INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 3 to January 4, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Chester County Intermediate Unit - Changes 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 4, 2008.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of employee records on January 3, 2008, the facility failed to document that the qualifications for the position of project director were met by employee #1.
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Plan of Correction
An exception will be submitted requesting authorization to identify another administrator who meets the qualifications as a project director. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill documentation on 1/4/08, the facility's fire drill record did not include exit route used, the complete number of persons in the facility at the time of the drill, including staff, problems encountered and whether the fire alarm or smoke detector was operative.
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Plan of Correction
Action: Clinical Supervisor will add columns on the fire log entitled:
A. Exit route used.
B. Total number of persons in the facility.
at the time of the drill including, staff.
C. Were fire/smoke detectors operated, if
so which detectors.
D. Were any problems were encountered.
Means: Clinical Supervisor will train Staff on the importance of conducting thorough fire drills that include completing all tasks identified on the fire log along with proper documentation. Clinical Supervisor will explain to all staff that should a problem be encountered during a fire drill that the problem is to be documented immediately on the fire log and brought to the clinical supervisor's or the facility's director's attention within 1 business day.
Person responsible: Clinical Supervisor will supervise initial fire drills ensuring compliance and staff understanding. Thereafter, Clinical Supervisor will check fire log for compliance.
Project will be in full compliance by 2/10/08
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records on 1/4/08, the facility failed to document alternate exit routes used during fire drills for each month since the last inspection.
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Plan of Correction
Action: Clinical Supervisor will add "alternate exit routes" to the fire log and review with staff possible fire exits.
Means: Clinical Supervisor will train Staff on the importance of having clients educated on the different building exits. Staff will be trained on the importance of having clients practice exiting the program from different exits during fire drills, including proper documentation.
Person responsible: Clinical Supervisor will supervise initial fire drills ensuring compliance and staff understanding. Thereafter, Clinical Supervisor will check fire log for compliance.
Project will be in full compliance by 2/10/08.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill records on 1/4/08, the facility failed to document that a fire alarm or smoke detector was set of during each fire drill.
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Plan of Correction
Action: Clinical Supervisor will add, "smoke detector/smoke alarm set off" to the fire log and review with staff this procedure.
Means: Clinical Supervisor will train Staff on the importance of testing smoke/fire alarms." Clinical Supervisor will train staff on the importance of appropriate documentation of such tests.
Person responsible: Clinical Supervisor will supervise initial fire drills ensuring smoke/fire alarms have been tested ensuring compliance and staff understanding. Thereafter, Clinical Supervisor will check fire log for compliance.
Project will be in full compliance by 2/10/08
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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on 1/4/08, the facility failed to document a complete psychosocial evaluation in five of five client records reviewed. The evaluations were unsigned and did not include a clinical assessment of how assets/strengths, support systems and negative factors impact the potential for treatment.
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Plan of Correction
Action: Clinical Supervisor will provide instruction during individual supervision on proper documentation of psychosocial evaluations including the importance of the clinician's signature and the importance of including in the clinical assessment of how the client's assets/strengths, support systems and negative factors impact the potential for treatment. Clinical Supervisor will add a signature and date line to the psychosocial assessment as well as categories assessing how the client's assets/strengths, support systems and negative factors impact the potential for treatment to serve as a reminder to clinician's completing the assessment.
Means: Clinical Supervisor will facilitate educating clinical staff on proper documentation and review subsequent psychosocial assessments.
Person Responsible: Clinical Supervisor
Project will be in full compliance by 2/10/08. |
709.83(a)(10) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(10) Discharge summary.
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Observations
Based on a review of client records on 1/4/08, the facility failed to document a complete discharge summary in three of three client records reviewed, #1, 5 and 6. The reasons for treatment were missing in #1, 5 and 6. The services offered were missing in two of three, #5 and 6.
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Plan of Correction
Action: Clinical Supervisor will provide instruction during individual supervision on proper documentation of discharge summaries, including the importance of including the reason why the client is sought treatment and services offered to the client while he/she was in treatment. The Clinical Supervisor will add "Reasons for Treatment" and "Services Offered" to the discharge summaries as a reminder to clinician's completing the discharge summary.
Means: Clinical Supervisor will facilitate educating clinical staff on proper documentation and review subsequent discharge summaries.
Person Responsible: Clinical Supervisor
Project will be in full compliance by 2/10/08.
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709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on a review of client records on 1/4/08, the facility failed to document follow-up information in the time period required by facility policy in two of three client records reviewed, #5 and 6.
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Plan of Correction
Action: Clinical Supervisor will provide instruction during individual supervision on facility policy in regards to client follow-up contacts and appropriate documentation of such follow-ups.
Means: Clinical Supervisor will facilitate educating clinical staff on proper documentation and review subsequent documentation of follow-up contacts.
Person Responsible: Clinical Supervisor
Project will be in full compliance by 2/10/08.
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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.
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Observations
Based on a review of administrative documents and an interview with the Facility Director on 1/3/08, the facility failed to document that the project director prepared and updated the manual delineating project policies and procedures.
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Plan of Correction
The Project Director will review and update the project policies and procedure manual annually, at the start of the fiscal year. This will be completed annually by the 15th of July.
The project will be in full compliance by 3/1/08. |
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.
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Observations
Based on a review of administrative documents and an interview with the facility director on 1/3/08, the facility failed to document an annual audit for the 2006/2007 Fiscal Year.
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Plan of Correction
A request for exception will be submitted to extend the time frame in which the annual audit needs to be made available. |
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.
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Observations
Based on a review of client records on 1/4/08, the facility failed to document that an informed and voluntary consent was obtained from the client in four of five client records reviewed. The specific information to be released to funding school districts exceeded 255.5 in three of five client records reviewed, #1, 2, and 5. The specific information to be released to probation exceeded 255.5 in client record #3.
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Plan of Correction
Action: Clinical Supervisor will provide instruction during individual supervision on importance of receiving informed and voluntary consent to funding school districts as mandated by 255.5 guidelines. The Clinical Supervisor will develop a release specific to funding school districts and probation departments to serve as a reminder to clinician's completing the releases.
Means: Clinical Supervisor will facilitate educating clinical staff on the information allowed to be released, within the scope of 255.5 guidelines. These areas are limited to:
Whether the client is or is not in treatment, client's prognosis, the nature of the project, a brief description of the client's progress and a short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
To assure compliance, the Clinical Supervisor will complete chart reviews within 1 business day of all new intakes. The Clinical Supervisor will also complete subsequent chart reviews on a monthly basis, or before discharge (whichever comes first), and upon completion of all discharge paperwork.
Person Responsible: Clinical Supervisor
Project will be in full compliance by 2/10/08.
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709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records on 1/4/08, the facility failed to document that a copy of a client consent was offered to the client in five of five client records reviewed.
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Plan of Correction
Action: Clinical Supervisor will provide instruction during individual supervision on importance offering the client a copy of each consent signed. The Clinical Supervisor will purge all consents that do not indicate he/she has been offered a copy and his/her decision to accept or refuse a copy. The accept/refuse lines should serve as a reminder to clinician's completing the releases to offer a copy to the client.
Means: Clinical Supervisor will facilitate educating clinical staff on the importance of offering a copy of signed releases to the client. To assure compliance, the Clinical Supervisor will routinely check documentation and review subsequent consents.
Person Responsible: Clinical Supervisor
Project will be in full compliance by 2/10/08.
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