Providing primary operational leadership for the programs
- Having responsibility for the overall management of the project and staff
- Her education and experience meets all requirement of chapter 704
- Can execute contracts, establish wage scales, approve personnel policies, manage fiscal matters, and perform related duties related to Addiction Medicine Services.
- Providing periodic scheduled as well as annual summary to Western Psychiatric Institute and Clinic executive management team as the governing body for WPIC.
WPIC's Director of TJC and Ambulatory Regulatory Compliance will submit to DDAP by September 28, 2012 the corrected staffing grids for each WPIC facility licensed by DDAP indicating the Project Director as A.S.and a letter from the CEO asserting AS meets the qualifications of Project Director. |