INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 18 - 20, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Berks Counseling Center, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 facility's staffing requirements facility summary report (SRFSR), the facility failed to ensure that staff persons and/or volunteers received 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 as per the regulatory requirements in two of eleven records reviewed.
The findings include:
The facility's SRFSR form completed by the facility on February 20, 2014 was reviewed on February 20, 2014. The form listed two staff as not having completed the mandatory training within the regulatory time frames
Employee # 5, a counselor, was hired on October 22, 2012. Employee #5 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by October 22, 2013. The training was not documented as of the date of the inspection.
Employee # 6, a counselor, was hired on January 26, 2013. Employee #6 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by January 26, 2014. The training was not documented as of the date of the inspection
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Plan of Correction
Both employee #5 and employee #6 completed HIV/AIDS training on 2/14/14-- slightly past the one year deadline. Effective April 1, clinical supervisors will assure training attended for the month is documented by the end of that month and will review training status of all employees quarterlyto better track requirements are met within applicable time frames. Human resources department will confirm the completion of all related training requirements in a timely manner. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure and document that the counselor completed at least 25 hours of training for the July 1, 2012 through June 3, 2013 training year in one of eleven personnel records reviewed.
The findings include:
Eleven personnel records were reviewed on February 18, 2014. Five employee records represented the counselors who were required to have obtained 25 hours of training for the July 1, 2012 through June 3, 2013 training year based on the hire dates, #4, 5, 6, 7 and 8.
Employee #7 was hired January 3, 2012 and was required to have obtained 25 hours of training for the July 1, 2012 through June 30, 2013 training year. Employee #7 only documented 21 hrs of training for training year July 1, 2012 through June 30, 2013.
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Plan of Correction
Employee #7 completed only 21 of 25 required training hours. All staff training hours will be documented monthly and reviewed quarterly by the clinical supervisors. This will begin the end of the third quarter, March 31,2014 and continue to occur quarterly thereafter. Human resources will monitor ongoing compliance with regard to training documentation and standards. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility doctor's/nurses' office included a heater that was not permanently mounted or installed.
The findings include:
The physical plant inspection took place on February 20, 2014. The doctor's/nurses' office had a heater that was not permanently mounted or installed. An interview with the clinical supervisor on February 20, 2014 confirmed the findings.
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Plan of Correction
The Officer Manager informed the employee, effective immediately, who removed the space heater from that office. Employee was informed that use of a space heater is a violation of licensure guidelines. Office Manager will monitor ongoing compliance with regard to this standard. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on the physical plant inspection, the facility failed to ensure that the fire extinguishers were inspected annually.
The findings include:
The physical plant inspection took place on February 20, 2014. The fire extinguisher located in the counseling department was last inspected October 2011. An interview with the clinical supervisor on February 20, 2014 confirmed the findings.
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Plan of Correction
Building owner, and fire inspection company, have been notifed of need to replace one extinguisher in counseling area effective this date. Office manager will confirm that this has been completed within one week per agreement.Safety Committee will be responsible establishing a system for tracking and monitoring fire extinguisher checks to assure they are up to date at all times. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative paperwork, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The findings include:
The letters of agreement were reviewed on February 18, 2014. The only letter of agreement regarding 24- hour emergency medical coverage was signed by the CEO of the company, but not signed by the hospital. There was no other documentation of a 24- hour emergency medical coverage agreement.
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Plan of Correction
The finalized letter of agreement, with hospital signature, was still pending at the time of our electronic submission. It was received actually during the inspection and a fully executed copy, signed by the hospital in addition to our CEO, is on file here. Office manager will be responsible for reviewing referral agreements annually, at the end of each fiscal year, and updating them according to due date. |
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 records, the facility failed to document annual performance evaluations four of eight personnel records.
The findings include:
Eleven personnel records were reviewed on February 18, 2014. Eight of the eleven records were required to include documentation of annual performance evaluations. There were no annual performance evaluations documented in personnel records #3, 4, 5 and 6.
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Plan of Correction
COO will remind all staff of importance of completing performance evaluations in a timely manner. Effective immediately, all overdue performance evaluations( as measured by more than 2 weeks post annual hire date) will result in an e-mail to that person's supervisor and formal disciplinary action. COO and Human Resources Manager will assume responsibility for assuring this occurs by monthly review of Excel spreadsheet tracking evaluation due dates and completion of same. |
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 client records, the facility failed to obtain an informed and voluntary consent in four of eleven records.
The findings include:
Eleven client records were reviewed on February 19, 2014. Eleven client records were required to have informed and voluntary consent forms.
The facility exceeded 4 PA Code. 255.5 by exceeding what it to be sent out to insurance companies. Per the State Law 255.5 (b) Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4), (7), (3) of subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following: (1) Whether the client is or is not in treatment, (2) Client's prognosis, (3) The nature of the Project, (4) A brief description of the client's progress and (5) A short statement as the whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Client #1 had a consent to release form dated July 11, 2013 documenting that they will give the insurance agency the following information:
1. Discharge Summaries
2. Psychiatric evaluations, medication records
3. Psychosocial Diagnosis to be related to other treatment providers only.
Letter was sent on July 30, 2013 and address "To Whom It May Concern".
Case Management note dated August 5, 2013 stated that there was communication between the case manager and crisis center pertaining to the client. There was no consent to release documented for this crisis center.
Client #3 had a consent to release form dated November 8, 2013 documenting that they will give the insurance agency the following information:
1. Discharge Summaries
2. Psychiatric evaluations, medication records
3. Psychosocial Diagnosis to be related to other treatment providers only.
In client, record #4 there was a letter dated October 16, 2013 to the client ' s parole officer and a call made on January 14, 2014 to the client ' s parole officer. There was no consent to release documented in the clients record for the clients parole officer.
Client #5 had a consent to release form dated October 4, 2013 documenting that they will give the government agency the following information:
1. Discharge Summaries
2. Psychiatric evaluations, medication records
3. Psychosocial Diagnosis to be related to other treatment providers only.
4. TB Test result records to meet State requirements
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Plan of Correction
Clinical supervisors will present a staff training on the accurate completion of consent to release forms. Each staff member who completes the training will be given an updated copy of the form and written instructions on how to complete it. Special emphasis will be placed on protocol for drug and alcohol and co-occurring patients. This training will occurr by 4/30/14.
Compliance checks will be scheduled monthly for the next 3 months to assure procedures as outlined are being followed. Compliance officer, COO, will assure this standard is being followed at the end of the three months and ongoing, thereafter, by completing regular, random record reviews. |
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 a review of client records, the facility failed to provide a psychosocial evaluation to include the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and/or counselor conclusions and impressions in nine of ten records reviewed.
The findings include:
Ten client records requiring documentation of psychosocial evaluations were reviewed on February 19, 2014. A psychosocial evaluation was reviewed in all client records.
The psychosocial evaluations in client records # 1, 2, 6, 9 and 10 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records # 1 and 9 did not include an evaluation of the client's support systems.
The psychosocial evaluations in client records # 1, 7 and 9 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records # 1, 2, 6, 9 and 10 did not include an evaluation of the negative factors of the client.
The psychosocial evaluations in client records # 1, 2, 9 and 10 did not include an evaluation of the client ' s attitude toward treatment.
Additionally, three of the ten client records did not documented a psychosocial evaluation, #3, 4 and 5.
Client #3 was admitted on November 8, 2013. As of the date of the licensing inspection, there was no documentation of a psychosocial evaluation in record #3.
Client #4 was admitted on September 19, 2013. As of the date of the licensing inspection, there was no documentation of a psychosocial evaluation in record #4.
Client #5 was admitted on October 4, 2013. As of the date of the licensing inspection, there was no documentation of a psychosocial evaluation in record #5.
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Plan of Correction
Clinical Supervisors will complete a training on effectively writing a psychosocial evaluation for all counselors by 4/30/14. Effective immediately, counselors will be required to review psychosocial evaluations on all new admissions as part of supervision, at their next supervision session following that admission. Compliance reviews will occur monthly for a period of three months to assure compliance with this standard. Clinical supervisors will be responsible for this and ongoing random compliance checks throughout the year. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to include the type and frequency of treatment and rehabilitation services in six of ten client records.
The findings include:
Ten client records were reviewed on February 19, 2014. Six of the ten records lacked documentation of the type and frequency of treatment and rehabilitation services on the client's treatment plan, #2, 3, 4, 8, 9 and 10.
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Plan of Correction
By 4/30/14, clinical supervisory staff will modify the electronic treatment plan to include a drop down box for type and frequency of treatment and rehabilitation services. In the interim, counselors were instructed at the March 6 meeting to implement this change manually until 4/30. Clinical supervisors will monitor ongoing compliance with regard to this standard when they review and sign treatment plans. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to have a complete record in seven of ten records reviewed.
The findings include:
Ten client records were reviewed on February 20, 2014. All of the reviewed client records were required to include case consultation notes. Three of the ten records lacked documented case consultations, #1, 3 and 5. Additionally, client record # 10 contained a case consultation between the counselor and the clinical supervisor; however, the counselor signed the case consultation on November 19, 2013 and the clinical supervisor signed it January 25, 2014.
Two client records were required to contain an aftercare plan, #8 and 10. The aftercare plan was not documented as of the date of the licensing inspection.
Client #8 was admitted on May 29, 2013 and discharged on October 23, 2013. Their aftercare plan was due prior to the client's discharge date. As of the date of the licensing inspection, the facility failed to document an aftercare plan for client #8.
Five client records were required to include documentation of a discharge summary, #5, 7, 8, 9 and 10. Two of the five records #6 & 10, contained discharge summaries that failed to document the client's reason for treatment.
Four client records were required to contain documentation of a follow-up attempt, #7, 8, 9 and 10. Two of the four did not contain documentation of a follow-up attempt, #7 and 10.
Client #7 was discharged on September 23, 2013 and as of the date of the licensing inspection; there was no documentation of a follow-up attempt.
Client #10 was discharged on December 5, 2013 and as of the date of the licensing inspection; there was no documentation of a follow-up attempt.
Additionally, there were issues surrounding the times staff were actually putting the information into the electronic records. The dates included on the documents by the automated system are conflicting and do not represent the dates actually completed.
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Plan of Correction
By April 30, Clinical Supervisors will conduct a training for all clinical staff on effective documentation with regard to a client record, common record keeping errors, and a special focus on improving those areas identified as in non-compliance.Effective immediately counselors will bring at least one record, for review, to each supervisory session. Clinical supervisors will conduct regular, randome record reviews to assure ongoing compliance with regard to these standards. |