INITIAL COMMENTS
|
This report is a result of an onsite follow-up inspection regarding the plans of correction for the October 15, 2010 licensure renewal inspection. The follow-up inspection was conducted on August 29, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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:
|
Plan of Correction
|
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.
|
Observations
Based on review of personnel records, the facility failed to ensure that each counselor completed 25 clock hours of required training in two of two personnel records reviewed.
The findings include:
On August 29, 2011, two personnel records of counselors were reviewed for documentation of the required 25 hours of training. The facility failed to document 25 clock hours of training in two of two records reviewed, specifically, records # 5 and 6.
Employee # 5, a counselor, was hired on July 30, 2007. The facility's training year is from July 1 through June 30. The training year for July 1, 2010 to June 30, 2011 was reviewed. Personnel record # 5 only had documentation of 7.5 clock hours of training for the July 1, 2010 to June 30, 2011 training year.
Employee # 6, a counselor, was hired on October 1, 2004. The facility's training year is from July through June. The training year for July 1, 2010 to June 30, 2011 was reviewed. Personnel record # 6 only had documentation of 7 clock hours of training for the July 1, 2010 to June 30, 2011 training year.
The facility director confirmed the findings during an interview conducted on August 29, 2011 at approximately 12:00 P.M.
This is a repeat citation. The facility was cited on October 15, 2010; November 18, 2009; November 7, 2008 for noncompliance with this standard.
|
Plan of Correction
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 Resource 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.
|
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.
|
Observations
Based on observation upon arriving at the facility on August 29, 2011, 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:
Upon arriving at the facility, it was observed at approximately 8:41 A.M. that the facility had a dumpster located in the facility's parking lot. The dumpster was only partially covered with lids.
An interview with the security supervisor conducted on August 29, 2011 at approximately 10:00 A.M. confirmed that the dumpster was partially covered with lids.
This is a repeat citation. The facility was cited on October 15, 2010 for failing to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
|
Plan of Correction
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 dumpster on the grounds of the physical plant was covered with proper lids as of August 29, 2011 @ 11 AM, by the Security Supervisor.
Monitoring:
The Facility Director along with the Facilities Director will monitor the dumpster to ensure that the dumpster is fully covered with proper lids at all times. In the event that the lids are removed, the contractor will be contacted immediately to ensure a replacement of the lids.
|
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.
|
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.
The Licensing Specialist was unable to determine if the facility had corrected the deficient practice at the time of the follow-up conducted on August 29, 2011. Employee #9 was no longer employed by the facility and had not completed the training prior to the departure from employment, and although the facility hired newer staff, the hire dates and dates of training were not provided to the Licensing Specialist.
|
Plan of Correction
Responsible: The Training and Licensing Director in conjunction with the Human Resource Director will be responsible to ensure new hires are instructed in the use of the fire extinguisher training upon staff employment.
In addition, they will be responsible for ensuring that documentation of the training is filed in the corresponding personnel records.
The fire extinguisher training will be provided by the Training and Licensing Director. New hires will sign?off on having participated in the fire extinguisher training and the sign-off sheet will be filed in their personnel record.
The Clinical Supervisor is responsible to meet with new hires and complete the On-Site Orientation Competency Checklist and Facility Orientation Checklist within two (2) weeks of the employee's hire date and complete Section C Facility Procedures: which includes site-specific emergency procedures, fire drill and smoking procedures, fire extinguisher, and fire system operation, emergency contact information, physical plant, appliances, security/keys, etc. within (7) days of hire.
Time Frame: As of 10/15/2011 staff # 9 and 12 and all other existing employees will have documentation of fire extinguisher training in their personnel records.
Monitoring: The Human Resource Director will monitor personnel records for the documentation of instruction in the use of the fire extinguisher and filing of the sign-off sheet for receiving fire extinguisher training along with employee on-site orientation competency checklist.
|
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.
|
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.
The Licensing Specialist was unable to determine if the facility had corrected the deficient practice at the time of the follow-up conducted on August 29, 2011. Employee #9 was no longer employed by the facility and had not completed the training prior to the departure from employment, and although the facility hired newer staff, the hire dates and dates of training were not provided to the Licensing Specialist.
|
Plan of Correction
Responsible: The Training and Licensing Director in conjunction with Human Resource Director will be responsible to ensure staff on all shifts is trained to perform assigned tasks during emergencies. The Training and Licensing Director will provide Disaster training to all new hires to be completed within 7 days of hire.
Time Frame: As of 9/16/11 employees
# 9 and 12 and all other existing employees have recieved and have verification of emergency training filed in the their individual personnel record.
Continuing after 9/16/11, all new hires will receive Disaster Training to be completed within 7 days of hire to ensure staff is trained to perform assigned tasks during emergencies.
Monitoring: The Human Resource Director will monitor personnel records of new hires for the documentation of staff on all shifts are trained to perform assigned tasks during emergencies. |
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.
|
Observations
Based on review of administrative materials and an interview with the division director, the facility failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of the fiscal year.
The findings include:
The administrative material was reviewed on August 29, 2011. The facility was required to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of their fiscal year. The facility's 2009 through 2010 fiscal year ended on June 30, 2010. However, the facility's financial audit for this period was not completed until March 25, 2011.
During an interview with the division director conducted on August 29, 2011 at approximately 11:00 A.M., it was confirmed that the facility's financial audit for the facility's 2009 through 2010 fiscal year was not completed until March 25, 2011.
This is a repeat citation. The facility was cited on October 15, 2010; June 29, 2010; November 18, 2009 for noncompliance with this standard.
|
Plan of Correction
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.
Time Frame: The CFO will ensure completion of the annual audit by independent public accountants by Sept. 1st of each year, following the close of the annual fiscal year, June 30th.
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.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanisms, and/or client's attitude toward treatment, and in accordance with the facility's policy and procedure with regard to timeframes.
The findings include:
The facility's policy titled: "Treatment/Rehabilitation Management" states:
"The Counselor/Primary Clinician completes the Psychosocial History and Psychosocial Evaluation within thirty (30) days following admission."
On August 29, 2011, eighteen client records were reviewed for documentation of a psychosocial evaluation.
The facility failed to document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanisms, and/or client's attitude toward treatment in nine of eighteen records reviewed, specifically client records # 1, 2, 3, 5, 6, 7, 8, 12, and 14.
The facility did not document a psychosocial evaluation within 30 days of admission as per their policy and procedures in six of eighteen records reviewed, specifically, client records
#7, 9, 11, 15, 16, and 17.
Client # 1 was admitted July 22, 2011. The psychosocial evaluation was completed August 22, 2011, but it did not include an evaluation of the client's assets/strengths, support systems, and coping mechanisms.
Client # 2 was admitted July 22, 2011. The psychosocial evaluation was completed August 22, 2011, but it did not include an evaluation of the client's assets/strengths, coping mechanisms, and client ' s attitude toward treatment.
Client # 3 was admitted April 11, 2011. The psychosocial evaluation was completed May 3, 2011, but it did not include an evaluation of the client's assets/strengths, support systems, and client ' s attitude toward treatment.
Client # 5 was admitted March 8, 2011. The psychosocial evaluation was completed March 21, 2011, but it did not include an evaluation of the client's assets/strengths, support systems, and coping mechanisms.
Client # 6 was admitted July 1, 2011. The psychosocial evaluation was completed July 28, 2011, but it did not include an evaluation of the client's support systems, coping mechanisms, and client's attitude toward treatment.
Client # 7 was admitted January 26, 2011; however, the psychosocial evaluation was not completed until April 6 2011. Also, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, coping mechanisms, and client's attitude toward treatment.
Client # 8 was admitted July 11, 2011. The psychosocial evaluation was completed August 3, 2011, but did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
Client # 9 was admitted January 19, 2011; however, client record # 9 did not include documentation of a psychosocial evaluation as of August 29, 2011.
Client # 11 was admitted February 7, 2011; however, client record # 11 did not include documentation of a psychosocial evaluation as of August 29, 2011.
Client # 15 was admitted May 23, 2011; however, client record # 15 did not include documentation of a psychosocial evaluation as of August 29, 2011.
Client # 16 was admitted June 17, 2011; however, client record # 16 did not include documentation of a psychosocial evaluation as of August 29, 2011.
Client # 17 was admitted January 14, 2011; however, client record # 17 did not include documentation of a psychosocial evaluation as of August 29, 2011.
During an ongoing dialogue with the facility director conducted on August 29, 2011 from approximately 12:10 P.M. to 12:25 P.M., the findings were confirmed.
This is a repeat citation. The facility was cited on October 15, 2010; June 29, 2010; November 18, 2009; November 7, 2008; and February 9, 2006 for noncompliance with this standard.
|
Plan of Correction
Responsible:
The Clinical Counseling staff 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 Clinical Counseling Staff will receive additional training focusing on the components of the psychosocial, mainly focusing on the deficient areas of: assets/strengths,
support systems, coping mechanisms, and the client's attitude towards treatment Training will be completed by 10/14/11.
Psychosocial evaluations contained in records # 1, 2, 3, 5, 6, 7, 8, 12, and 14 will be updated to ensure that the clinician addresses their evaluation of all elements to include: client's assets/strengths, support systems, coping mechanisms, and/or client's attitude toward treatment by 10/21/11.
Records # 9, 11, 15, 16, and 17 will contain a psychosocial evaluation that meets all requiremed elements by 10/14/11.
Monitoring: Clinical Supervisors will provide bi-weekly supervision notating review of Bio Psycho Social completion within the required 30 day time frame, as well as ensuring all required components of the bio psycho social are present and are evaluative.
|
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.
|
Observations
Based on a review of client records, the facility failed to document case consultations in accordance with the facility's policy and procedures.
The findings include:
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".
On August 29, 2011, twelve records were reviewed for documentation of case consultations. The facility did not document case consultations in accordance with the facility's policy and procedures in eleven of eighteen client records reviewed, specifically, records # 3, 4, 5, 7, 10, 11, 13, 14, 15, 17 and 18.
Client # 3 was admitted April 11, 2011, a case consultation was due to be completed no later than July 10, 2011. Client record # 3 did not include documentation of a case consultation as of August 29, 2011.
Client # 4 was admitted April 20, 2011, a case consultation was due to be completed no later than July 19, 2011. Client record # 4 did not include documentation of a case consultation as of August 29, 2011.
Client # 5 was admitted March 8, 2011, a case consultation was due to be completed no later than June 6, 2011. Client record # 5 did not include documentation of a case consultation as of August 29, 2011.
Client # 7 was admitted January 26, 2011. The initial case consultation was completed April 26, 2011; however, a second case consultation was due no later than July 25, 2011, client record # 7 did not include documentation of a second case consultation as of August 29, 2011.
Client # 10 was admitted January 14, 2011. The initial case consultation was completed April 7, 2011; however, a second case consultation was due no later than July 4, 2011, client record # 10 did not include documentation of a second case consultation as of August 29, 2011.
Client # 11 was admitted February 7, 2011, a case consultation was due to be completed no later than May 8, 2011 and a second case consultation would have been due no later than August 6, 2011. Client record # 11 did not include documentation of a case consultation as of August 29, 2011.
Client # 13 was admitted January 25, 2011, a case consultation was due to be completed no later than April 25, 2011 and a second case consultation would have been due no later than July 24, 2011. Client record # 13 did not include documentation of a case consultation as of August 29, 2011.
Client # 14 was admitted January 18, 2011. The initial case consultation was completed April 18, 2011. A second case consultation would have been due no later than July 17, 2011. Client record # 14 did not include documentation of a second case consultation as of August 29, 2011.
Client # 15 was admitted May 23, 2011, a case consultation was due to be completed no later than August 21, 2011. Client record # 15 did not include documentation of a case consultation as of August 29, 2011.
Client # 17 was admitted January 14, 2011, a case consultation was due to be completed no later than April 14, 2011 and a second case consultation would have been due no later than July 13, 2011. Client record # 17 did not include documentation of a case consultation as of August 29, 2011.
Client # 18 was admitted March 11, 2011, a case consultation was due no later than June 9, 2011. The case consultation in client record # 18 was not completed until July 29, 2011.
During an ongoing dialogue with the facility director conducted on August 29, 2011 from approximately 12:10 P.M. to 12:25 P.M., the Facility Director confirmed the findings.
This is a repeat citation. The facility was cited on October 15, 2010 for noncompliance with this standard.
|
Plan of Correction
Responsible Party(s):
The Clinical Counseling Staff and the Clinical Supervisors are responsible for ensuring that the patient record includes Case Consultation notes regarding each patient.
Medical Records staff is responsible for ensuring that Case Consultation Notes are filed into the patient record once received from the Clinical Staff.
Timeframe:
The Clinical Counseling staff and Clinical Supervisors will receive training regarding the importance of completing case consultation notes at least once per quarter during the patient's first year of treatment and annually thereafter, by October 14, 2011.
Records # 3, 4, 5, 7, 10, 11, 13, 14, 15, 17 and 18 will be reviewed by managment staff by 10/7/11. All missing case consults will have an updated consult completed by 10/14/11.
The Medical Records staff will be trained regarding the importance of filing Case Consultation Notes into the patient record in a timely manner by October 28, 2011.
Monitoring:
The Clinical Supervisors will responsible for providing bi-weekly to monthly supervision to Clinical Staff ensuring that Case Consultation Notes are completed as required.
The Facility Director will provide weekly to bi-weekly supervision with the Medical Records staff to ensure that current case Consultation Notes are filed in the patient record as required.
The Clinical Supervisors and the Facility Director will review patient records bi-weekly to monthly to ensure continued compliance with this standard.
|