INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 9 - 11, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Center for Psychiatric and Chemical Dependency Services 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 13, 2009. .
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Plan of Correction
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) 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 review and update treatment and rehabilitation plans at least every 60 days in one of four client records.
The findings include:
Twenty-one client records were reviewed on February 9 - 11, 2009. Sixteen outpatient client records were reviewed. Treatment plan updates were required in four client records. The facility failed to complete a treatment plan update within 60 days, as required by agency policy, in client record # 8.
In client record # 8, the treatment plan was completed on 10/7/08. The treatment plan update was due 12/7/08. There was no documentation of a treatment plan update.
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Plan of Correction
The Facility Director shall ensure that compliance to developing individualized treatment plan updates in timely fashion will be evidenced by periodic quality reviews by the Facility Director combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plan updates will occur in individual supervisory sessions conducted by the Facility Director. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Facility Director beginning no later than 3/15/09 and continuing through the course of the licensing review period. |
711.95(b) LICENSURE Efficient Retrieval of Data
711.95. Uniform Data Collection System.
(b) A data collection system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
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Observations
Based on the review of client record case lists and an interview with the facility director, the facility failed to demonstrate an efficient retrieval of data needed to measure the project's performance.
The findings include:
On February 9 - 11, 2009, two outpatient client record lists were reviewed in order to obtain client records for review of the project's performance. The facility director reports the electronic record system cannot generate a list of clients that would include an admission and discharge date. Numerous cases had to be reviewed to find client records with the admission and discharge dates in the appropriate timeframe for the inspection. This resulted in a loss of time for the licensing specialists and did not present for an efficient retrieval of data needed to measure the project's performance.
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Plan of Correction
The facility director will meet with Information Services Department (ISD) and Health Information Management (HIM) to identify a strategy to generate the lists of medical records that fit the needs of the Division staff presenting to conduct the licensing review. These lists shall include at a minimum, admission and discharge dates clearly indicating appropriate parameters for the review period. This meeting shall take place no later than 4/15/09. |
711.82(e) LICENSURE Provision of Services re: TX Plan
711.82. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document the provision of counseling services according to the individual treatment and rehabilitation plans in two of five client records.
The findings include:
Twenty-one client records were reviewed on February 9 -11, 2009. Five partial hospitalization client records were reviewed. Five client records were required to have counseling services provided according to their individual treatment and rehabilitation plans.
In client record # 4, the individual rehabilitation and treatment plan specified the client would receive two hours of individual counseling per week. No individual counseling sessions were scheduled for the weeks of 1/26/09 and 2/2/09.
In client record # 5, the individual rehabilitation and treatment plan specified the client would receive two hours of individual counseling per week. The client had only one individual counseling session scheduled for the weeks of 12/22/08 and 12/29/08.
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Plan of Correction
The Facility Director shall ensure through supervision and quality assurance chart review, that a minimum of 2 individual sessions are provided on a weekly basis to all members of the partial program. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Facility Director beginning no later than 3/15/09 and continuing through the course of the licensing review period. |
711.82(f)(1) LICENSURE Ind Counseling - 2X WK
711.82. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on the review of client records, the facility failed to document the provision of individual counseling services, at least twice weekly in two of five client records.
The findings include:
Twenty-one client records were reviewed on February 9 -11, 2009. Five partial hospitalization client records were reviewed. Five client records were required to have individual counseling at least twice weekly.
In client record # 4, no individual counseling sessions were scheduled for the weeks of 1/26/09 and 2/2/09.
In client record # 5, the client had only one individual counseling session scheduled for the weeks of 12/22/08 and 12/29/08.
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Plan of Correction
The Facility Director shall ensure through supervision and quality assurance chart review, that a minimum of 2 individual sessions are provided on a weekly basis to all members of the partial program. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Facility Director beginning no later than 3/15/09 and continuing through the course of the licensing review period. |
711.83(c)(2)(ii) LICENSURE Specific Information Disclosed
711.83. Client records.
(c) Confidentiality.
(2) 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:
(ii) The specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on the consent to release information forms in two of five client records.
The findings include:
Twenty-one client records were reviewed. Five partial hospitalization client records were reviewed. Five client records were required to have consent to release information forms completed. The facility failed to document the specific information to be disclosed on the consent to release information form in client records # 2 and 4.
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Plan of Correction
The Facility Director will ensure, through supervision and quality assurance chart review, that all program staff obtain an informed and voluntary consent in writing authorizing the release of protected drug and alcohol information prior to the release of such information. The consent form shall be in compliance with 4 PA 255.5 as well as directly in 42 CFR Part 2, Subpart C, subsection 2.32 and indirectly at subsection 2.31 as regards confidentiality of drug and alcohol treatment records, and shall demonstrate the patient's intent to release information voluntarily. This form shall contain the following information: The name of the person, agency, or organization to whom disclosure is made; the specific information disclosed; the purpose of disclosure and, the dated signature of the client or guardian. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Facility Director beginning no later that 3/15/09 and continuing through the course of the licensing review period. |
711.83(c)(2)(iii) LICENSURE Purpose of Disclosure
(c) Confidentiality.
(2) 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:
(iii) The purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on the consent to release information forms in two of five client records.
The findings include:
Twenty-one client records were reviewed. Five partial hospitalization client records were reviewed. Five client records were required to have consent to release information forms completed. The facility failed to document the purpose of disclosure on the consent to release information form in client records # 2 and 4.
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Plan of Correction
The Facility Director will ensure, through supervision and quality assurance chart review, that all program staff obtain an informed and voluntary consent in writing authorizing the release of protected drug and alcohol information prior to the release of such information. The consent form shall be in compliance with 4 PA 255.5 as well as directly in 42 CFR Part 2, Subpart C, subsection 2.32 and indirectly at subsection 2.31 as regards confidentiality of drug and alcohol treatment records, and shall demonstrate the patient's intent to release information voluntarily. This form shall contain the following information: The name of the person, agency, or organization to whom disclosure is made; the specific information disclosed; the purpose of disclosure and, the dated signature of the client or guardian. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the Facility Director beginning no later that 3/15/09 and continuing through the course of the licensing review period. |
711.85(b) LICENSURE Efficient Retrieval of Data
711.85. Uniform Data Collection System.
(b) A data collection shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
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Observations
Based on the review of client record case lists and an interview with the facility director; the facility failed to demonstrate an efficient retrieval of data needed to measure the project's performance.
The findings include:
On February 9 - 11, 2009, two partial hospitalization client record lists were reviewed in order to obtain client records for review of the project's performance. The facility director reports the electronic record system cannot generate a list of clients that would include an admission and discharge date. Numerous cases had to be reviewed to find client records with the admission and discharge dates in the appropriate timeframe for the inspection. This resulted in a loss of time for the licensing specialists and did not portray an efficient retrieval of data need to measure the project's performance.
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Plan of Correction
The facility director will meet with Information Services Department (ISD) and Health Information Management (HIM) to identify a strategy to generate the lists of medical records that fit the needs of the Division staff presenting to conduct the licensing review. These lists shall include at a minimum, admission and discharge dates clearly indicating appropriate parameters for the review period. This meeting shall take place no later than 4/15/09. |
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, the facility failed to document HIV/AIDS and TB/STD training in two of nine personnel records.
The findings include:
Ten personnel records were reviewed on February 9 - 11, 2009. HIV/AIDS and TB/STD training was required in nine personnel records. The facility did not document HIV/AIDS and TB/STD training in personnel records # 7 and 8.
Employee # 7 is a counselor and was hired on 9/11/06. HIV/AIDS and TB/STD training was due to be completed by 9/11/07. Employee # 7 did not have documentation of the required 6 hours of HIV/AIDS training and 4 hours TB/STD training.
Employee # 8 was hired on 9/20/05. HIV/AIDS and TB/STD training was due to be completed by 9/20/07. Employee # 8 did not have documentation of HIV/AIDS or TB/STD training.
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Plan of Correction
The Facility Director Supervisor shall ensure that all staff complete at least 25 clock hours of training from the approved curriculum list on an annual basis. Particular attention shall be focused upon the Mandatory Communicable disease training which includes 6 hours of HIV/AIDS and 4 hours of TB, sexually transmitted disease and other related health topics. This shall be monitored in on-going supervision, and staff will be facilitated opportunity to attend training. To be completed during the Addiction Medicine training year which runs 1/1/09 ? 12/31/09 |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel training records, CPR/first aid certification cards and an interview with the facility director, the facility failed to ensure that at least one person trained in CPR/first aid skills was onsite during the project's hours of operation.
The findings include:
Twenty-two personnel training records and CPR/first aid certification cards were reviewed on February 9 - 11, 2009. Only four employees had documentation of current CPR/first aid certification. The facility director reports the project does not have staff scheduled with current CPR/first aid certification during the Thursday hours of operation, from 6:00 p.m. to 8:00 p.m.
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Plan of Correction
The Facility Director Supervisor shall ensure that all staff complete at least 25 clock hours of training from the approved curriculum list on an annual basis. Particular attention shall be focused upon ensuring that a minimum of one staff member who is CPR certified and trained in first aid is available onsite during all hours of program operation. This shall be monitored in on-going supervision, and staff will be facilitated opportunity to attend training. To be completed during the Addiction Medicine training year which runs 1/1/09 ? 12/31/09 |
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 required twenty-five clock hours of annual training for counselors in three of six personnel records.
The findings include:
Seven personnel records of counselors were reviewed. Six counselors were required to have the twenty-five clock hours of training annually. The facility did not document the twenty-five hours of training in personnel records # 7, 8 and 10.
Employee # 7 had fourteen clock hours of annual training documented.
Employee # 8 did not have any documentation of annual training.
Employee # 10 had sixteen clock hours of annual training documented.
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Plan of Correction
The Facility Director Supervisor shall ensure that all staff complete at least 25 clock hours of training from the approved curriculum list on an annual basis. Particular attention shall be focused upon 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) This shall be monitored in on-going supervision, and staff will be facilitated opportunity to attend training. To be completed during the Addiction Medicine training year which runs 1/1/09 ? 12/31/09 |