INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 22 and 23, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD/New Start 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 July 27, 2009.
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Plan of Correction
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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on the review of the personnel records, the facility failed to ensure that the Counselor Assistant met the requirements for counselor for the completion of 5 years of employment.
Findings:
Five personnel records were reviewed on June 22, 2009. Personnel record #5 showed a hire date of 9/10/03 as a counselor assistant. Personnel record #5 revealed that the counselor assistant who had been employed on a full time basis at the facility for over 5 years had not met the requirements for a counselor position. Counselor should have obtained that status by 9/10/08.
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Plan of Correction
The Counselor Assistant was immediately removed from performing all clinical duties. Her caseload was reassigned to a master's level therapist who assumed the caseload on 7/31/2009. The Clinical Supervisor will monitor the counselor assistant to ensure no clinical client contact until the counselor assistant meets the requirements for a Therapist. The counselor assistant has been reassigned to do intake and residential duties. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based upon the review of personnel records, the facility failed to insure that the counselor assistant was eligible to be included in the determination of the FTE ratio.
Findings:
Five personnel records were reviewed on June 22, 2009. Upon review of personnel record #5, it was determined that the counselor assistant had not met requirements for becoming a counselor after exceeding the 5 year period and therefore was not eligible for a caseload. Therefore the counselor assistant was not eligible for inclusion in the determination of the FTE ratio. Employee #5 was hired 9/10/03 and counselor status should have been achieved by 9/10/08.
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Plan of Correction
A master's level therapist was assigned to assume the caseload full-time starting 7/31/2009. The Clinical Supervisor will monitor the caseload to ensure that the ratio does not exceed 8:1. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation of the physical plant, the facility failed to prohibit portable heaters on the premises.
Findings:
During a physical plant inspection of the facility on June 23, 2009 at 10:20 AM, a portable electric heater was observed to be stored in an office on the 3rd floor. The facility may not utilize heaters that are not permanently installed.
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Plan of Correction
The Residential Team Leader removed the heater from the facility and the Facility Director posted a notice to all staff and residents that the facility cannot utilize free-stnding heaters that are not permantley installed. The Residential Team Leader will check the facility for compliance monthly and report the findins to the Director. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill records, the facility failed to document that fire drills were conducted during resident sleeping hours at least every 6 months.
Findings:
The facility's fire drill records for the period from 7/08 through 6/09 were reviewed on June 22, 2009. The fire drill records showed that from July 2008 through December 2008, there was no documentation that fire drills were conducted during sleeping hours.
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Plan of Correction
The Facility Director and Residential Supervisor conducted a training with all residential staff to outline the need for montlhy fire drills. The residential supervisor will ensure that the drills are done monthly with at least two overnight fire drills to occur at least every six month period. This standard will be in full compliance 8/3/2009. |
709.32(c)(7) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(7) Medication errors and drug reactions.
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Observations
Based on a review of the medication administration records, the facility failed to consistently document medication dosages, medication reactions, and medication errors.
Findings:
Medication administration records of 10 residents were reviewed on June 23, 2009. Resident # 6 was prescribed Humalin injections in dosages of 20 Units in AM and 15 Units at HS (hour of sleep). The medication log showed that during the month of June 2009, Humalin was self administered by the client at 8 AM and 4 PM daily. The resident Medication Consent form containing all current orders did not show any change in administration times. Therefore, resident #6 was not receiving the PM dose of Humalin at the time prescribed. There was no comment on the Medication Administration Record as to why the medication was given at 4 PM rather than at bedtime.
The medication administration record of resident #7 showed a missed 20 mg dose of Fluoxetine (Prozac) on 6/20/09 with no documentation as to the reason. Facility policy states that all drug omissions, errors and reactions will be documented on the medication administration record.
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Plan of Correction
After speaking with Client #6 stated that he had refused his evening dosage of Humalin based up his sugar reading and he was afraid his insulin level would have been to low. The staff person failed to complete the refusal sheet indicating the client's refusal and the reason for that refusal.
The Residential Team Leader will monitor medication weekly and sign off to ensure that staff follow the outlined procedures.He will give the Director a written report monthly of the outcome.This will be monitored for three months. If there are any problems with staff not complying with the outlined procedures the Director will be informed of the problem the week the problem occurs and further action will be taken as warranted. The monitoring will begin the week of 8/1/2009 with full compliance
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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, the facility failed to document complete psychosocial evaluations in 2 of 2 records reviewed.
Findings:
Four client records were reviewed on June 23, 2009. Psychosocial evaluations were required in 2 records. The Psychosocial evaluations did not contain the counselor's assessment of client's assets/strengths, problems/needs, coping mechanisms, negative factors that impact response to treatment, and the client's attitude towards treatment in records #1 and 4.
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Plan of Correction
The Clinical Supervisor will revise the second page of the psychosocial evaluation to reflect the standard as outlined in 709.51(b)(6). The Client Supervisor will conduct a training with the clinical staff and intake counselor emphazining that assessments must contain and address the counselor's assessment of the client's assests/strengths, problems/needs, coping mechanisms, negative factors that impact response to treatment, and the client's attitdue towards treatment. Once the training is conducted the Clinical Supervisor will ensure on-going compliance by conducting weekly reviews of psychosocials and onces compliance is established the Clinical Supervisor will review quarterly thereafter. The date for compliance is set for 8/20/2009 with full compliance in 11/20/2009. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document complete treatment plan updates in two of two client records reviewed.
Findings:
Four client records were reviewed on June 23, 2009. Treatment plan updates were required in 2 client records. Treatment plan updates did not include the client's progress in relationship to the stated goals of the treatment plan, but rather stated generalized comments that were not specific to each client's progress in treatment in records #1 and 3.
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Plan of Correction
The Clinical Supervisor will conduct training with the clinical staff on Treatment Plan updates with an emphasis on client progress in relation to the specific goals being addressed during the update period. In addition the status/outcome or progress on the goals will be listed.Once training is conducted the Clinical Supervisor ensure compliance of the standard through monthly monitoring. The date for compliance is 8/20/2009. |