INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 10, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Addictive Disease - Main Line Affiliates 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(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
Based on a review of the personnel records and the facility's Staffing Requirements Facility Summary Report from, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff.
The findings include:
From October 9, 2012 to October 10, 2012, two personnel records and the Staffing Requirements Facility Summary Report form were reviewed to verify that employees had HIV/AIDS and STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff. The facility failed to ensure that staff persons received a minimum of 6 clock hours of HIV/AIDS training from a curriculum approved by the Department in one of two personnel records reviewed, specifically, personnel record # 2.
Employee # 2 is the facility director and clinical supervisor and was hired on September 25, 2006. Employee # 2 would have been due to complete the HIV/AIDS training by September 25, 2007 from a curriculum approved by the Department. Employee # 2's record did include documentation of several HIV/AIDS trainings that were completed prior to September 25, 2007. However, the HIV/AIDS trainings were not from a curriculum approved by the Department.
The findings were confirmed during an interview with the project director on October 10, 2012 at approximately 11:30 A.M.
This is a repeat citation. The facility was cited on February 8, 2012 for noncompliance with this standard.
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Plan of Correction
The facility director, employee #2 is scheduled to attend HIV/AIDS training in January which is the next available Department of Drug and Alcohol Programs training. The Program Director is responsible to ensure that employee #2 completes this training 0n January 16th. Additionally, all current staff are compliant with the HIV/AIDS and TB/STD training. Any new staff hired by practice and policy are mandated to obtain the HIV/AIDS and TB/STD trainings within the first year of hire. The Project Director is responsible to review all employee's files on a quarterly basis to ensure compliance. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, first aid cards and Cardio Pulmonary Resuscitation (CPR) certifications, the facility failed to ensure that a sufficient number of staff persons in first aid and CPR skills are present during all the project's hours of operation.
The findings include:
On October 10, 2012 the facility's personnel records and CPR certifications were reviewed. The facility is open Monday through Thursday from 8:30 A.M. to 9:00 P.M. and Friday from 8:30 A.M. to 5:00 P.M. Three staff members had documentation of CPR certification. However, only the psychiatrist had first aid training and the psychiatrist is not at the facility during the facility's entire hours of operation.
The findings were confirmed during an interview with the project director on October 10, 2012 at approximately 8:30 A.M.
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Plan of Correction
A first aid training was held 12/22/12. 8 employee's received certifications. The Project Director also participated, therefore can assure that all are certified. The Project Director is responsible for ensuring a sufficient number of staff on each shift during the hours of operation. This is accomplished by quartly reviewing scheduling. The facility was found to have a sufficent number of CPR certified staff on each shift and with all CPR staff being First Aid certified as of 12/22/12 the Project Director ensures the hours of operation are covered. |
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
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) form completed by the facility on October 10, 2012, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
On October 10, 2012, the SRFSR form completed by the facility was reviewed. The form listed one clinical supervisor/counselor and seven counselors as having a caseload, employees # 2, 3, 4, 5, 6, 7, 8, 9, and 10.
Employee# 2 had 6 clients and a caseload of 27:1, employee # 3 had 19 clients and a caseload of 30:1, employee # 4 had 19 clients and a caseload of 31:1, employee # 5 had 35 clients and a caseload of 35:1, employee # 6 had 10 clients and a caseload of 67:1, employee # 8 had 28 clients and a caseload of 38:1, employee # 9 had 24 clients and a caseload of 24: 1, employee # 10 had 4 clients and a caseload of 20:1.
The facility's standard work week, as reported by the facility on the SRFSR form, was 40 hours per week.
Based on the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40), and the total number of clients assigned to the following employees on October 10, 2012, employees # 6 and 8 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the client's treatment by the facility ' s standard workweek.
The number of hours per week devoted by Employee # 6 to client treatment, as reported by the facility on the SRFSR from, was 40 hours per week. The facility reported on the SRFSR form that employee # 6 had 10 active clients on October 10, 2012.
Employee # 6 (6/40 = 0.15 FTE 10 clients/0.15 FTE = 67: 1 caseload)
The number of hours per week devoted by Employee # 8 to client treatment, as reported by the facility on the SRFSR from, was 30 hours per week. The facility reported on the SRFSR form that employee # 8 had 28 active clients on October 10, 2012.
Employee # 8 (30/40 = 0.75 FTE 28 clients/0.75 FTE = 38: 1 caseload)
The findings were confirmed during an interview with the project director on October 10, 2012 at approximately 8:30 A.M.
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Plan of Correction
The clients on Employee's #6 and #8 were reassigned to make ratio 35:1. Caseload reports will done on a monthly basis by the Project Director to ensure the 35:1 ratio is maintained. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record that included documentation of the exit route used.
The findings include:
Fire drill records were reviewed on October 10, 2012. The records were reviewed from the period covering November 2011 to October 2012. The facility did not have documentation for the exit route used in eleven of twelve months reviewed, specifically, December 7, 2011; January 11, 2012; February 9, 2012; March 7, 2012; April 11, 2012; May 9, 2012; June 6, 2012; July 18, 2012; August 9, 2012; September 20, 2012; and October 2, 2012.
The findings were confirmed during an interview with the project director on October 10, 2012 at approximately 9:30 A.M.
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Plan of Correction
The Office Manger will amend the form which the documentation of the fire drill is gathered to include which exit was used. The Office Manger is responsible to change the form and then review the documentation monthly going forward to ensure the exit used is specifically documented. |
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.
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Observations
Based on a review of fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill records were reviewed on October 10, 2012. The records were reviewed from the period covering November 2011 to October 2012. In all the months reviewed, the facility only documented the exit route used on November 3, 2011. Because the facility only documented the exit route used in one month, there was no way to determine if the facility had prepared alternate exit routes to be used during fire drills.
The findings were confirmed during an interview with the project director on October 10, 2012 at approximately 9:30 A.M.
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Plan of Correction
The Office Manger will amend the form which the documentation of the fire drill is gathered to include which exit was used. The Office Manger is responsible to change the form, prepare alternative exit routes to be used and then review the documentation monthly going forward to ensure the exit used is specifically documented and is not consistently the same exit, therefore, an alternative was prepared, provided and utilized. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. 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, the facility failed to document a psychosocial evaluation that included an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and/or counselor conclusions/impressions.
On October 10, 2012, eight records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation that include an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and/or counselor conclusions/impressions in six of eight records reviewed, specifically, client records # 1, 2, 5, 6, 7, and 8.
Client # 1 was admitted April 26, 2012. The psychosocial evaluation was completed on April 26, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment.
Client # 2 was admitted March 7, 2012. The psychosocial evaluation was completed on March 7, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and counselor conclusions/impressions.
Client # 5 was admitted July 19, 2012. The psychosocial evaluation was completed on July 19, 2012. However, the psychosocial evaluation did not include an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and counselor conclusions/impressions.
Client # 6 was admitted July 9, 2012. The psychosocial evaluation was completed on July 9, 2012. However, the psychosocial evaluation did not include an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and counselor conclusions/impressions.
Client # 7 was admitted July 26, 2012. The psychosocial evaluation was completed on July 26, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and negative factors.
Client # 8 was admitted March 15, 2012. The psychosocial evaluation was completed on March 15, 2012. However, the psychosocial evaluation did not include an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, and counselor conclusions/impressions.
The findings were confirmed during an interview with the facility director on October 10, 2012 at approximately 3:30 P.M.
This is a repeat citation. The facility was cited on October 12, 2011 for noncompliance with this standard.
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Plan of Correction
The Facility Director will provide training to all assessors for improving the quality of documentation to ensure they are completing the assessment including an evaluation of problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, and also including the counselor's conclusions/impressions. Further, the Facility Director will monitor progress on a quarterly basis, reviewing l5% of all psychosocial evaluations for each counselor for 90 days. Counselors who score above 95% will be reduced to random audits, those scoring below 95% will continue quarterly monitoring. |
711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document the short-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan.
The findings include:
On October 10, 2012, eight client records requiring documentation of short-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan were reviewed. The facility did not document the short-term goals for treatment in seven of eight records reviewed, specifically, client records # 1, 2, 3, 4, 5, 6, and 7.
Client # 1 was admitted April 26, 2012. The individual treatment and rehabilitation plan was completed on July 17, 2012, but it did not include documentation of the short-term goals for treatment as of October 10, 2012.
Client # 2 was admitted March 7, 2012. The individual treatment and rehabilitation plan was completed on April 11, 2012, but it did not include documentation of the short-term goals for treatment as of October 10, 2012.
Client # 3 was admitted May 29, 2012. The individual treatment and rehabilitation plan was completed on July 2, 2012, but it did not include documentation of the short-term goals for treatment as of October 10, 2012.
Client # 4 was admitted May 4, 2012. The individual treatment and rehabilitation plan was completed on May 24, 2012, but it did not include documentation of the short-term goals for treatment as of October 10, 2012.
Client # 5 was admitted July 19, 2012. The individual treatment and rehabilitation plan was completed on August 3, 2012, but it did not include documentation of the short-term goals for treatment as of October 10, 2012.
Client # 6 was admitted July 9, 2012. The individual treatment and rehabilitation plan was completed on September 26, 2012, but it did not include documentation of the short-term goals for treatment as of October 10, 2012.
Client # 7 was admitted July 26, 2012. The individual treatment and rehabilitation plan was completed on August 25, 2012, but it did not include documentation of the short-term goals for treatment as of October 10, 2012.
The findings were confirmed during an interview with the project director on October 9, 2012 at approximately 3:30 P.M.
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Plan of Correction
The facility will change the form for documenting the treatment plan. The new form will include both short term and long term goal delineation. The Facility Director is responsible to educate clinicians and implement new treatment plan. The Facility Director will be responsible for reviewing the treatment plans monthly to ensure that the treatment plans include documentation of both short-term and long-term goals. |
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.
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Observations
Based on a review of client records, the facility failed to document a treatment and rehabilitation plan update and/or subsequent treatment and rehabilitation plan update in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Management of Treatment/Rehab Services," states:
"Treatment Plan Update are to be done the patient's therapist at 60-day intervals from the date of treatment plan. For the IOP they are to be done by at 30-day intervals from the date of the treatment plan. They are to include a summary of the progress the patient is making on the various problems included in the treatment plan."
On October 10, 2012, six client records requiring documentation of a treatment and rehabilitation plan update were reviewed. The facility failed to document a treatment and rehabilitation plan update and/or subsequent treatment and rehabilitation plan update according to their policy and procedures in three of six records reviewed, specifically, client records # 2, 4, and 5.
Client # 2 was admitted March 7, 2012. The individual treatment and rehabilitation plan was completed on April 11, 2012 and the treatment and rehabilitation plan update was completed on June 8, 2012. The subsequent treatment plan updates were completed on June 22, 2012; July 27, 2012; and August 14, 2012. However, the treatment and rehabilitation plan update and subsequent treatment and rehabilitation plan updates did not an assessment of the client's progress.
Client # 4 was admitted May 4, 2012. The individual treatment and rehabilitation plan was completed on May 24, 2012 and the treatment and rehabilitation plan update was completed on July 25, 2012. The subsequent treatment plan updates were completed on August 17, 2012, August 23, 2012 and September 4, 2012. However, the subsequent treatment and rehabilitation plan updates did not an assessment of the client's progress.
Client # 5 was admitted July 19, 2012. The individual treatment and rehabilitation plan was completed on August 13, 2012, the treatment and rehabilitation plan update was completed on September 14, 2012, and the subsequent treatment plan update was completed on October 2, 2012. However, the treatment and rehabilitation plan update and subsequent treatment and rehabilitation plan update did not an assessment of the client's progress.
The findings were confirmed during an interview with the facility director on October 10, 2012 at approximately 3:30 P.M.
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Plan of Correction
The Facility Director will change the form for documenting the treatment plan and subsequent reviews/updates to include a more comprehensive review of client progress. The Facility Director will audit quarterly to ensure compliance. |
711.94(e) LICENSURE Follow-up Policy
711.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to failed to develop a written client follow-up policy that address when clients have been discharged and referred to an outside resource, have successfully completed treatment and discharged, and all other clients who are not administratively discharged.
The findings include:
On October 9, 2012, the facility's policy and procedures manual was reviewed. The facility's follow-up policy did not address when clients have been discharge and referred to an outside resource, have successfully completed treatment and discharged, and all other clients who are not administratively discharged.
The facility's policy titled: "Follow-Up Policy - Outpatient & Intensive Outpatient," states:
"Follow-up is a means to determine the following:
Determine the patient's status in regards to their recovery. Determine patient satisfaction with the treatment experience here at CAD in both Outpatient and Intensive Outpatient Programs. For those patients completing their CAD treatment successfully, this will be done using the Patient Satisfaction Surveys on their last day of treatment. For those patients who do NOT complete, but are administratively discharged, the Patient Satisfaction Survey will be mailed out within 30 days of their day of discharge. All surveys, either mailed to the patient or given to them to complete on their last day, will be documented in a binder showing the patient name, the date of discharge, and the date the survey was completed/mailed. Returned surveys will be filed in the same binder under the month in which they were completed or returned."
The findings were confirmed during an interview with the project director on October 9, 2012 at approximately 3:30 P.M.
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Plan of Correction
The follow-up policy was revised and approved by the project director 11/12/12. The revised follow-up policy addresses when clients have been discharge and referred to an outside resource, have successfully completed treatment and discharged, and all other clients who are not administratively discharged. The Project Director will ensure that the revised policy remains in place at the facility. |