INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15, 2009 through June 16, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Family House 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 15, 2009.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on the review of personnel records on June 15, 2009, the facility failed to sure that all counselors meet the qualification for the position of counselor in one of three records.
Findings:
Ten personnel records were reviewed on June 15, 2009. Qualifications for the positions of counselor was required in three personnel records. Employee #5 did not have the required degree or clinical experience to meet the qualifications for the position of counselor.
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Plan of Correction
1. The employee not qualified for the position of counselor was removed from all clinical duties.
2. Program Director will review state qualifications for the position of counselor against credentials contained in personnel files for all new employees.
This corrective action plan went into effect on 6/16/2009.
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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 the review of CPR/First Aid cards and the facility's four week schedule for the months of May 2009 and June 2009, the facility failed to have sufficient number of staff persons who were CPR certified.
Findings
During the review of the facility's summary report and 4 week work schedule on June 15, 2009 it was revealed that the facility did not have sufficient CPR coverage for the overnight shifts (12 AM to 8 AM) on May 3, 4, 5, 6, 7, 11, 12, 13, 17, 18, 19, 20, 21, 26, 27, 28, 31, 2009 and June 1, 2, 3, 5, 7, 8, 9, 10, 11, 14, 15, 2009. The staff assigned to those shifts did not have their CPR/First Aid certifications. Employee # 7's CPR expired 3/18/09.
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Plan of Correction
1.Manager of Support Services modified ADL schedule removing non-certified staff member from shift.
2.Deficiency corrected on 6/16/09. Staff member received CPR training.
3.Program Director and Office Manager will regularly review personnel charts to ensure staff members meet the state requirements for CPR certification.
4.Program has a certified CPR instructor on staff that will conduct annual staff trainings to ensure CPR certifications do not expire. In addition, this staff member will be available to conduct additional CPR trainings as needed to maintain compliance with safety standards.
This corrective action plan went into effect on 6/16/2009.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of the facilities policy and procedure manual and client records, the facility failed to timely document physical examinations in four of five client records.
Findings:
Seven client records were reviewed on June 16, 2009. Physical examinations were required in five client records. The facility's policy and procedure, reviewed on June 15, 2009, stated that physical examinations will take place within 7 days after clients admission date. Client #1 was admitted on 4/30/09 and their physical examination did not take place until 6/3/09. Client #2 was admitted on 5/5/09 and their physical examination did not take place until 6/8/09. Client #3 was admitted on 2/10/09 and their physical examination did not take place until 2/24/09. Client #6 was admitted on 11/4/08 and their physical examination did not take place until 12/24/08.
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Plan of Correction
1. As a part of the intake process, ADL will attempt to obtain a physical examination for all incoming clients within 7 days of admission.
2. Client's that are unable to obtain a physical examination from their primary care physician will be set up with an appointment with a local physician prior to the 7th day in treatment to ensure physical is still completed within 7 days of admission.
3. Program will obtain linkage agreements with 2 more local physician offices to ensure that physical appointments can be obtained within 7 days.
4. Program will maintain all linkage agreements with local physicians to ensure physical examinations can be obtained within 7 days.
5. Program Director and Manager of Support Services will review intake paperwork to ensure physical examinations are competed within 7 days.
This corrective action plan will go into effect on 7/13/2009.
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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 a review of client records, the facility failed to complete psychosocial evaluations in five of five client records.
Findings:
Seven client records were reviewed on June 16, 2009. Psychosocial evaluations were required in five client records. The facility failed to provide documentation of a clinical assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment of the client in client records #1, 2, 3, 6, and 7.
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Plan of Correction
1.All clinical staff will attend a clinical documentation training facilitated by the program's Managed Care Coordinator that will address how to document a clinical assessment of client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment. This training is scheduled for 7/23/2009.
2.Program Director will review all psychosocial assessments to ensure they are complete.
This corrective action plan will go into effect on 7/10/2009.
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709.52(a)(1) LICENSURE Short/Long term TX Goals
709.52. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of client records, the facility failed to document short term goals with action steps in five of five records reviewed.
Findings:
Seven client records were reviewed on June 16, 2009. Short and long-term goals were required in five client records. Action steps were not documented in short term goals in client records #1, 2, 3, 6 and 7.
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Plan of Correction
1.All clinical staff will attend a clinical documentation training facilitated by the program's Managed Care Coordinator that will address documenting specific, measurable long-term and short-term goals with action steps. This training is scheduled for 7/23/2009.
2.Program Director will conduct weekly audits of treatment plans as they become due to ensure compliance.
This corrective action plan will go into effect on 7/10/2009.
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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.
Findings:
Seven client records were reviewed on June 16, 2009. Treatment plans updates were required in two client records. In client records #3 and 6 treatment plan updates did not include the client's progress in relationship to the specific stated goals of the treatment plan.
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Plan of Correction
1.All clinical staff will attend a clinical documentation training facilitated by the program's Managed Care Coordinator that will address documenting client progress from the previous treatment plan in relationship to the specific goals stated in the treatment plan. This training is scheduled for 7/23/2009.
2.Program Director will conduct weekly audits of treatment plans as they become due to ensure compliance.
This corrective action plan will go into effect on 7/10/2009.
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709.53(a)(5) LICENSURE Progress Notes
709.53. 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 the review of client records, the facility failed to document a complete progress note in three of three client records.
Findings:
Seven client records were reviewed on June 16, 2009. Group progress notes were required in three client records. The facility failed to document the therapist's assessment of the client in group notes in client records #1, 2 and 3. Group note documentation did not provide an assessment of the client.
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Plan of Correction
1.All clinical staff will attend a clinical documentation training facilitated by the program's Managed Care Coordinator that will address how to document a clinical assessment of the client. This training is scheduled for 7/23/2009.
2.Program Director will conduct a weekly audit of all progress notes to ensure quality documentation and assessment of client progress.
This corrective action plan will go into effect on 7/10/2009.
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