INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 9, 2008 through January 10, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Asociacion De Puertorriquenos En Marcha Proyecto Nueva Vida 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 February 7, 2008.
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records and client records, the facility failed to document supervision for one of one counselor assistant reviewed, #7. The facility did not document three months of direct observation of the counselor assistant in the personnel record or in progress notes within three client records reviewed, #1, 2 and 8. Documentation that the counselor assistant was directly observed during counseling session was not evident in the following records and days: client record #1 on 9/11/07 and 10/16/07; client record #2 on 10/16/07, 10/18/07 and 10/23/07; and client record #8 on 8/16/07, 8/24/07, 9/07/07, 9/21/07, 9/25/07, 10/02/07 and 10/09/07.
|
Plan of Correction
The evaluation for the Counselor Assistant(C.A.)was in the Personnel File but not signed by the staff. The agency no longer hires a Counselor Assistant.
It was an oversight of the supervisor not to sign the counseling notes on 3 charts that the Counselor Assistant worked on.
In the future, if a C.A. is to be hired the position will be directly supervised by the clinical supervisor with proper chart documenting the supervision and documentation of an evaluation filed in the personnel file.
The Facility Director in-serviced the clinical supervisor on this policy on 1/24/08. The Project Director will monitor for compliance if an when a C.A. is hired by the agency.
|
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
Based on a review of the facility's policies and procedures, the facility failed to document procedures that included time frames for the completion of the assessment of staff training needs and the overall training plan. In addition, the policy and procedure did not include who was responsible for the development of the overall training plan.
|
Plan of Correction
The Staff Development policy was revised to include language that described that the Facity Director with the approval of Project Director will be responsible for the overall Staff development plan and that the Project Director will sign of on the plan. The existing plan had the time frame for the completion of the overall staff development plan but needed a time frame for new hires(30 days).
This was completed on 1/25/08.
This policy will be monitored by the Project Director.
|
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
Based on a review of personnel and training records, the facility failed to document fire extinguisher training within the required time frame in one of two records reviewed, #3. Employee #3 was hired on April 27, 2007, but the training was not completed until August 24, 2007.
|
Plan of Correction
Staff hired for the D & A program receive instuction on the use of the fire extinguisher but the form created to document the training has not been properly used.
A new Director of Human Resources was hired and was inserviced on this procedure by the Facility Director on 1/28/08.
The Facility Director will monitor to insure that this procedure is followed and that the form is properly used to document the training for all new program hires.
|
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
Based on a review of personnel and training records, the facility failed to document the training of staff to perform assigned tasks during emergencies within the required time frame in one of two records reviewed, #3. Employee #3 was hired on April 27, 2007, but the training was not completed until August 24, 2007.
|
Plan of Correction
The staff person in question was a transfer to the unit. The proper documentation was not done but this has been corrected with the new hire of a Director of Human Resources.
The Director of Human Resources was inserviced on 1/28/08 on this regulation by the Facility Director.
The Director of Human Resources will include this training in the training packet during the orientation process for new hires and transfers into the drug and alcohol program.
The training of staff to perform assigned tasks during emergencies will be accomplished within the required time frame (7 days). The documentation will be loged in the training orientation check off list and will consist of a writen document included in the orientation packet.
The Facility Director will monitor personnel files for compliance. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
|
Observations
Based on a review of the written manual and administrative records, the facility failed to document that the project director annually updated the written manual for the 2007 - 2008 fiscal year.
|
Plan of Correction
The Policy and Procedure manual was revised to include the documentation that the Project Director will annually update the written manual for the program. This will be documented with the the signature of the Project Director and signature date on the manual.
Policy Revision completed 1/25/08.
In addition, the Project Director signed of on the Manual for 2007-2008 on 1/25/08.
|
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
Based on a review of administrative records, the facility failed to document an annual audit of financial activities from an independent public accountant for the July 2006 through June 2007 fiscal year.
|
Plan of Correction
Timeframe for completion:
The audit for 2006-2007 will be completed by March 31, 2008. The Chief Financial Officer(CFO)is the person responsible for correcting the difficiency.The CFO will continue to work with the independent auditors to complete the report by the scheduled timeframe.
Monitoring:
The President/CEO who is the Project Director for this license will monitor for compliance to insure this does not happen again.
|
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
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client in five of five client records reviewed, #1, 2, 5, 7 and 8. The purpose of disclosure was identical on consent to release information forms to the client's probation officer, Community Behavioral Health and the Department of Public Welfare. The purpose did not clearly identify the reason for the release of information to each person or entity. The purpose of the release of information was stated as " ...for the sole purpose of: Identifying client as a potential patient in treatment or as a client already admitted to treatment .... ".
|
Plan of Correction
The consent forms were available but needed to be revised to correct difficiency.
The consent form was revised and staff in-serviced on the proper use of the revised form.
Time frame:
Completed 1/11/08
The facility manager will monitor for compliance.
|
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
|
Observations
Based on a review of client records, the facility failed to document that clients were made aware of their rights under Chapter 709.30(a)(3)(i) and (ii) in five of five client records reviewed, #1, 2, 5, 7 and 8.
|
Plan of Correction
The clients rights form given to the clients was revised to match the Policy Manual on 1/11/08.
The clinical supervisor and clinical staff was in-serviced by the facility director on the revision on 1/11/08 and 1/25/08.
Time frame:
Completed 1/25/08.
The facility director will monitor for compliance. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on a review of client records, the facility failed to document a complete drug and alcohol history in six of six client records reviewed, #1, 2, 5, 6, 7 and 8. Drug and alcohol histories did not include the lengths and patterns of use.
|
Plan of Correction
The clinical supervisor corrected the biopsychosocial to include in the drug and alcohol histories the lengths and patterns of use. The clinical staff was in-serviced by the clinical supervisor on 1/25/08.
Completed on 1/25/08.
The facility director will monitor for compliance.
|
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
Based on a review of client records, the facility failed to document a complete treatment plan update that included an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in four of five client records reviewed, #1, 4, 7 and 8.
|
Plan of Correction
The clinical supervisor had an in-service with clinical staff on 1/24/08.
This was to improve documentation of the progress of the client in the Up-Dated Treatment Plan reflecting upon each goal for each problem identified in the previous Treatment Plan.
Time frame: Completed 1/24/08
The facility director will monitor for compliance. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
|
Observations
Based on a review of the facility's policy and procedure, the facility failed to develop a follow up policy that included the method of contact and the manner of documentation.
|
Plan of Correction
The facility director revised the policy to include the method and the manner of documenting follow-up.The policy now matches the procedures used by staff.
Completed: 1/25/08
Project Director reviewed the policy and approved.
|