INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 23, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Carbon Monroe Pike Drug and Alcohol Commission, 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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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.
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Observations
Based on a review of eight outpatient and six intake, evaluation and referral client records on March 23, 2018, the facility failed to document in 7 of 14 records reviewed,
that the consent is subject to revocation at any time.
Consent to release information forms in the following client records stipulated that the client could only revoke the consent via verbal or written communication to the Case Manager or other specified staff.
Outpatient client #4 was admitted on September 21, 2017. A consent to release information form dated 09/21/2017, stipulated that the client could only revoke the consent via verbal or written communication to the Case Manager or other specified staff.
The finding was reviewed with facility staff during the licensing inspection.
Based on a review of 6 client records on March 23, 2018, the facility failed to provide documentation of the clients right to revoke consents to anyone other than the case manager and stated it had to be either in writing or verbal for clients #9, #10, #11, #12, #13, #14.
Client #9 was admitted on September 26, 2017. A consent to release information form in client record #9, dated September 26, 2017, stipulated that the client could only revoke the consent via verbal or written communication to the Case Manager or other specified staff.
Client #10 was admitted on September 25, 2017
Client #11 was admitted on January 1, 2018
Client #12 was admitted on August 11, 2017
Client #13 was admitted on October 2, 2017
Client #14 was admitted on July 12, 2017
The Finding was reviewed with facility staff during the licensisng inspection.
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Plan of Correction
Wording of release of information will be changed to state the following..the authorization to release information expires if rescinded by me verbally or in writing, except to the extent that action based on this consent has already been taken. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
During the on-site inspection conducted on 03/23/2018, the facility failed to document in their client rights policy and procedures the fact that the facility director and/or project director may temporarily remove items from client records. Additionally, the facility failed to document in the policy and procedure that the reason for removal of such information prior to client's review shall be documented in the client record.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Consumer Rights and Responsibilies will read.....
2. You can expect to have the right to inspect your own record within five (5) days of your written request to the Project, Facility, or Clinical Director.
2a. Be aware, that the Project, Facility, or Clinical Director has the right to temporarily remove or blackout portions of the record that he/she feels may be harmful to your progress in treatment. The reason for removing sections shall be documented in client record.
2b. If after you review your file, you find that you disagree with some part of the information contained in it, you may make a request to Project, Facility, or Clinical Director to have your file corrected or to have the data removed due to the information being inaccurate, irrelevant, outdated, or incomplete. However, if he/she does not grant your request, you may submit in writing "your side of the story" for the record. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the facilities unusual incident policy and procedure on March 23, 2018, the facility failed to develop and implement specific policies and procedures addressing the following:
- Selling or use of illicit drugs on the premises
- Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
- Theft, burglary, break-in or similar incident at the facility.
- Event at the facility requiring the presence of police, fire or ambulance personnel.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Reporting of Unusual Incidents to DDAP Licensing
Policy: To notify DDAP Division of Licensure in the case of an unusual incident
Procedure: Follow the established licensing alert below in addition to completion of Carbon Monroe Pike Drug and Alcohol Commission's incident report in the event of any of the unusual incidents listed below within the time frame designated.
LICENSING ALERT
Molly Raphael May 1997
Deputy Secretary for Quality Assurance
Division of Drug and Alcohol Program Licensing
Licensing Alert 5-97
Reporting of Unusual Incidents
The Division of Drug and Alcohol Program Licensing has noticed an increase in unusual
incidents, and as an extension of regulatory oversight, will now request the reporting of the
following incidents to the Division:
(1) Death or serious injury due to trauma, suicide, medication error, or unusual circumstances while in a residential treatment, or when known by a facility, for ambulatory services
(2) An injury, trauma, or illness requiring hospitalization that occurs when the
individual is at the facility or under the supervision of the facility
(3) Suicide attempt
(4) Physical assault by staff or resident
(5) Sexual assault by staff or resident
(6) An individual who is missing more than 24 hours or who could be in jeopardy if
missing at all
(7) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification
(8) An incident requiring the services of a fire department, ambulance personnel, or law enforcement agency
(9) Significant disruption of services due to disaster such as fire, storm, flood, or other occurrence that results in closure of the facility for more than one scheduled day of operation
(10) Fire or structural damage to the facility
(11) Misuse or alleged misuse of client's funds or property
(12) Incident the facility director believes may lead to community concern
(13) Theft, burglary, break-in, or similar incident at the facility
(14) Selling or use of illicit drugs on the premise
THE PROCEDURE TO BE FOLLOWED IN FILING AN UNUSUAL INCIDENT
REPORT IS AS FOLLOWS:
(1) The facility should notify the Licensing Division of DDAP within 24 hours (telephone 717-783-8675 or facsimile 717-787-3188), and within 72 hours file a written report using the Division's Unusual Incident Report Form (Form #HD1062F).
(2) The facility should initiate an investigation and file an Unusual Incident Report
Form on numbers 11 and 12 within five working days of the occurrence.
(3) The facility should notify others, including all appropriate officials, of an unusual
incident, maintaining client confidentiality.
(4) When an unusual incident affects the physical or emotional well-being of a client,
facility staff should insure that the client is safe from further injury, receives
medical and programmatic attention as soon as possible, is sensitive to the
emotional needs of the client, and arranges for specialized counseling, if
appropriate.
(5) The Division shall conduct investigations of unusual incidents when warranted.
(6) All reporting should be done to the extent permitted by State and Federal confidentiality laws
Specific protocol for each of the following reportable unusual incidents:
- Death or serious injury due to trauma, suicide, medication error, or unusual circumstances while in a residential treatment, or when known by a facility, for ambulatory services
- An injury, trauma, or illness requiring hospitalization that occurs when the
individual is at the facility or under the supervision of the facility
- Individuals who require a transfer to a hospital or other treatment facility will be informed of this decision and the staff will facilitate such transfer as is necessary
- Suicide attempt
- In the event where communication with EMS need to be contacted regarding suicide attempt the staff member who observed the act will be responsible for making contact with EMS via 911. The staff member will document all sources contacted and outcomes, if known. The staff member assigned to the client will consult with their supervisor regarding the incident
- Physical assault by staff or resident
- In the event where communication with law enforcement authorities need to be contacted regarding suspected physical assault by staff or client the staff member who observed or was informed of the suspected criminal act will be responsible for making contact with appropriate authorities. The staff member will document all sources contacted and outcomes, if known. The staff member assigned to the client will consult with their supervisor regarding the incident
- Sexual assault by staff or resident
- In the event where communication with law enforcement authorities need to be contacted regarding suspected sexual assault by staff or client the staff member who observed or was informed of the suspected criminal act will be responsible for making contact with appropriate authorities. The staff member will document all sources contacted and outcomes, if known. The staff member assigned to the client will consult with their supervisor regarding the incident
- An individual who is missing more than 24 hours or who could be in jeopardy if
missing at all
- Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification
- Individuals with communicable disease who inform staff of such will be informed that the program may need to inform authorities or referral sources of their present situation in reference to this. Individuals in the active phase of a communicable disease will be required to utilize universal precautions while obtaining services within the program. If they are not under the care of a physician or other health provider, they will be encouraged to do so and offered assistance and referral to the most appropriate provider.
- An incident requiring the services of a fire department, ambulance personnel, or law enforcement agency
- In the event where communication with law enforcement authorities, fire department, or ambulance personnel need to be contacted regarding an incident that occurred at the facility, staff member who observed or became aware of the incident will be responsible for making contact with appropriate authorities. The staff member will document all sources contacted and outcomes, if known. The staff member assigned to the client will consult with their supervisor regarding the incident
- Significant disruption of services due to disaster such as fire, storm, flood, or other occurrence that results in closure of the facility for more than one scheduled day of operation
- ENVIORMENTAL RELATED EMERGENCIES (Inclement Weather, Nuclear Event or Accident, Toxic Biological or Chemical Event or Accident or other Natural or Manmade disaster)
a. The Supervisors or their designee shall monitor local radio news broadcasts.
b. In the event that a severe windstorm, tornado, flash flood or other environmental emergency alert is broadcasted, Supervisors or their designee shall:
i. If practical, seek direction from the Assistant Administrator or Executive Director.
ii. Immediately dismiss clients unless local Emergency Management authorities deem it safer to remain inside rather than to leave.
iii. Dismiss staff and evacuate the building, unless local Emergency Management authorities deem it safer to remain inside rather than to leave.
iv. Take all necessary precautions to safeguard the building and its contents and if necessary secure windows, doors.
v. The Supervisors/s or their designee shall conduct a direct inspection of all rooms (including rest rooms) to be certain that no one remains inside the building.
c. If evacuation is not deemed appropriate, the Supervisor(s) or their designee will direct staff and consumers to gather in the designated safe room within the interior of their building. The following items shall be maintained in these locations:
i. Flashlight
ii. Radio
iii. Duct tape
iv. Telephone
d. Safe Room Locations:
i. Carbon Office: The Safe Room is located behind the door of the Staff kitchen/break room.
e. All Staff are expected to assist the Supervisors in taking whatever precautions are necessary to safeguard the individuals inside the building, the building itself and its contents, and if necessary shall secure windows, doors, and if appropriate sealed with duct tape.
f. The Supervisors or their Staff shall:
i. Attempt to build trust and credibility with all involved by taking control of the situation
ii. Remain calm, empathic and caring
iii. Explain the recommendations made by the local emergency management agency
iv. Do not over reassure, acknowledge uncertainty and people's fears
v. If possible, give people things to do
If possible, maintain regular contact with Emergency Management Officials to obtain information about when it might be safe to evacuate and/or to facilitate the transfer of Consumers and Staff to another safer location
- Fire or structural damage to the facility
- FIRE RELATED EMERGENCIES (In the Event of a Fire)
g. The Staff member who discovers the fire or who is first alerted of a fire shall:
i. In the Carbon Office, set-off the manual fire alarm
1. A Code Blue announcement will cancel the Code Red.
h. Assuming the phone system is working, the staff member who discovered the fire should also immediately contact the local fire department. The local Fire Department in each County can be reached by dialing "911".
i. Staff members shall remove the fire extinguishers from the wall mounts closest to their location and they shall, with extinguisher in hand, attempt to lead consumers and other staff to the nearest exit form their location in the building in an orderly fashion.
i. Do not attempt to fight the fire unless it is blocking all exits from the building.
ii. Do not allow anyone to leave the safe location outside the building until a head-count is conducted.
j. The Clerk Typist or other Staff member closest to the reception desk should remove the appointment book, scheduling software printout and/or group rosters available to them at the time of the fire.
k. A Staff member shall conduct a head count of all persons known to be in the building at the time of the evacuation in a safe location outside each of the offices:
i. Carbon - Across the street on the west side of 7th Street;
ii. The Supervisors/s or their designee shall, when possible, conduct a direct inspection of all rooms (including rest rooms) to be certain that no one remains inside the building
l. The first Staff member to exit the building shall not assume that the fire department was contacted and should attempt to place a phone call notifying the local department of the fire.
m. No attempt to contain or extinguish the fire should be made until after the safety of clients and staff is assured and then only if the fire is confined to a small area.
n. In the event of a fire, the Executive Director shall notify the Department of Health's D&A Licensing Bureau within 48 hours.
o. Carbon office shall conduct fire drills every 30 days. The Assistant Director and the Treatment Supervisor in each office shall maintain a written record of each drill.
- Misuse or alleged misuse of client's funds or property
- Follow agency policy regarding progressive disciplinary action
- Incident the facility director believes may lead to community concern
- Theft, burglary, break-in, or similar incident at the facility
- In the event where communication with law enforcement authorities need to be contacted regarding suspected criminal acts the staff member who observed the suspected criminal act will be responsible for making contact with appropriate authorities. The staff member will document all sources contacted and outcomes, if known. The staff member will consult with their supervisor regarding the incident
- Selling or use of illicit drugs on the premise
- In the event where communication with law enforcement authorities need to be contacted regarding suspected criminal acts the staff member who observed the suspected criminal act will be responsible for making contact with appropriate authorities. The staff member will document all sources contacted and outcomes, if known. The staff member will consult with their supervisor regarding the incident
GENERAL RESPONSIBILITIES:
(1) The Division should maintain a record of unusual incidents reported. (A copy of
an incident report will also be maintained in the facility file.) This information
will be useful in insuring appropriate follow-up on individual incidents, as needed,
and in identifying statewide trends for use in regulation setting, as well as
determining the need for increased monitoring visits.
(2) Incident identification and reporting will encourage facilities to develop policies
and procedures on prevention and management of unusual incidents, including:
(a) In-service for staff in prevention, detection, investigation, and reporting of
unusual incidents;
(b) Identification of who in the facility should be notified of unusual incidents;
(c) Procedures for contacting families, other regulatory entities;
(d) Modification of circumstances or conditions that constitutes a high probability
of unusual incidents occurring based on previous experiences.
(e) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident by facility administration.
(f) Implementation of a timely and appropriate corrective action plan, when indicated and ongoing monitoring of the corrective action plan by facility administration.
Updated 5/3/2018
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of 8 client records on March 23, 2018, the facility was unable to provide verification that the treatment plans were developed with the clients in two of eight records reviewed.
Client #4 was admitted on September 21, 2017. A comprehensive treatment plan was developed on 10/4/17; however, a progress note in the client record indicated that the treatment plan was to be worked on at the next individual session. There was no signature of the client on the plan to indicate that they participated in the development of the treatment plan.
Client #6 was admitted on September 12, 2017. The treatment plan was signed on 10/4/17 withyout client signature and noted will develop plan with the client at next individual session on 10/17/18.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Outpatient Supervisor will hold an in-house training and review of development of treatment plans and accurate documentation of progress notes. Outpatient Supervisor will also review 2 files weekly from each OP staff member to assure treatment plans and notes are done correctly. |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of staff records on March 23, 2018, the facility failed to provide documentation of supervision by a full-time clinical supervisor for counselor assistant staff #5.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Based on 704.5 (a) we only have one location and therefore do not need a facility director.
Executive Director will continue to hold the position of Project Director
Outpatient supervisor will become the full time clinical supervisor and will not hold a caseload to provide supervision to counselor assistants and counselors. This will become effective 6/1/2018
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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of staff records March 23, 2018, the facility failed to provide documentation of a semi-annual review performed for staff #5 within 6 months of the start of supervision.
Employee # 5 was promoted to the position of Counselor Assistant on August 28, 2017 and the semi-annual performance review was due to be completed by February 28, 2018. At the time of the inspection on March 23, 2018 there was no documentation of a semiannual performance review.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon completion of 6 month probationary period for a counselor assistant the counselor assistant and supervisor will review the attached evaluation form. With a successful rating the counselor assistant shall be eligible for a full caseload. The attached form shall be used as their semiannual review.
Carbon-Monroe-Pike Drug & Alcohol Commission, Inc.
Probationary Employee Evaluation Form ? End of 6 months for Trainee Pg. 1
(To be done weekly the 1st full month of employment and monthly 2nd thru 6th month)
Evaluation # 9
Job Title:
Check here if this is the Final
Probationary Evaluation
X
Employee Name:
Date:
EMPLOYER EXPECTATIONS
See guide below: Rate 1 6
Employee's Rating
Supervisor's Rating
COMMENTS (Written comments required for 1 & 2 ratings)
ATTITUDE (pleasant, courteous, good manners)
COOPERATION (with employer/
consumers)
DEPENDABILITY (follows through on responsibility)
PUNCTUALITY (arrives at work early or on time)
ATTENDANCE (available for scheduled work)
WORK HABITS (knows system and paper flow)
INITIATIVE (wants to learn and takes action)
QUALITY OF WORK (neatness, accuracy and organization)
RELATIONSHIP WITH CO-WORKERS (respectful, helping)
PERSONAL APPEARANCE (cleanliness, neatness, dress)
PROBLEM SOLVING (ID's objectively and initiates solutions)
TEAM ORIENTED (ID`s and communicates Goals of Unit)
COMMUNICATION SKILLS (communicates questions and concerns directly)
FOLLOWS DIRECTION (both verbal and written)
FEEDBACK Direct Supervision (if required) Date #1:_________
Date #2:_________
Date #3:_________
Date #4:_________
Signature of staff observing: _________________
Signature of staff observing: _________________
Signature of staff observing: _________________
Signature of staff observing: _________________
1. Unsatisfactory: Fails to meet standards and requirements for effective performance.
2. Development Needed: Requires improvement and growth to effectively meet job requirements.
3. Satisfactory: Meets expectations and requirements for the job phases.
4. Above Average: Frequently exceeds expectations and requirements of job description.
5. Outstanding: Always exceeds expectations and requirements for all job description.
6. Not Applicable: Too early to evaluate performance in this area.
Carbon-Monroe-Pike Drug & Alcohol Commission, Inc.
Probationary Employee Evaluation Form ? End of 6 months for Trainee Pg. 2
(To be done weekly the 1st full month of employment and monthly 2nd thru 6th month)
Evaluation # 9
Job Title:
Check here if this is the Final
Probationary Evaluation
X
Employee Name:
Date:
See guide below: Rate 1 6
Employee's Rating
Supervisor's Rating
COMMENTS (Must include date full caseload to begin)
CLIENT CASELOAD
(Discuss increasing to full client caseload upon successful completion of 6-month period)
Signatures
Employee:
Date:
Supervisor:
Date
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