INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 26, 2013 to August 27, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Self Help Movement, Inc. 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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704.11(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.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed 25 clock hours of required training in one of four personnel records reviewed.
The findings include:
On August 26, 2013, four personnel records requiring documentation of 25 clock hours of training were reviewed. The facility failed to provide documentation of 25 clock hours of training in one of four personnel records reviewed, specifically, personnel record # 9.
Employee # 9 is a counselor and was hired for his current position on March 15, 1999. Employee # 9 was required to complete 25 clock hours of annual training hours by December 31, 2012. However, personnel record # 9 only had documentation of 12 clock hours of annual training for the January 1, 2012 to December 31, 2012 training year as of August 26, 2013.
The findings were confirmed during an interview with the Director of Administration on August 26, 2013 at approximately 3:00 P.M.
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Plan of Correction
Beginning 9/1/13, the Compliance Officer will keep a tracking sheet for each counselor to ensure that they receive the proper amount of training hours required for counselors. When needed, the Compliance Officer and/or Clinical Director will send the counselors to outside training to ensure that they receive the 25 clock hours required annually. The Human Resources Manager will then ensure that the certificates are placed in the counselor's personnel record. |
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, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information that included verification or documentation that a copy of the client consent was offered to a client in nine of nine records reviewed.
The findings include:
On August 26, 2013 to August 27, 2013, nine client records requiring documentation of an informed and voluntary consent for the disclosure of information were reviewed. The facility did not obtain an informed and voluntary consent from the client for the disclosure of information that included verification or documentation that a copy of the client consent was offered to a client in nine of nine records reviewed, specifically, client records # 1, 2, 3, 4, 5, 6, 7, 8, and 9.
Client record # 1 contained consents to release information to the client's doctor, sister, and an agency dated 6/10/13; however, the facility could not provide verification or documentation that a copy of the consent was offered to client # 1. Additionally, the facility was unable to provide documentation that the client was informed of his or her right to receive a copy of the consent to release information either through a policy statement posted in the facility, documentation in an orientation packet, or any other documentation in client record # 1.
Client record # 2 contained consents to release information to the client's family and an agency dated 6/24/13; however, the facility could not provide verification or documentation that a copy of the consent was offered to client # 2. Additionally, the facility was unable to provide documentation that the client was informed of his or her right to receive a copy of the consent to release information either through a policy statement posted in the facility, documentation in an orientation packet, or any other documentation in client record # 2.
Client record # 3 contained consents to release information to the client's probation officer, mother, and an agency dated 6/30/13; however, the facility could not provide verification or documentation that a copy of the consent was offered to client # 3. Additionally, the facility was unable to provide documentation that the client was informed of his or her right to receive a copy of the consent to release information either through a policy statement posted in the facility, documentation in an orientation packet, or any other documentation in client record # 3.
Client record # 4 contained consents to release information to the client's doctor and mother dated 5/13/13; however, the facility could not provide verification or documentation that a copy of the consent was offered to client # 4. Additionally, the facility was unable to provide documentation that the client was informed of his or her right to receive a copy of the consent to release information either through a policy statement posted in the facility, documentation in an orientation packet, or any other documentation in client record # 4.
Client record # 5 contained consents to release information to the client's doctor, mother, and a local court dated 4/12/13; however, the facility could not provide verification or documentation verifying that a copy of the consent was offered to client # 5. Additionally, the facility was unable to provide documentation that the client was informed of his or her right to receive a copy of the consent to release information either through a policy statement posted in the facility, documentation in an orientation packet, or any other documentation in client record # 5.
Client record # 6 contained consents to release information to the client's doctor, mother, and a local court dated 6/3/13; however, the facility could not provide verification or documentation that a copy of the consent was offered to client # 6. Additionally, the facility was unable to provide documentation that the client was informed of his or her right to receive a copy of the consent to release information either through a policy statement posted in the facility, documentation in an orientation packet, or any other documentation in client record # 6.
Client record # 7 contained consents to release information to the client's doctor, probation officer, aunt, and a local court dated 6/11/13; however, the facility could not provide verification or documentation that a copy of the consent was offered to client # 7. Additionally, the facility was unable to provide documentation that the client was informed of his or her right to receive a copy of the consent to release information either through a policy statement posted in the facility, documentation in an orientation packet, or any other documentation in client record # 7.
Client record # 8 contained a consent to release information to the client's mother dated 3/28/13; however, the facility could not provide verification or documentation that a copy of the consent was offered to client # 8. Additionally, the facility was unable to provide documentation that the client was informed of his or her right to receive a copy of the consent to release information either through a policy statement posted in the facility, documentation in an orientation packet, or any other documentation in client record # 8.
Client record # 9 contained consents to release information to the client's doctor, probation officer, and wife dated 5/9/13; however, the facility could not provide verification or documentation that a copy of the consent was offered to client # 9. Additionally, the facility was unable to provide documentation that the client was informed of his or her right to receive a copy of the consent to release information either through a policy statement posted in the facility, documentation in an orientation packet, or any other documentation in client record # 9.
The findings were confirmed during an interview with the Clinical Director on August 27, 2013 at approximately 3:30 P.M.
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Plan of Correction
Beginning 09/02/2013, the Director of Intake as well as the intake staff shall ensure that all client intake/orientation packets include documentation for release of confidential information with written indication that a client was offered and received/declined a copy of the signed consent to release information form. Additionally, a policy statement was created and posted on the bulletin board on all floors and public offices of the facility, including the Intake and counselors' offices, regarding the client's right to copy of all consent to release information forms. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the project failed to notify the client in writing of a decision to involuntarily terminate the client's treatment at the project's Inpatient Non-Hospital Drug Residential Treatment and Rehabilitation Program in one of one record reviewed. Also, based on a review of client records, the project failed to notify the client in writing of a decision to involuntarily terminate the client at the project's Inpatient Non-Hospital Transitional Living Facility Program in four of four records reviewed.
The findings include:
The facility's policy titled: "Notification of Termination," states:
"If a client is discharged from Self Help Movement, the client has the right to appeal the decision with the Clinical Director and/or the CEO. Upon discharge (or within one week of discharge if the client is not available), the client will receive a letter notifying them of their termination, the reasons for such, and the contact names and telephone numbers to initiate their appeal."
From August 26, 2013 to August 27, 2013, one client record in the Inpatient Non-Hospital Drug Residential Treatment and Rehabilitation Program and four client records in the Inpatient Non-Hospital Transitional Living Facility Program requiring documentation that the project notified the client in writing of a decision to involuntarily terminate the client at the project were reviewed. The project failed to notify the client in writing of a decision to involuntarily terminate the client's treatment at the project's Inpatient Non-Hospital Drug Residential Treatment and Rehabilitation Program in one of one record reviewed, specifically client record # 10. Also, the project failed to notify the client in writing of a decision to involuntarily terminate the client at the project's Inpatient Non-Hospital Transitional Living Facility Program in four of four records reviewed, specifically, client records # 7, 9, 10, and 11.
Client # 7, from the Inpatient Non-Hospital Transitional Living Facility Program, was admitted November 15, 2012 and involuntarily terminated January 9, 2013. Client # 7 was due to receive notification in writing of a decision to involuntarily terminate client # 7 from the project by January 16, 2013. However, client record # 7 did not include documentation of a decision to involuntarily terminate client # 7 from the project as of August 27, 2013.
Client # 9, from the Inpatient Non-Hospital Transitional Living Facility Program, was admitted September 28, 2012 and involuntarily terminated January 21, 2013. Client # 9 was due to receive notification in writing of a decision to involuntarily terminate client # 9 from the project by January 28, 2013. However, client record # 9 did not include documentation of a decision to involuntarily terminate client # 9 from the project as of August 27, 2013.
Client # 10, from the Inpatient Non-Hospital Transitional Living Facility Program, was admitted September 8, 2011 and involuntarily terminated February 18, 2013. Client # 10 was due to receive notification in writing of a decision to involuntarily terminate client # 10 from the project by February 25, 2013. However, client record # 10 did not include documentation of a decision to involuntarily terminate client # 10 from the project as of August 27, 2013.
Client # 10, from the Inpatient Non-Hospital Drug Residential Treatment and Rehabilitation Program, was admitted February 12, 2013 and involuntarily terminated May 6, 2013. Client # 10 was due to receive notification in writing of a decision to involuntarily terminate client # 10 from the project by February 19, 2013. However, client record # 10 did not include documentation of a decision to involuntarily terminate client # 10 from the project as of August 27, 2013.
Client # 11, from the Inpatient Non-Hospital Transitional Living Facility Program, was admitted April 24, 2013 and involuntarily terminated July 26, 2013. Client # 11 was due to receive notification in writing of a decision to involuntarily terminate client # 11 from the project by August 2, 2013. However, client record # 11 did not include documentation of a decision to involuntarily terminate client # 11 from the project as of August 27, 2013.
The findings were confirmed during an interview with the Director of Administration and the Clinical Director on August 27, 2013 at approximately 3:30 P.M.
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Plan of Correction
Beginning 08/29/2013, the individual counselors will ensure that all discharge summaries (regardless of type of discharge) include a signature line for the client to indicate his participation, as well as a statement indicating whether or not the client received copy. In the event the client is not present, a second statement is included regarding mailing of discharge summary to the client's last known address/forwarding address UNLESS the client specifically indicated that he did not want anything mailed to this address. Mailing address will be included and, when necessary, a written statement by the counselor if the document cannot be mailed (i.e., client was homeless upon admission and left facility without indicating destination; client expressly stated that nothing be mailed to the home). The individual counselors will also be responsible for placing the discharge summary into the client's chart as well as ensuring either the client receives a copy before he leaves or mailing a copy to the client's last known address. The individual counselor of client #10, will be responsible for sending the discharge summaries to the last known address and placing evidence in the client's chart.
The Case Manager of the Transitional Living Facility will ensure that the residents who are involuntarily discharged will receive a copy of their discharge letter and a copy placed in the resident's chart. If the resident leaves before receiving a copy of their discharge letter, a copy will be sent to their last known address.
The Case Manager of the TLF will be responsible for sending discharge summaries to their respective last known addresses and placing evidence in the clients' charts #7, #9, and #11.
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709.53(a) LICENSURE Complete Client Record
709.53. 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:
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project regarding verification of work therapy in the comprehensive treatment plan and/or treatment plan update in eight of eight records reviewed. Also, based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project regarding documentation of a comprehensive treatment plan in one of nine records reviewed.
The findings include:
The facility's policy titled: "Treatment and Rehabilitation Services," states:
"The Counselor is required to jointly develop a Comprehensive Treatment Plan (CTP) with each client within thirty calendar days for level 3C clients and for level 3B clients from the date of assignment or admission; therefore the admission date shall be included in all treatment plans."
From August 26, 2013 to August 27, 2013, nine client records requiring documentation of a complete client record on an individual which includes information relative to the client's involvement with the project were reviewed. The facility did not document a comprehensive treatment plan in one of nine records reviewed, specifically, client record # 3. Also, the facility did not document verification of work therapy in the comprehensive treatment plan and/or treatment plan update in eight of eight records reviewed, specifically, client records # 1, 2, 4, 5, 6, 7, 8, and 9.
Client # 1 was admitted June 10, 2013. The comprehensive treatment plan was completed June 24, 2013 and the treatment plan updates were completed July 10, 2013 and August 7, 2013. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan updates. However, client record # 1 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of August 27, 2013.
Client # 2 was admitted June 24, 2013. The comprehensive treatment plan was completed July 24, 2013. The facility was required to document work therapy on the comprehensive treatment plan. However, client record # 2 did not include documentation of work therapy in the comprehensive treatment plan as of August 27, 2013.
Client # 3 was admitted July 1, 2013. The comprehensive treatment plan was due July 31, 2013. However, client record # 3 did not include documentation of a comprehensive treatment plan as of August 27, 2013.
Client # 4 was admitted May 13, 2013. The comprehensive treatment plan was completed June 12, 2013 and the treatment plan update was completed July 12, 2013. The facility was required to document work therapy on the comprehensive treatment plan and the treatment plan update. However, client record # 4 did not include documentation of work therapy in the comprehensive treatment plan and the treatment plan updates as of August 27, 2013.
Client # 5 was admitted April 12, 2013. The comprehensive treatment plan was completed April 22, 2013 and the treatment plan updates were completed May 12, 2013, June 11, 2013, July 1, 2013, and August 10, 2013. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan updates. However, client record # 5 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of August 27, 2013.
Client # 6 was admitted June 3, 2013. The comprehensive treatment plan was completed July 3, 2013 and the treatment plan update was completed August 2, 2013. The facility was required to document work therapy on the comprehensive treatment plan and the treatment plan update. However, client record # 6 did not include documentation of work therapy in the comprehensive treatment plan and the treatment plan update as of August 27, 2013.
Client # 7 was admitted June 11, 2013. The comprehensive treatment plan was completed June 11, 2013 and the treatment plan update was completed July 11, 2013. The facility was required to document work therapy on the comprehensive treatment plan and the treatment plan update. However, client record # 7 did not include documentation of work therapy in the comprehensive treatment plan and the treatment plan update as of August 27, 2013.
Client # 8 was admitted March 28, 2013 and discharged May 7, 2013. The comprehensive treatment plan was completed April 11, 2013 and the treatment plan update was completed April 27, 2013. The facility was required to document work therapy on the comprehensive treatment plan and the treatment plan update. However, client record # 8 did not include documentation of work therapy in the comprehensive treatment plan and the treatment plan update as of August 27, 2013.
Client # 9 was admitted May 9, 2013 and discharged July 2, 2013. The comprehensive treatment plan was completed June 7, 2013. The facility was required to document work therapy on the comprehensive treatment plan. However, client record # 9 did not include documentation of work therapy in the comprehensive treatment plan as of August 27, 2013.
The findings were confirmed during an interview with the Director of Administration and the Clinical Director on August 27, 2013 at approximately 3:30 P.M.
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Plan of Correction
All counselors were notified on 08/28/2013 that all comprehensive treatment plans discussed with and prepared for 3C/3B LOC/Halfway House clients shall include information relative to the client's involvement with the project regarding verification of work therapy in the comprehensive treatment plan and/or treatment plan update. The individual counselors will include work therapy in all the client's charts #1 - #9. The documentation for client #3 was placed into the chart on 8/28/13.
The Compliance Officer will continue to prepare tracking sheets to monitor the counselors' progress in documentation and promptly alert the counselors when necessary documentation is due. Counselor's progress with documentation will be assessed by the Clinical Director during each counselor's bi-weekly individual meeting with the Clinical Director.
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