INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 3 & 4, 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 May 3, 2007.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
The facility failed to complete the 2006-2007 overall training plan.
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Plan of Correction
While the facility had identified training needs and addressed those needs individually, no overall summary had been provided.
In order to demonstrate compliance, an Annual Staff Development Plan form has been developed. This form will be completed upon receipt of all of the individual needs questionnaires, and will summarize the facility needs and then a plan with timeframes to address them.
The form has been developed and will be completed by the Facility Director for the training year 2006-07 by 5/31/07.
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to consistently obtain feedback on completed training.
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Plan of Correction
The agency training request form previously included a feedback
section. However, when the form was revised, that area was inadvertently omitted.
A Lickert Scale Questionnaire has been developed to solicit feedback from staff following the completion of training. This will be used agency wide and will be submitted with verification of training hours.
This form was completed on 4/24/07, for immediate use. Oversight for compliance will be the responsibility of Human Recourse
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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
The facility failed to ensure that staff represented by personnel record #6 completed the general training requirements within the required time frames..
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Plan of Correction
Staff #6 attended a training covering all required topics. However, it was only approved for six hours. Therefore, it did not meet total compliance.
The next available training will be held in Erie, Pennsylvania on May 16, 2007. Staff #6 has already been registered to attend to earn the additional hours. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
The facility failed to ensure compliance with the outpatient client to counselor caseload requirements. Two counselors (personnel records # 4 and 5) had caseloads which exceeded 35 clients. The current overall caseload size is 39:1.
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Plan of Correction
Due to an influx of service requests, and difficulty with recruitment of staff, caseloads rose above the limit. Additionally, the current system reports a client as open from the point of registration, not upon receipt of services. Because of this, the report reflects an inflated number of clients on each caseload.
We are currently in the process of instituting a new computer system which will allow for accurate reporting of both registration and actively treated clients. The system is scheduled to "go live" in September 2007.
Additionally, we are continuing to actively recruit additional staff, with a target date of 6/1/07. Currently, a waiting list has been instituted and a case monitoring report which can be viewed daily has been developed.
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709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
709.14 Restriction on License (a)(5) Authorized capacity.
The facility had a census of 79 for the outpatient drug free activity on April 4, 2007. This exceeds the authorized maximum capacity of 70.
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Plan of Correction
As stated above, the caseload size is inflated due to the current computer system reporting. However, as the request for services has steadily risen, there is a need to expand services.
Additional staff will be hired as soon as possible. Once that is accomplished, the facility will request a capacity increase in accordance with regulations.
In the meantime, a waiting list has been instituted, and caseloads are monitored daily by the Clinical Supervisor.
Target date for completion of computer system and staffing increase is September 2007.
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The facility failed to document a procedure regarding duty to warn for drug and alcohol clients which is consistent with the federal regulations at 42 CFR Part 2, Subpart E, Subsection 2.63. Facilities that exercise duty to warn for drug and alcohol clients must have a procedure that is consistent with state and federal law and regulation.
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Plan of Correction
No policy and procedure was written specifically for Drug and Alcohol clients as this is addressed in the Agency wide Policies.
A policy specific to the Drug and Alcohol Program has been developed and instituted as of 4/23/07. A brief overview was provided to staff 4/19/07, with a more in depth training to be scheduled by 6/30/07
The clinical Supervisor will be responsible for providing the training.
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709.28(c) 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:
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Observations
The facility has failed to comply with the law and regulation governing the confidentiality of client identifying information. This is evidenced by the following:
1.) A parent/guardian signature line continues to be included on the treatment plan and treatment plan update forms. 71 P. S. Subsection 1690.112 states that minors may seek treatment on their own without parental consent. The federal regulations at 42 CFR Part 2, Subpart B, Subsection 2.14(b) declares that in states where minors may seek treatment on their own, only the minor can consent to the release of information.
2.) The facility has allowed clients to sign incomplete consent to release information forms. Release of information forms are to be completed in their entirety. The specific information section, purpose section, release to/request from, and copy offered to the client sections of the consent to release information forms were not always complete.
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Plan of Correction
The current treatment plan is a computerized form used by all Outpatient Services. For that reason, a signature line for parent/guardian was placed on the treatment plan, though not used with Drug and Alcohol clients.
In accordance with the reviewer's recommendation, a disclaimer has been added to the treatment plan under the parent signature line stating that it is "Not applicable to Drug and Alcohol Clients"
This change was completed 4/23/07 by the MIS director.
277(b) While review of the confidentiality requirements is addressed frequently, the staff sometimes overlooks an area. Additionally, while the fiscal technician who usually does registration is very conscientious about consents, others in the department who cover the position do not use the drug and alcohol consents regularly and are less complete.
As recommended by the reviewer, the" request from "option has been removed from the consent form. Additionally, a brief review of completing the form was given on 4/19/07. An additional 1 hour training which will include fiscal personnel will be given by 6/30/07.
The clinical Supervisor and Compliance Office will be responsible for auditing charts to assure completion of consents is consistent.
The first audit will be done 1 month after the training is given.
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709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
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Observations
The facility failed to document case consultations in client records # 1 and 4.
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Plan of Correction
Differing timeframes for the required paperwork has made it difficult to track case consults in particular.
The new computer system will significantly improve tracking and record completion. This is targeted for Sept.1,2007. Additionally, the policy addressing timeframes has been changed to require a case consult every two months in conjunction with the treatment plan update.
The policy was completed on 4/24/07 and will begin 5/1/07. The Clinical supervisor will be responsible for monitoring ongoing compliance.
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