INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 28, 2011 through December 1, 2011 licensure renewal inspection. The follow-up inspection was conducted on September 13, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Kirkbride Center 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on the review personnel records, the facility failed to document that each counselor met the qualifications for the position in one personnel records reviewed.
The findings included:
Eleven personnel records were reviewed on September 13, 2012. One counselor personnel record was reviewed. The facility failed to document qualifications for counselor in one personnel record, #8.
A review of personnel record # 8 revealed that they were not demoted to counselor assistant from counselor since the last inspection. Personnel #8 at the time of the inspection last year, November 28, 2011, had no documentation that she had any experience for the position based on a review of the employee's application that listed less than a year of clinical experience with a Bachelor's degree in a related field.
The findings were reviewed with facility staff and the findings were not disputed.
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Plan of Correction
1. The status of Employee #8 was changed on September 14, 2012, from Counselor to Counselor Assistant.
2. Employee #8 is supervised by the facility's Clinical Director and he has initiated direct and close supervision for a period of six months.
3. Although Employee #8 has a master's degree in business, the master's degree does not count toward education for the purposes of being a Counselor Assistant. Therefore, the facility has recognized the employee's Bachelor's degree in Sociology, with a concentration in Criminal Justice. The Clinical Director will continue to document close and direct supervision for a period of six months, as per state standards for a Counselor's Assistant with a bachelor's degree. At that time, the employee will be considered for promotion to Counselor status. |
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on the review of the staffing requirements facility summary report and personnel records, the facility failed to to ensure that an assessment of training needs was completed by all staff. Documentation was not provided for support staff.
The findings included:
The annual onsite licensing inspection was conducted November 28, 2011, to December 1, 2011 at this facility. As part of the inspection, personnel records were reviewed. Sixty nine personnel records were reviewed that required an assessment of training needs. The facility did not document individual assessments of training needs for the support staff.
The Project Director was interviewed on November 30, 2011. The Project Director confirmed that a needs assessment was not completed on each support staff member for the 2011 training year.
This deficiency remained out of compliance at the time of the follow-up conducted on September 13, 2012.
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Plan of Correction
1. The facility has hired a Human Resources consultant to complete several projects.
2. Among the projects is completion of the Individual Training Plans for all support staff.
3. The consultant will make a status report on the Individual Training Plans to the Clinical Management Team by October 31, 2012. The purpose of the status report is to ensure the team provides oversight and monitoring to the process. |
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.
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Observations
Based on the review of the staffing requirements facility summary report and personnel records, the facility failed to provide documentation of individual training plans in 48 out of 69 personnel records.
The findings included:
Sixty-nine personnel records were reviewed on the staffing requirements summary report on November 28, 2011, through December 1, 2011. All personnel records required an individual training plan. The facility did not document individual training plans for the July 1, 2010 - June 30, 2011 training year in 48 records according to the staffing requirements report.
The Project Director was informed of the findings. The findings were not disputed.
This deficiency remained out of compliance at the time of the follow-up conducted on September 13, 2012.
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Plan of Correction
1. The facility has hired a Human Resources consultant to complete several projects.
2. Among the projects is completion of the Individual Training Plans for all support staff.
3. The consultant will make a status report on the Individual Training Plans to the Clinical Management Team by October 31, 2012. The purpose of the status report is to ensure the team provides oversight and monitoring to the process. |
709.123(c)(5) LICENSURE Follow-up information
709.123. Treatment and rehabilitation.
(c) Client records. 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:
(5) Follow-up information.
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Observations
Based on a review of client records in the psychiatric hospital, the facility failed to document follow-up information in one of one client record.
The findings included:
One discharge client record was reviewed on September 13, 2012. Follow-up information was required in record #12. In accordance with the facility's policy, follow-ups are to be done seven days following discharge. The facility failed to document follow up in record #12.
Facility staff was informed that the follow up was not documented. The findings were not disputed.
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Plan of Correction
1. As a result of an announced Methadone certification visit in July 2011, the Clinical Director initiated a four-month audit of closed charts to ensure compliance with the standard governing seven-day follow-ups. The audit consisted of a review of 50 charts monthly from September through December 2011. The result: 100 percent compliance with the follow-up standard.
2. To correct the current deficiency of one record discovered during the unannounced visit in September 2012, the Clinical Director will resume the previous audit for a period of four months from November 1, 2012, through February 28, 2013.
3. Results of the audits will be reported monthly for four months to the Executive Committee, internally called Dashboard,for oversight and monitoring. |
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on a review of the facility's policy and procedure, the facility failed to identify the process for selecting a project director.
The findings included:
The facility policy and procedure manual and the corporate Bylaws were reviewed on November 28, 2011. No process for selection of a project director by the Board was specified in the documentation in the By Laws or in written facility policy.
During a dialogue with the Project Director on November 29, 2011, the Project Director acknowledged that there was no process for selection. The findings were not disputed.
This deficiency remained out of compliance at the time of the follow-up conducted on September 13, 2012.
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Plan of Correction
1. The Project Director developed a policy and procedure on March 31, 2012, outlining the steps the Board of Directors would take in the event the current Project Director's position would need to be filled.
2. That policy was presented to the full Board of Directors during the group's quarterly meeting on September 20, 2012.
3. The policy was approved unanimously as presented. |
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.
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Observations
Based on a review of facility documentation, the facility failed to make an annual report available to the public which included a financial statement of income and expenses.
The findings included:
The annual report for the fiscal year July 1, 2010, to June 30, 2011, was requested for review during the onsite inspection of November 28 to December 1, 2011. The annual report did not include a financial statement of income and expenses.
The findings were reviewed with the Project Director and were not disputed.
This deficiency remained out of compliance at the time of the follow-up conducted on September 13, 2012.
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Plan of Correction
1. The facility has revised its annual report for Fiscal Year Ending 2011 (July 1, 2010, through June 30, 2011) to include a statement of expenses for the fiscal year.
2. The annual report did include a statement of income for the same fiscal year.
3. The revised annual report is available for public review.
4. The Chief Financial Officer and the Project Officer will ensure that the annual report for Fiscal Year Ending 2012 (July 1, 2011, through June 30, 2012) includes a statement concerning both income and expenses.
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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 facility documentation, the facility failed to document an annual audit of financial activities.
The findings included:
The fiscal documents were reviewed during the onsite licensing inspection conducted from November 28 to December 1, 2011. The certified public accountant's dated and signed comments at the beginning of the fiscal document indicated that the document was a review only, not an audit.
During a dialogue with the Project Director on November 29, 2011, the Project Director acknowledged the documentation. The findings were not disputed.
This deficiency remained out of compliance at the time of the follow-up conducted on September 13, 2012.
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Plan of Correction
1. The facility has signed an engagement letter with an accounting firm to perform a financial audit for Fiscal Year Ending 2011 (July 1, 2010, through June 30, 2011).
2. The financial audit is scheduled to begin November 1, 2012.
3. Once the audit is completed, the facility will notify the Division of Drug and Alcohol Program Licensure.
4. Moving forward, the Board of Director will ensure that an audit is completed within six months of the closing of each fiscal year, which is June 30.
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709.26(d)(5)(i) 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:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on the review of the staffing requirements facility summary report and personnel records, the facility failed to document the completion of an annual work performance evaluation in seven of eleven personnel records.
The findings included:
Eleven personnel records were reviewed on September 13, 2012. Eight personnel records required the completion of an annual work performance evaluation, #1, 2, 3, 4, 5, 10 and 11. The facility failed to document a current annual work performance evaluation in personnel records # 1, 2, 3, 4, 5 and 10.
Employee # 2 was hired on September 8, 20003. The last documented work performance evaluation was on June 23, 2010. At the time of the inspection, the facility failed to document a work performance evaluation for 2011 and 2012.
Employee # 1 was hired on September 3, 2008. The last documented work performance evaluation was on June 29, 2010. At the time of the inspection, the facility failed to document a work performance evaluation for 2011 and 2012.
Employee # 5 was hired on February 20, 2006. The last documented work performance evaluation was on June 29, 2010. At the time of the inspection, the facility failed to document a work performance evaluation for 2011 and 2012.
Employee # 4 was hired on November 11, 2002. The last documented work performance evaluation was on November 15, 2008. At the time of the inspection, the facility failed to document a work performance evaluation for 2011.
Employee # 3 was hired on October 26, 2008. The last documented work performance evaluation was on June 14, 2010. A performance evaluation was due on June 14, 2011. A work performance evaluation was developed; however, there was no documentation that ensured it was completed within a year. The evaluation was not signed and dated.
Employee # 10 was hired on August 11, 2008. The last documented work performance evaluation was on July 8, 2010. At the time of the inspection, the facility failed to document a work performance evaluation for 2011 and 2012.
Employee # 11 was hired on June 24, 2009. The last documented work performance evaluation was on August 28, 2009. At the time of the inspection, the facility failed to document a work performance evaluation for 2011 and 2012.
The findings were reviewed with facility staff. The findings were not disputed.
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Plan of Correction
1. The annual evaluations for all primary therapists and supervisors of the Chemical Dependency Programs are typically conducted in July.
2. This year, due to proposed changes in job descriptions and evaluation methods, it was decided to postponed the evaluations.
3. The evaluations will be completed during the month of October 2012.
4. Compliance results will be reported to the Executive Committee, internally called Dashboard, during November 2012 for oversight and monitoring.
5. The next round of annual evaluations have been scheduled for July 2013.
6. The Manager of Human Resources will monitor for compliance. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records in the detoxification program, the facility failed to document psychosocial evaluations in five of five client records.
The findings included:
Twelve client records were reviewed on September 13, 2012. A completed psychosocial evaluation was required in all client records. The facility failed to document psychosocial evaluations in five client records, # 1, 2, 3, 4 and 5.
The psychosocial evaluation in client records # 1, 2, 3, 4 and 5 did not include a composite picture of the client.
The psychosocial evaluation in client records #1, 2, 3, 4 and 5 did not include an evaluation of the client's problems/needs and how they would impact treatment.
The psychosocial evaluation in client records #1, 2, 3, 4 and 5 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluation in client records #1, 2, 3, 4 and 5 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluation in client records #1, 2, 3, 4 and 5 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluation in client records #1, 2, 3, 4 and 5 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluation in client records #1, 2, 3, 4 and 5 did not include an evaluation of the counselor's conclusion and impression of the client.
The findings were reviewed with facility staff. The findings were not disputed.
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Plan of Correction
1. The Clinical Director has expanded the psychosocial evaluation section of the biopsychosocial, called Case Conceptualization. The expansion of the document from one to two pages has been approved by the facility's Forms Committee.
2. The expansion requires clinicians to respond specifically to the various aspects of the Case Conceptualization required by standard, including but not limited to:
A. A composite picture of the patient.
B. A review of the patient's problems/needs and how they would impact treatment.
C. An evaluation of the patient's assets/strengths and how they would impact treatment.
D. An evaluation of the patient's support systems and how they would impact treatment.
E. An evaluation of the patient's coping mechanisms and how they would relate to or impact treatment.
F. An evaluation of the patient's negative factors and how they would impact treatment.
G. The counselor's conclusions and impressions of the patient.
3. Compliance will be monitored by the Clinical Director. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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 in the drug and alcohol rehabilitation program, the facility failed to document psychosocial evaluations in six of six client records.
The findings included:
Twelve client records were reviewed on September 13, 2012. A completed psychosocial evaluation was required in all client records. The facility failed to document psychosocial evaluations in six client records, # 6, 7, 8, 9, 10 and 11.
The psychosocial evaluation in client records # 6, 7, 8, 9, 10 and 11 did not include a composite picture of the client.
The psychosocial evaluation in client records #6, 7, 8, 9, 10 and 11 did not include an evaluation of the client's problems/needs and how they would impact treatment.
The psychosocial evaluation in client records #6, 7, 8, 9, 10 and 11 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluation in client records #6, 7, 8, 9, 10 and 11 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluation in client records #6, 7, 8, 9, 10 and 11 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluation in client records # 6, 7, 8, 9, 10 and 11 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluation in client records #6, 7, 8, 9, 10 and 11 did not include an evaluation of the counselor's conclusion and impression of the client.
The findings were reviewed with facility staff. The findings were not disputed.
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Plan of Correction
1. The Clinical Director has expanded the psychosocial evaluation section of the biopsychosocial, called Case Conceptualization. The expansion of the document from one to two pages has been approved by the facility's Forms Committee.
2. The expansion requires clinicians to respond specifically to the various aspects of the Case Conceptualization required by standard, including but not limited to:
A. A composite picture of the patient.
B. A review of the patient's problems/needs and how they would impact treatment.
C. An evaluation of the patient's assets/strengths and how they would impact treatment.
D. An evaluation of the patient's support systems and how they would impact treatment.
E. An evaluation of the patient's coping mechanisms and how they would relate to or impact treatment.
F. An evaluation of the patient's negative factors and how they would impact treatment.
G. The counselor's conclusions and impressions of the patient.
3. Compliance will be monitored by the Clinical Director. |