INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16-18, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northern Tier Counseling 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 and a plan of correction is due on November 14, 2007.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a reviewed of agency training files the facility did not comply with this regulation. No documentation of the assessment of staff training needs for the current training year was available at the time of the inspection..
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Based on a review of agency training files the facility did not comply with this regulation. No documentation was available of the staff training plan for the current training year (7/1/07 to 6/30/08).
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on a physical plant inspection and interview with staff the facility is not in compliance with this regulation. There is an attic in the building . No smoke detector is installed in the attic.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection and staff interview the facility is not in compliance with this regulation. Staff reported that the square footage of the facility is 8068 square feet. There were only three fire extinguishers in place at the time of the inspection. There should be a fire extinguisher for every 2000 square feet.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of employee personnel and training records it was determined that the facility failed to meet the requirements of this regulation because employee # 9 did not receive the required training for the use of fire extinguishers within seven days of the employment date.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of employee personnel and training records it was determined that the facility failed to meet the requirements of this regulation because employee # 9 did not receive the required training to ensure the employee is trained to perform assigned tasks during emergencies.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative materials the facility failed to meet this regulation. The agency manual was presented in three volumes. Policies in the manual conflicted with other policies in several instances. New and old policies were filed together making it difficult to ascertain which policies and procedures were current. The general organization of the manual made the review difficult and increased the potential for misunderstanding the intent of various procedures.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel files and administrative policies and procedures the facility failed to meet the requirements of this regulation as evidenced by the absence of annual performance reviews in the personnel record sample. In personnel records # 6 and 8 reviews were not documented on an annual basis and, were last documented in 2002. In personnel record # 7 no probationary performance evaluation was documented in accordance with agency policy. The total record sample reviewed was nine records.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Based on a review of agency policy and administrative documents the facility failed to meet the requirements of this regulation. There is a substantial body of agency policy which addresses the HIPAA requirements. The language in this portion of the manual is not consistent with the requirements of applicable confidentiality laws at 28 Pa. Code Subsection 709.28(a), 4 Pa. Code Subsection 255.5 and the federal regulations at 42 CFR Part 2, Subparts A through E, and in fact contradicts the letter and intent of these laws in a number of instances.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Based on a review of administrative documentation and client records, the facility failed to meet the requirements of this regulation. The consents used in each of the client files reviewed contained incorrect language which was confusing. The manner in which the consents to release information are constructed does not clearly state what is occurring with the information outlined on the form. The use of verbiage such as "receive information from"; "the following information is to be gathered" - as noted on forms which are identified as Release of Information forms - is unclear. For a consent to rise to the level of an "informed" consent the client who is asked to sign it must be able to comprehend what information is being released and who it is being released to.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on information reviewed in client records the facility failed to comply with this regulation. The consent to release information forms did not clearly identify what information was to be released prior to the client signing the forms. Language used on each consent to release information form identified the information which was, presumably, to be released to in the following manner: "The following information is to be gathered:". This issue was identified in each of the five client records reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on reviews of client records the facility failed to meet this regulation. The purpose stated on each consent to release information on each form reviewed in each of the five files reviewed was generic in nature ("...for the purpose of interagency coordination to give a continuum of care to this client") and did not clearly identify the reason that the entity or person receiving the information released needed the specific information that the client was agreeing to release..
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 the review of client records the facility failed to meet the requirements of this regulation. Documentation that the client was offered a copy of each consent was not consistently completed in client records # 1, 2, 4 and 5.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of a sample of client records , the facility failed to meet the requirements for this regulation because histories lacked detail on family dynamics/interactions, in client records # 1, 2, 3, 4 and 5. Details were lacking on sexual histories in client records # 3, 4. The educational histories were incomplete in client records # 2, 4 and 5. Legal and employment histories were incomplete in client record # 4. The total sample reviewed was five client records.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of client records, the facility filed to meet the requirements of its own policy regarding physical exams. The policy indicated that a physical examination needed to be documented for all medical assistance clients. Physical examinations should have been documented in client records # 1, 2, 3 and 4 ( 4 of 4 applicable ) . No documentation was found in these client records.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records it was determined that the facility failed to meet the requirements of this regulation because required components of the psychosocial evaluation were missed in the following client records: # 1, 2, 3 and 4 (4 of 5 records).
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records the facility failed to meet the requirements of this regulation in client records # 3 and 4 . The plan section of the progress notes in client record #3 did not set a treatment goal for next session based on information obtained in the current session. The total sample was 5 records.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Based on a review of administrative materials the facility failed to meet the requirements of this standard. The facility failed to provide documentation that the facility medical director was the physician of record listed with the Office of Medical Assistance for OMA billing purposes.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |