INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 5-7, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Center for Psychiatric and Chemical Dependency Services 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on the review of the Project ' s Staffing Requirements Facility Summary Reports, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the project.
The findings include:
The Project ' s Staffing Requirements Facility Summary Reports were reviewed by licensing staff from July 5-July 26, 2011 . Per regulation, a drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both. The review of the Project ' s Staffing Requirements Facility Summary Reports identified that the facility had 22 full time equivalent counselors or counselor assistants in the project, which would require 2 full time clinical supervisors. The documentation showed that the project employed 1 full time clinical supervisor.
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Plan of Correction
The project has hired 6 staff to provide supervision of 22 counselors. The Project Director and Program Managers will ensure that two supervisors are dedicated to provide only supervision duties and have no other assigned duties. The Program Managers will review supervisory duties each quarter to ensure that they do not exceed supervision activities.
The Project Director will follow-up with the Program Managers to ensure that 2 Supervisors have only supervision duties by September 15, 2011.
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records and a interview with the facility director, the facility failed to document that the clinical supervisor completed a core curriculum training in clinical supervision in one of one personnel record.
The findings include:
Eight personnel records were reviewed on July 5- 7, 2011. Two personnel records were reviewed as supervisors. One supervisor personnel record required documentation of the completion of a core curriculum training in clinical supervision. The facility did not document the completion of the training in personnel record # 3.
Employee #3 was hired by the facility on March 23, 2007 and promoted to clinical supervisor on January 5, 2009. As of the date of the personnel record review on July 5-7, 2011, there was no documentation that the employee had completed a core curriculum training in clinical supervision.
Interviews with the facility director on July 5 and 7, 2011 confirmed that employee #3 had not completed a core curriculum training in clinical supervision.
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Plan of Correction
Under the direction of the Program Director of her designee, all Clinical Supervisors and Lead Counselors will complete a core curriculum in clinical supervision within 1 year of functioning as a supervisor.Documentation of completion of training will be included in the personnel record. For those current supervisory staff who have not completed their core curriculum training, this will be completed by 12/31/2011. |
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 personnel records and an interview with the facility director, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment in two of two personnel records.
The findings include:
Eight personnel records were reviewed on July 5-7, 2011. Two personnel records were required to include documentation of fire extinguisher training. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records # 6 and 8.
Employee # 6 was hired on November 29, 2010. The instruction of the employee in the use of the fire extinguisher was not completed until December 21, 2010.
Employee # 8 was hired on June 27, 2011. The instruction of the employee in the use of the fire extinguisher was not completed until July 7, 2011.
Interviews with the Facility Director on July 6 and July 7, 2011 confirmed the fire extinguisher training had been not been completed upon employment for employees # 6 and 8.
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Plan of Correction
Under the direction of the Program Director or her designee, all new staff will complete fire extinguisher training within 7 days of employment. This will be documented and kept in the CPCDS Training Binder. Documentation of completed fire extinguisher training will also be documented in the employees personnel record. For identified employees #6 and #8 fire extinguisher training has been completed. |
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 personnel records and an interview with the facility director, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in two of two personnel records.
The findings include:
Eight personnel records were reviewed on July 5-7, 2011. Two personnel records were required to document that personnel on all shifts were trained to perform assigned tasks during emergencies. The facility failed to document personnel on all shifts were trained to perform assigned tasks during emergencies in personnel records # 6 and 8.
Employee # 6 was hired on November 29, 2010. Documentation that the employee was trained to perform assigned tasks during emergencies was not completed until December 21, 2010.
Employee # 8 was hired on June 27, 2011. Documentation that the employee was trained to perform assigned tasks during emergencies was not completed until July 7, 2011.
Interviews with the facility director on July 6 and July 7, 2011 confirmed that the training had been not been completed upon employment for employees # 6 and 8.
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Plan of Correction
Under the direction of the Program Director or her designee, all new staff will be trained to perform assigned tasks during emergencies within 7 days of employment. Documentation of completed training will be included in employees training record and personnel file. For employees 6 and 8, they have received the required training. |
711.82(f)(1) LICENSURE Ind Counseling - 2X WK
711.82. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document that the client was provided individual counseling, at least twice weekly, in six of six partial hospitalization client records.
The findings include:
Nineteen client records were reviewed on July 5-7, 2011. Six client records were reviewed as partial hospitalization records. Six client records were required to have documentation of individual counseling at least twice weekly. Per regulation, counseling shall be provided to a client on a regular and scheduled basis to include individual counseling, at least twice weekly. The facility failed to document that individual counseling was provided twice weekly in client records # 7, 8, 9, 10, 11 and 12.
Client # 7 was admitted to the partial hospitalization program on December 15, 2010 and discharged on January 28, 2011. For the week of December 20-24, 2010, one individual counseling session was scheduled on December 20, 2010. For the week of December 27-31, 2010, one individual counseling session was scheduled on December 27, 2010. For the week of January 3-7, 2011, one individual counseling session was scheduled on December 20, 2010. For the week of January 17-21, 2011, one individual counseling session was scheduled on January 20, 2011.
Client # 8 was admitted to the partial hospitalization program on June 9, 2011. For the week of June 13-17, 2011, one individual counseling session was scheduled on June 15, 2011.
For the week of June 20-24, 2011, one individual counseling session was scheduled on June 20, 2011.
Client # 9 was admitted to the partial hospitalization program on May 26, 2011 and discharged on June 24, 2011. For the week of May 30-June 3, 2011, there were no individual counseling sessions scheduled. For the week of June 6-June 10, 2011, there were no individual counseling sessions scheduled.
Client # 10 was admitted to the partial hospitalization program on June 1, 2011. For the week of June 6-10, 2011, one individual session was scheduled for June 10, 2011. For the week of June 13-17, 2011, one individual counseling session was scheduled on June 14, 2011.
Client # 11 was admitted to the partial hospitalization program on June 6, 2011. For the week of June 13-17, 2011, one individual counseling session was scheduled on June 15, 2011. For the week of June 20-24, 2011, one individual counseling session was scheduled on June 23, 2011.
Client # 12 was admitted to the partial hospitalization program on April 11, 2011 and discharged on May 6, 2011. For the week of April 25-29, 2011, one individual counseling session was scheduled on April 26, 2011. For the week of May 2- 6, 2011, one individual counseling session was scheduled on May 3, 2011.
The clinical supervisor reviewed the above client records with the licensing inspector on July 6, 2011 and confirmed that the clients were not receiving two individual counseling sessions per week as required by regulation.
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Plan of Correction
Under the direction of the Program Director or her designee, counseling shall be provided to a client on a regular and scheduled basis to include individual counseling, at least twice weekly. Program Supervisors will be responsible for reviewing scheduled appointments in their weekly supervision with partial staff commencing 7/25/2011. Program Supervisors will report monthly commencing 8/1/2011 to the Program Director the compliance of individual counseling occurring at least twice weekly . |
711.83(a)(7) LICENSURE Follow-up Information
711.83. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document follow-up information in three of three client records.
The findings include:
Nineteen client records were reviewed on July 5-7, 2011. Nine client records were reviewed as partial hospitalization records. Three of the nine client partial hospitalization records were reviewed as closed records. Three of the three closed client partial hospitalization records required follow-up information. Per facility policy, follow-up is to be completed within 7 days of discharge. The facility did not document follow-up information per facility policy, in client records # 14, 15 and 16.
Client # 14 was admitted to the partial hospitalization program on May 26, 2011 and discharged on June 17, 2011. Follow-up was to be completed by June 24, 2011. There was no documentation that follow-up had been completed.
Client # 15 was admitted to the partial hospitalization program on May 26, 2011 and discharged on June 13, 2011. Follow-up was to be completed by June 20, 2011. There was no documentation that follow-up had been completed.
Client # 16 was admitted to the partial hospitalization program on June 9, 2011 and discharged on June 17, 2011. Follow-up was to be completed by June 24, 2011. There was no documentation that follow-up had been completed.
An interview with the facility director on June 7, 2011 confirmed that the follow-ups were not documented.
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Plan of Correction
Under the direction of the Program Director or her designee, follow up phone calls on all discharged partial patients will be completed and documented within 7 days of discharge. Program Supervisors will review all closed charts and follow up phone calls on a monthly basis and will log cases which were reviewed and discussed with Program Director in supervision. Beginning, 8/1/2011 monthly reviews of closed charts will be completed by Program Supervisor or designee to further ensure compliance. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) 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 the review of client records and an interview with the facility director, the facility failed to document that an individual treatment and rehabilitation plan was developed with a client in four of six client records.
The findings include:
Nineteen client records were reviewed on July 5-7, 2011. Nine client records reviewed were outpatient client records. Six of the outpatient records reviewed required an individual treatment and rehabilitation plan that was developed with the client. The facility did not document that the individual treatment and rehabilitation plan was developed with the client in client records # 2, 3, 4 and 5.
Client # 2 was admitted on January 27, 2011. The individual treatment and rehabilitation plan was completed and signed by the counselor on April 27, 2011. The client did not sign the treatment plan until May 19, 2011. There was no documentation that the client had participated in the development of the treatment plan.
Client # 3 was admitted on January 5, 2011. The individual treatment and rehabilitation plan was completed and signed by the counselor on January 28, 2011. The client did not sign the treatment plan until March 4, 2011. There was no documentation that the client had participated in the development of the treatment plan.
Client # 4 was admitted on November 24, 2010. The individual treatment and rehabilitation plan was completed and signed by the counselor on December 9, 2010. There was no documentation of a client's signature. There was no documentation that the client had participated in the development of the treatment plan.
Client # 5 was admitted on March 3, 2011. The individual treatment and rehabilitation plan was completed and signed by the counselor on March 28, 2011. There was no documentation of a client's signature. There was no documentation that the client had participated in the development of the treatment plan.
An interview with the clinical supervisor was conducted on July 7, 2011 and the findings were not disputed.
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Plan of Correction
Under the direction of the Program Director of her designee, all individual treatment plans will be developed inconjunction with the patient and documented accordingly. In staff meeting to be held by 8/31/11, staff will be re-educated on compliance with treatment plan formulation and consumer participation and signing of treatment plans. In staff weekly supervision, supervisors will review all new and reviewed treatment plans to ensure that documentation is completed regarding consumers involvement in their treatment plans. Program Supervisors will report monthly to Program Director monthly in supervision status of compliance. |
711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) 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 and an interview with the facility director, the facility failed to document the frequency of treatment and rehabilitative services on the individual treatment plan in three of seven client records.
The findings include:
Nineteen client records were reviewed on July 5-7, 2011. Ten client records were reviewed as outpatient client records. Seven outpatient client records required documentation of the frequency of treatment and rehabilitative services on the individual treatment plan. Per regulation, an individual treatment and rehabilitation plan shall be developed with a client to include the type and frequency of treatment and rehabilitative services. The facility failed to document the frequency of treatment and rehabilitative services in client records # 1, 2 and 4.
Client # 1 was admitted to the outpatient program on November 18, 2010. The individual treatment and rehabilitation plan was completed on November 22, 2010. The individual treatment plan documented the client would receive individual counseling sessions, but did not include the frequency of the individual counseling sessions.
Client # 2 was admitted to the outpatient program on January 27, 2011. The individual treatment and rehabilitation plan was completed on April 27, 2011. The individual treatment plan documented the client would receive individual counseling sessions, but did not include the frequency of the individual counseling sessions.
Client # 4 was admitted to the outpatient program on November 24, 2010. The individual treatment and rehabilitation plan was completed on December 9, 2010. The individual treatment plan documented the client would receive individual counseling sessions, but did not include the frequency of the individual counseling sessions.
An interview with the facility director on July 7, 2011 confirmed the treatment plans did not document the frequency of the individual counseling sessions.
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Plan of Correction
Under the direction of the Program Director or her designee, all treatment plans will include type and frequency of treatment services. Supervisors will re-educate all staff on completing the type and frequency portion of the treatment plan at a staff meeting to be held by 8/31/2011. Program supervisiors will review treatment plans weekly to ensure that type and frequency of interventions is documented on the plan. Supervisors will meet with Program Director monthly to ensure that all plans include type and frequency of treatment services. |
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document the the project assured that the counseling services were provided according to the individual treatment and rehabilitation plan in four of seven client records.
The findings include:
Nineteen client records were reviewed on July 5-7, 2011. Ten client records were reviewed as outpatient client records. Seven outpatient client records required documentation that counseling services were provided according to the individual treatment and rehabilitation plan. The facility did not document that services were provided according to the individual treatment and rehabilitation plan in client records # 2, 3, 4 and 5.
Client # 2 was admitted on January 27, 2011. The treatment plan, completed on April 27, 2011, stated that the client was to receive 1 group counseling session per week. The client was also to receive individual counseling sessions, however, the frequency was not noted. The client had no documented group or individual counseling sessions scheduled for the weeks of March 21, March 28 and April 4, and May 26, June 6 and June 13, 2011.
Client # 3 was admitted on January 5, 2011. The treatment plan, completed on January 28, 2011, stated that the client was to receive 1 individual counseling session per week. The client had no documented individual counseling sessions scheduled for the weeks of January 31, February 7, March 21, April 4, May 16, May 23 and June 6, 2011.
Client # 4 was admitted on November 24, 2010. The treatment plan, completed on December 9, 2010, stated that the client was to receive individual counseling sessions. However, the frequency was not noted. The client had no documented individual counseling sessions scheduled for the weeks of June 13, June 20 and June 27, 2011.
Client # 5 was admitted on March 3, 2011. The treatment plan, completed on March 28, 2011, stated that the client was to receive 1 individual counseling session per week. The client had no documented individual counseling sessions scheduled for the weeks of April 11, April 25, May 9, May 23, May 30, June 13 and June 27, 2011.
An interview with the facility director on July 7, 2011 confirmed that the clients were not receiving counseling services as according to the individual treatment and rehabilitation plan.
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Plan of Correction
Under the direction of the Program Director or her designee, counseling sessions will be scheduled according to the treatment plan. Beginning 8/1/2011, Program Supervisors will review appointments in the electronic medical record to ensure that they are scheduled according to the treatment plan. Supervisors will report to the Program Director monthly to ensure that this goal is met. |
711.92(f) LICENSURE Couns. Prov.- Reg & Sched.
711.92. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to provide counseling on a regular and scheduled basis in four of thirteen client records.
The findings include:
Thirteen complete client records were reviewed on July 6-7, 2011. Counseling which is provided on a regular and scheduled basis was required in all thirteen client records. Client records # 1, 2, 3 and 4 did not have documentation that clients were provided counseling on a regular and scheduled basis.
Client #1 was admitted to treatment on November 18, 2010. The client did not attend treatment or sessions were cancelled for the following dates: 12/7/10, 1/21/11, 2/7/11, 3/4/11, 5/16/11, 5/20/11, 5/26/11, 6/14/11, 6/16/11, 6/23/11 and 6/24/11. There was no documentation in this client record showing that these appointments were rescheduled.
Client #2 was admitted to treatment on January 27, 2011. The client did not attend treatment or sessions were cancelled for the following dates: 2/2/11, 2/16/11, 3/18/11, 4/28/11, 5/12/11, 5/31/11 and 6/21/11. There was no documentation in this client record showing that these appointments were rescheduled.
Client #3 was admitted to treatment on January 5, 2011. The client did not attend treatment or sessions were cancelled for the following dates: 1/11/11, 1/21/11, 3/11/11, 3/14/11, 4/12/11, 4/19/11, 4/25/11, 5/6/11, 6/1/11, 6/14/11 and 6/20/11. There was no documentation in this client record showing that these appointments were rescheduled.
Client #4 was admitted to treatment on November 24, 2010. The client did not attend treatment or sessions were cancelled for the following dates: 1/10/11, 1/19/11, and 4/15/11. In addition, a progress note dated June 7, 2011 indicated that this client's therapist was terminating employment with the facility and this client would be reassigned a new therapist for individual sessions. As of July 7, 2011, no contact has been made with this client and no individual sessions have been scheduled with this client.
An interview with the facility director took place on July 7, 2011. Additional documentation was provided to show that contact was made/attempted in a few instances with these clients; however, it was confirmed that no additional therapy sessions were scheduled in addition to those reflected on the record of service.
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Plan of Correction
Under the direction of the Program Director or her design, counseling will be provided on a regular and scheduled basis. Beginning August 2011, for consumers who fail to keep a scheduled appointment, documentation of follow-up calls will be made in the electronic medical record verifying rescheduling of consumers and/or attempts to reach consumers to schedule. In weekly staff supervision,commencing August 2011 Program Supervisors will review the electronic medical record to ensure compliance. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document follow-up information in two of three client records.
The findings include:
Nineteen client records were reviewed on July 5-7, 2011. Ten client records were reviewed as outpatient records. Three of the ten client outpatient records were reviewed as closed records. Three of the three closed client outpatient records required follow-up information. Per agency policy, follow-up is to be completed within 7 days of discharge. The facility did not document follow-up information per agency policy, in client records #18 and 19.
Client # 18 was admitted to the outpatient program on November 26, 2010 and discharged on May 18, 2011. Follow-up was to be completed by May 25, 2011. There was no documentation that follow-up had been completed.
Client # 19 was admitted to the outpatient program on November 30, 2010 and discharged on June 17, 2011. Follow-up was to be completed by June 24, 2011. There was no documentation that follow-up had been completed.
An interview with the facility director on June 7, 2011 confirmed that the follow-ups were not documented
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Plan of Correction
Under the direction of the Program Director or her designee, commencing August 2011, follow up phone calls on all discharged outpatients will be completed within 7 days of discharge and documented in the electronic medical record. In weekly staff supervision, Program Supervisors will monitor compliance. |