INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9, 2007 to July 11, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on August 9, 2007.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
The facility failed to ensure that the clinical supervisor completed the clinical supervisor training. The clinical supervisor has been in the position for 1 year and has not had 2 years of experience as a supervisor.
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Plan of Correction
The clinical supervisor has been scheduled for the appropriate training and will complete same as of mid-October, 2007. |
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:
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Observations
The facility failed to complete the staff development program policy. This standard was not met by failing to have a time frame for the overall plan and not having a clear policy for collecting feedback.
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Plan of Correction
The Project Director will author a staff development program policy, including sections regarding appropriate time frames and the collection of staff feedback. |
705.23 (1) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(1) Maintain space for both individual and group counseling sessions.
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Observations
The facility failed to maintain the physical plant space for both individual and group counseling. Duct tape was used to repair deteriorating carpet. Ceiling tiles were missing. The counseling areas are not well maintained.
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Plan of Correction
The landlord/owner has sold the property which The Care Center now leases, therefore will not purchase new carpet or make other repairs. The facility will be relocating by year's end. |
709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The facility failed to complete drug and alcohol histories. The histories failed to consistently document progression of the clients use/abuse as a part of the lengths and patterns of substance use/abuse. This was missing in client records # 6, 11 and 12.
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Plan of Correction
The referenced client histories will be corrected and the clinical supervisors will provide training and supervision to all staff regarding documenting histories comprehensively. Documentation of use/abuse progression will be highlighted in the training. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
The facility failed to complete the treatment plan update. The treatment plan update was documented but failed to include the client's progress on all objectives. This was not consistently documented in client record # 6.
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Plan of Correction
Client record #6 will be corrected. All staff will be given training and supervision regarding the thorough documentation of progress on treatment plan updates. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
The facility failed to completely assist the governing body in formulating policy in the current fiscal year. Documentation was not provided for board minutes or board of director approval of the annual goals and objectives.
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Plan of Correction
This had been scheduled for the regular Board of Director's meeting in July. This work is routinely done in July so that the Board can assess progress on the previous year's Goals and Objectives. For the future, Project Director has instructed the corporate secretary to annually include the development, review and adoption of annual project goals and objectives on the Board of Directors' agenda with sufficient notice to ensure their timeliness. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The facility failed to complete project goals and objectives. Goals and objectives for the current fiscal year were not documented at the time of the site visit.
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Plan of Correction
This had been scheduled for the regular Board of Director's meeting in July. This work is routinely done in July so that the Board can accurately assess progress on the year's Goals and Objectives and establish appropriate Goals and Objectives for the current year. For the future, Project Director has instructed the corporate secretary to annually include the development, review and adoption of annual project goals and objectives on the Board of Directors' agenda with sufficient notice to ensure their timeliness. |
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 failed to complete informed and voluntary consents to release information on a consistent basis. Consent forms did not consistently document whether a client accepted or rejected a copy of the consent in client records# 4, 5 and 8. The purpose for the release of information was unclear and failed to rise the level of an informed consent on release forms in client records # 10 and 11. The purpose must identify the reason for the release of information to the person or entity specified. PCPC forms included client specific information exceeding the limitations imposed at 4 Pa. Code Subsection 255.5(b) in client records # 2 and 6. Specific information was not listed on a release form in client record # 6.
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Plan of Correction
The clinical supervisors will provide training and ongoing supervision to all staff regarding the proper completion of consent to release information forms and PCPC forms. Deficient areas noted will be reviewed thoroughly with staff and ongoing compliance will be monitered. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
The facility failed to complete the medical assistance program requirements. The facility did have a signed provider agreement with the Department of Public Welfare that complies with 55 Pa. Code Part III. Treatment plans in records funded by the Office of Medical Assistance were not signed by the physician.
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Plan of Correction
The facility will assure that treatment plans funded by the Office of Medical Assistance will be signed by a physician. |