INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 26 through 27, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on March 28, 2007.
|
Plan of Correction
|
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
The staff development program policy and procedure does not identify how and when the training needs assessment, overall training plan, and mechanism to collect feedback on completed training will be created and documented.
|
Plan of Correction
The staff development program policy had been changed to reflect that the training needs assessment, overall training plan, and mechanism to collect feedback will be completed yearly in May and reviewed with staff individually prior to July 1. The Program Director is responsible. |
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.
|
Observations
The staff training questionnaires for the current training year were missing for all of the employees reviewed.
|
Plan of Correction
All staff training questionnaires will be kept in the training manual. The Office Manager in conjunction with the Program Director,is responsible for the training manual. |
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.
|
Observations
The individual training plans were completed late, between the months of October and November, for three of six employees reviewed, # 1, 4, and 6.
|
Plan of Correction
All individual training plans will be completed by June every year. The Program Director is responsible to complete the training plans yearly. |
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.
|
Observations
Employee # 3 earned only 18 of 25 training hours for the prior training year. Employee # 4 earned only 6 of 25 training hours for the prior training year.
|
Plan of Correction
All employee's are aware that 25 hours of training must be completed per year. There is a new policy in place for FY'07 that ensures employee's complete 25 hours per year. The Office Manger and the Program Director are responsible to review documentation of trainings quarterly. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
|
Observations
There was no ventilation in the male or female bathrooms.
|
Plan of Correction
Estimates have been obtained, and fans are scheduled to be installed by 4/16/07. The Office Manger is responsible to ensure completion of work. |
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
No documentation was provided for the required training for two of six employees reviewed, # 1 and 4. Additionally, the training was provided after the seven days of hire for two of six employees reviewed, # 5 and 6.
|
Plan of Correction
The emergency fire extinguisher training is now completed during the Departmental Orientation on the employee's first day. The Office Manger is responsible to ensure all new employee's are trained on their first day. |
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
No documentation was provided for the required training for two of six employees reviewed, # 1 and 4. Additionally, the training was provided after the seven days of hire for two of six employees reviewed, # 5 and 6.
|
Plan of Correction
The emergency fire exit training is now completed during the Departmental Orientation on the employee's first day. It will be reviewed with all employee's what their assisgned tasks are during emergency situations. The Office Manger is responsible to ensure all new employee's are trained on their first day. |
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.
|
Observations
Exit route(s) were not documented in the fire drill log.
|
Plan of Correction
Will consistenly document which exit route is used and will ensure that exit route is alternated. The Office Manger is responsible for documentation of fire drills. |
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.
|
Observations
The program utilizes a verbal announcement system for conducting fire drills although there is no exception from the Division of Drug and Alcohol Program Licensure to use an alternative method.
|
Plan of Correction
A letter will be sent to the Director of Drug and Alcohol Services for the State of PA, requesting an exception to use an alternative method. Program Director is responsible. |
711.82(g)(1) LICENSURE Medical/Dental Support Services
711.82. Treatment and rehabilitation services.
(g) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
|
Observations
There was no documentation of dental supportive services.
|
Plan of Correction
A Letter of Agreement will be mailed 4/30/07 for supportive dental services. Follow up to ensure Letter of Agreement is signed will occur 5/15/07. Director is responsible. |
711.82(g)(7) LICENSURE Recreational/social Support Services
711.82. Treatment and rehabilitation services.
(g) The project shall assist the client in obtaining the following supportive services when necessary:
(7) Recreational/social.
|
Observations
There was no documentation of recreational/social support services.
|
Plan of Correction
A Letter of Agreement will be sent for recreational/social support services by 4/30/07. Follow-up will occur to ensure signatures were obtained by 5/15/07. Director is responsible. |
711.84(e) ELEMENT Follow-up Policy
711.84. Project management services.
(e) The project shall develop a written follow-up policy.
|
Observations
The follow-up policy does not indicate follow-up contact with the client after their discharge date.
|
Plan of Correction
The policy has been revised to reflect that follow-up will occur no greater than 60 days from day of discharge. Every 3rd Monday of the month, surveys will be sent for the prior month's client discharges. The Office Manger is responsible to ensure surveys are sent and documentation is maintained. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
The psychosocial evaluation form does not include sections for the counselor to provide the following information: client's composite picture, client's available/potential support systems, and the client's attitude towards treatment, thus these areas were missing.
|
Plan of Correction
We have begun to gather Psychosocial evaluations from other providers and are in the process of developing a new Psychosocial form. As of 5/1/2007 we will begin using this new form that will include a composite picture of the client, the available/potential support systems and the client's attitude towards treatment. The Clinical Director is responsible to complete, and monitior. |
711.91(b)(7) LICENSURE Preliminary Treatment Plan
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
The preliminary treatment plans were missing from all client records reviewed.
|
Plan of Correction
Preliminary treatment plans will be completed for all patients during the assessment process. The Clinical Director is responsible for developing the form and training staff on proper use. |
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.
|
Observations
The treatment plan updates did not provide a review of progress on previously stated goals in two of three client records reviewed, # 1 and 3.
|
Plan of Correction
The Clinical Director is responsible to supervise, train and review with staff the proper completion of treatment plans. The Clinical Director will ensure that staff are completing the treatment plan reviews and will be doing a review of all treatment plan reviews four times in the next six months to assess for accurate completion. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
|
Observations
Aftercare plans did not include the re-entry process and contact person in two of three client records reviewed, #4 and 6. Additionally, the aftercare plans had goals that were general in their scope and some either had "on-going" as a timeframe for achievement or did not include a timeframe at all in three of three aftercare plans reviewed, # 4, 5 and 6.
|
Plan of Correction
CAD has a new Aftercare form that was implemented 3/1/07. The form includes re-entry process, specific goals with timeframes within 4 months of discharge. The new form was shared with the State Reviewer. Clinical Director is responsible for monitioring accurate completion of new form. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
|
Observations
The follow-up attempts were not conducted after the client's date of discharged in three of three client records reviewed, # 4, 5 and 6.
|
Plan of Correction
A follow-up attempt will be made on every client no greater than 60 days post discharge. Every third Monday of the month, previous month's discharged clients will be mailed an after care survey. Office Manager is responsible to ensure surveys are mailed and documented for every client. |
711.94(e) LICENSURE Follow-up Policy
711.94. Project management services.
(e) The project shall develop a written client follow-up policy.
|
Observations
The follow-up policy does not indicate follow-up contact with the client after their discharge date.
|
Plan of Correction
The policy has been revised to reflect that follow-up will occur no greater than 60 days from day of discharge. Every 3rd Monday of the month, surveys will be sent for the prior month's client discharges. The Office Manger is responsible to ensure surveys are sent and documentation is maintained. |