INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 14-15, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Consortium 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 19, 2010.
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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 the review of personnel records and an interview with the Human Resources Director, the facility failed to document a minimum of 4 hours of TB/STD training in two of ten personnel records.
The findings include:
Ten personnel records were reviewed on October 8, 2010 for documentation of 4 hours of TB/STD training. The facility did not document 4 hours of TB/STD training in personnel records # 10 and 11.
Personnel #10 and 11 were identified as counselors and required documentation of 4 hours of TB/STD training within the first year of employment.
Personnel #10 was hired in August 2008, but TB/STD training was not documented at the time of inspection.
Personnel #11 was hired in March 2009, but TB/STD training was not documented at the time of inspection.
An interview with the Human Resources Director on October 8, 2010, confirmed that personnel records #10 and 11 did not contain documentation of 4 hours of TB/STD training.
This is a repeat citation. The facility was cited on 11/18/09 and 6/29/10, for failing to document 4 hours of TB/STD training.
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Plan of Correction
0067
704.11 (c)(1)
Responsible Party(s): The Clinical Supervisors are responsible for ensuring that all clinical counseling staff receive TB/STD training within the first year of employment with the agency. The employees identified as not being in compliance, will be registered for the next available TB/STD training.
Timeframe for completion:
TB/STD Training will be completed by clinical counseling staff who has been employed with the agency for more than one year, by January 30, 2010
Monitoring: Supervisors will review employee annual training plans with their respective staff once per month, to ensure that all staff receive TB/STD training within one year of employment with the agency.
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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 the review of personnel records and an interview with the Human Resources Director, the facility failed to document at least 25 clock hours of training annually in three of six personnel records.
The findings include:
Six personnel records identified as counselors during the 2009-2010 training year were reviewed on October 8, 2010 for documentation of 25 clock hours of training. The facility did not document 25 hours of training during the 2009-2010 training year in personnel records # 5, 6 and 11.
Personnel record #5 only had 16 hours of documented training for the 2009-2010 training year.
Personnel record #6 only had 17.5 hours of documented training for the 2009-2010 training year.
Personnel record #11 only had 11 hours of documented training for the 2009-2010 training year.
An interview with the Human Resources Director on October 8, 2010, confirmed that personnel records # 5, 6 and 11 did not contain at least 25 hours of training for the 2009-2010 training year.
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Plan of Correction
0083
704.11(f)(2) Training Hours Req. Counselor
Responsible Party(s): Each counselor will be responsible for completing at least 25 clock hours of training annually. Clinical Supervisors in conjunction with the Human Resources Department will monitor the completion of training hours through submission of certificates of completion.
Time Frame: Documentation of 25 hours of approved annual training will be submitted to the Facility Director and filed in the employee's Human Resource personnel file
Monitoring:The Program Director and/or Clinical Supervisor will monitor the completion of staff annual training hours and ensure submission of certificates of completion to the HR department.
The Clinical Supervisor will review status of annual required training hours during bi-monthly supervision
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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on a tour of the physical plant and an interview with the project director, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A tour of the facility was conducted on October 15, 2010. During the tour, at approximately 1:20 P.M., the outside dumpster was found to not be covered and it did not have a cover.
An interview with the project director conducted on October 15, 2010 confirmed that the dumpster was not covered and did not have a cover.
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Plan of Correction
P183
705.22 (4) LICENSURE
Building exterior and grounds.
Responsible Party(s):
The Facilities Director will be responsible for ensuring that the physical plant has all trash, garbage, and rubbish in non combustible, covered containers that prevent the penetration of insects and rodents.
Timeframe:
The trash container on the grounds of the physical plant was covered with a proper lid as of October 25, 2010.
Monitoring:
The Facility Director along with the Facilities Director will monitor the trash container to ensure that the trash can is covered with a lid at all times. In the event that the lid is removed, the contractor will be contacted immediately to ensure a replacement.
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a tour of the physical plant and an interview with the facility director, the facility failed to ventilate bathrooms by exhaust fan or window.
The findings include:
A tour of the facility was conducted on October 15, 2010. During the tour, at approximately 1:15 P.M., one of the women ' s bathrooms on the first floor and one of the men ' s bathrooms on the first floor were not ventilated by exhaust fan or window. The bathrooms had vents present at the time of the inspection. However, the vents did not provide ventilation.
An interview with the facility director conducted on October 15, 2010 confirmed that the bathrooms were not ventilated.
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Plan of Correction
P201
705.24 (5) LICENSURE
Bathrooms
Responsible Party(s):
The Facilities Director will be responsible for ensuring that working exhaust fans are installed to ensure adequate ventilation of the male and female bathrooms on the first floor.
Time Frame:
Working exhaust fans will be installed to properly ventilate the male and female bathrooms on the first floor by 12/31/10.
Monitoring:
The Facilities Director and the Maintenance Staff will monitor the exhaust fans for proper working conditions to ventilate the male and female bathrooms.
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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 the review of personnel records, the facility failed to document that fire extinguisher training was provided upon employment in two of fifteen personnel records reviewed.
The findings include:
Fifteen personnel records were reviewed on October 8, 2010 for documentation of fire extinguisher training provided upon employment. The facility did not document that fire extinguisher training was provided upon employment in personnel record # 9 and 12.
Personnel #9 was hired on 4/5/10, but verification of this training was not documented at the time of review on 10/8/10.
Personnel #12 was hired on 5/24/10, but verification of this training was documented on 6/15/10.
An interview with the Human Resources Director on October 8, 2010, confirmed that personnel records # 9 and 12 did not contain documentation of fire extinguisher training provided upon employment.
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Plan of Correction
P271
705.28 (c) (4) LICENSURE
Fire safety
Responsible Party(s):
The Clinical Supervisors in collaboration with the Facilities Department is responsible for ensuring that all staff receives training in the use of fire extinguishers upon employment.
Timeframe:
All newly employed staff who has not received the fire extinguisher training will be provided with the training by 11/30/10.
Monitoring:
The Clinical Supervisors will ensure that all new staff that is hired for the program receives the fire extinguisher training during the first week of onsite orientation training. Acknowledgment of receipt of the training will be filed in the personnel record.
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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 the review of personnel records, the facility failed to provide documentation verifying that all personnel on all shifts are trained to perform assigned tasks during emergencies in two of fifteen personnel records reviewed.
The findings include:
Fifteen personnel records were reviewed on October 8, 2010 for documentation of emergency training provided upon employment. The facility did not document that emergency training was provided upon employment in personnel record # 9 and 12.
Personnel #9 was hired on 4/5/10, but verification of this training was not documented at the time of review on 10/8/10.
Personnel #12 was hired on 5/24/10, but verification of this training was documented on 6/15/10.
An interview with the Human Resources Director on October 8, 2010, confirmed that personnel records # 9 and 12 did not contain documentation of emergency training provided upon employment.
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Plan of Correction
P277
705.28 (d) (3) LICENSURE
Fire safety
Responsible Party: The Facilities Department is responsible for ensuring that all personnel on all shifts, including all new hires, are trained to perform assigned tasks during emergencies.
Timeframe:
All staff that has not been trained to perform assigned tasks during emergency situations will be trained by the Facilities Department by 12/15/10.
Monitoring:
All new staff will receive emergency training as part of the on site orientation process, which is delivered by the Clinical Supervisor within the first week of employment with the agency. The Facilities Department will be responsible for delivering the required training.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of administrative documentation and an interview with the Division Director, the facility failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility ' s administrative records were reviewed on October 5, 2010. The facility was required to document a financial audit following the end of their fiscal year. The facility ' s 2008-2009 fiscal year ended on June 30, 2009, but the financial audit for this period was dated August 27, 2010.
An interview with the Division Director on October 5, 2010, confirmed that the financial audit had not been documented following the end of the fiscal year.
This is a repeat citation. The facility was cited on 11/25/09 for failing to document an annual financial audit.
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Plan of Correction
0169
709.25(a) LICENSURE
Fiscal Management
Responsible:
The Chief Financial Officer (CFO) will be responsible to facilitate the financial statement audit process. An independent certified public accounting firm will be engaged by the organization's Board of Directors finance committee to complete the financial statement audit for the fiscal year end of June 30. In addition, the CFO will request for a waiver of the industry standard to the Department of Health for the components of the audited financial statements related the organization's drug and alcohol programs.
Time Frame:
The request for waiver will be submitted to the Department of Health by November 30, 2010.
Monitoring:
The CFO will coordinate and monitor the process of obtaining the services of an independent certified public accounting firm to perform the financial statement audit for each fiscal year end.
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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 the review of personnel records and an interview with the Human Resources Director, the facility failed to document a performance evaluation at least annually in six of nine personnel records.
The findings include:
Nine personnel records were reviewed on October 8, 2010 for annual performance evaluations. The facility did not document an annual performance evaluation in personnel record #3, 5, 6, 7, 10 and 11.
Personnel #3 was hired on 9/4/01, but the last documented performance evaluation was dated 10/29/08.
Personnel #5 was hired on 7/30/07, but the last documented performance evaluation was dated 2/6/09.
Personnel #6 was hired on 10/1/04, but the last documented performance evaluation was dated 10/20/08.
Personnel #7 was hired on 3/12/01, but the last documented performance evaluation was dated 10/14/08.
Personnel #10 was hired on 8/11/08, but the last documented performance evaluation was dated 2/13/09.
Personnel #11 was hired on 3/30/09, but the last documented performance evaluation was dated 6/30/09.
An interview with the Human Resources Director on October 8, 2010, confirmed that an annual performance evaluation had not been documented for personnel # 3, 5, 6, 7, 10 and 11.
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Plan of Correction
0227
709.26(d)(5)(i) LICENSURE
Personnel Management
Responsible:
The Clinical and Support Staff Supervisors are responsible for ensuring that each supervisee receives a work performance evaluation including individual staff performance on an annual basis.
Timeframe:
All staff who did not receive an annual work performance evaluation will have one completed by 12/15/10.
Monitoring:
All Management staff will ensure that each of their staff have an annual work performance evaluation completed at least once during the fiscal year. All work performance evaluations will be forwarded to the HR department for filing in the personnel record.
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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 tour of the facility ' s physical plant an interview with the facility director, the facility failed to maintain the confidentiality of the clients ' identity.
The findings include:
A tour of the facility ' s physical plant and an interview with the facility director was conducted on October 15, 2010 at approximately 1:00 PM. The licensing specialist observed a client sign-in book, in the reception area, with the first and last names of clients presently or previously at the facility. The facility director confirmed the practice of having all clients sign the sign-in book upon arrival.
This is a repeat citation. The facility was cited on 6/29/10 for failing to maintain the confidentiality of the clients ' identity.
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Plan of Correction
0271
709.28(a)(1) LICENSURE
Confidentiality:
Responsible:
The Facility Director will be responsible for developing a written procedure 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.
Timeframe:
A sign in log will be developed that only identifies the first initial and last name of persons served.
The log will be developed and implemented by 11/15/10.
Monitoring:
The Facility Security Staff, Program Supervisors and Program Director will monitor the log in book daily to ensure the confidentiality of the members enrolled in the program.
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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 and a review of the facility ' s policy manual, the facility failed to document a psychosocial evaluation in eleven of eleven client records.
The findings include:
Eleven client records were reviewed on October 14-15, 2010 for psychosocial evaluations. The facility did not document a psychosocial evaluation, as per facility policy, in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 11 and 12.
The facility ' s policy titled " 715.9- INTAKE, 709.24- TREATMENT/REHABILITATION MANAGEMENT, 709.91- INTAKE " states:
" Within 30 days following admission the Counselor/Primary Clinician completes the Psychosocial History with the client. The Counselor then completes the Psychosocial Evaluation, developing a list of problems to be reported in the Comprehensive Treatment Plan. "
PROCEDURE DESCRIPTION: The procedure outlines what is needed for the completion of the Biopsychosocial Assessment.
1)The Biopsychosocial Assessment will be completed during the intake Process
2)The completed assessment will identify all presenting problems.
3)Both past and present information will be used in the assessment, including physical, psychiatric emotional, educational, maturational, spiritual, nutritional, vocational, legal, sexual and social elements of the consumer ' s life.
4) A comprehensive medical history that includes current and past medications, any medical treatments being received, current medical conditions, and food drug and environmental allergies will be included in the assessment.
5)The assessment will include a comprehensive substance abuse history.
6)The assessment will include information that indicates the consumer ' s strengths, weaknesses and barriers to treatment.
The facility did not document a psychosocial evaluation to include the client ' s assets/strengths that can contribute to the resolution of identified problems in client records # 1, 2, 3, 4, 6, 9, 11 and 12.
The facility did not document a psychosocial evaluation to include the client ' s preferred coping mechanisms in client records # 1, 2, 3, 4, 6, 7, 9, 11 and 12.
The facility did not document a psychosocial evaluation to include the client ' s negative factors that might affect treatment in client records # 1, 2, 3, 4, 6, 8, 9, 11 and 12.
Additionally, client #5 was admitted to the program on 6/10/10, but a psychosocial evaluation was not documented at the time of review on 10/15/10.
An interview with the facility director on October 15, 2010 confirmed that client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 11 and 12 did not have a psychosocial evaluation documented in accordance with facility policy.
This is a repeat citation. The facility was cited on 6/29/10, 11/18/09 and 11/7/08, for failing to document psychosocial evaluations.
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Plan of Correction
1871
709.91(b)(6) LICENSURE
Intake and admission
Responsible:
The Intake worker is responsible for ensuring that patient records include a comprehensive psychosocial history and evaluation within 30 days of treatment that satisfies all components identified in the agency's policy.
Timeframe:
The Intake Worker will receive additional training focusing on the components of the psychosocial, mainly focusing on the deficient areas of: assets/strengths
preferred coping mechanisms, and
the client ' s negative factors that might affect treatment. Training will be completed by 11/30/10.
Monitoring: The Intake Supervisor will review the psychosocial for all new admissions during bi-weekly supervision, ensuring that they are completed within the first 30 days of the client's treatment and that they include all required components.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records and a review of the facility ' s policy manual, the facility failed to document a case consultation in four of eleven client records.
The findings include:
Eleven client records were reviewed on October 14-15, 2010 for case consultations. The facility did not document a case consultation, as per facility policy, in client records # 4, 5, 6 and 7.
The facility ' s policy titled " Ongoing Treatment Management " states:
" Case conferences will be conducted at least every ninety days during the first year of treatment, and at least annually thereafter. "
Client #4 was admitted on 4/21/10. A case consultation was due by 7/21/10, but a case consultation was not documented at the time of review on 10/15/10.
Client #5 was admitted on 6/10/10. A case consultation was due by 9/9/10, but a case consultation was not documented at the time of review on 10/15/10.
Client #6 was admitted on 5/26/10. A case consultation was due by 8/25/10, but a case consultation was not documented at the time of review on 10/15/10.
Client #7 was admitted on 7/2/10. A case consultation was due by 10/1/10, but a case consultation was not documented at the time of review on 10/15/10.
An interview with the facility director on October 15, 2010 confirmed that client records # 4, 5, 6 and 7 did not have case consultations documented in accordance with facility policy.
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Plan of Correction
1905
709.93(a)(8)
LICENSURE
Client records
Responsible: The Clinical Counseling Staff are responsible for ensuring that patient records include a Case conference to be completed at least every ninety days during the first year of treatment, and at least annually thereafter.
Timeframe: All clinical counseling staff was re-trained on the timelines for completion of client case consultations on October 19, 2010.
Monitoring: Clinical Supervisors will monitor the status of case consultation completion within the required timeframes during bi-weekly supervision.
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