INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 16-21, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights 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 September 14, 2007.
|
Plan of Correction
|
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.
|
Observations
Based on a review of administrative documentation it was determined that the facility failed to provide a sufficient number of staff persons for the period from the end of June, 2007 to August 17, 2007, so that at least one person trained in CPR certification and first aid training is onsite during the project's hours of operation.
|
Plan of Correction
Even thought the CPR instruction occurred on August 18th, 2007, there was a two-month lapse in this annual training requirement. In order to assure compliance for next year, in May 2007 the Executive Director will contact the American Red Cross to reschedule this CPR refresher course by June 30th, 2008. Therefore this four-hour instruction will occur within (1) year of the previous training date of August 2007. |
704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
|
Observations
Based on documentation filed in employee training files, it was determined that the facility did not comply with this regulation since less than half of the training provided was conducted by outside trainers.
|
Plan of Correction
The monitoring of staff training hours for Clinical Staff will be converted to an automated system. Upon staff submitting evidence of trainings obtained, that information will be data entered on an ongoing basis. The training evidence, certification (and/or) training report form, will be inserted in the Annual Training report binder. The policy will be revised that will require the Executive Director to review a monitoring report indicating the status of staff training hours on a quarterly basis. At these quarterly reviews, Clinical Staff members will be made aware of their total training hour requirement; and to assure that at least half of these training hours are obtained externally. This task will be the joint responsibility of the Executive Director, Billing Supervisor, and full-time Support Staff person (Lemoyne). The programming of this new automated system will be the task of the Billing Suprevisor, and will be in place by December 31st, 2007. The Executive Director and Support Staff person will be responsible for maintaining and monitoring these reports of trainings. The Executive Director will revise the policy that will clearly describe this new procedure. |
704.11(d)(1) LICENSURE Training Req-Proj/Fac Directors
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
|
Observations
Based on documentation reviewed in agency training files it was determined that this employee (#1) did not have the minimum number of training hours for the last training year. Only 9 hours of appropriately documented training was found in the training file.
|
Plan of Correction
The Executive Director has been registered for a six (6) hour external training on September 17th, 2007. The training is titled Mastering Macromedia Dreamweaver and will provide information on utilizing the Dreamweaver software to improve the design and capability of our website. The completion of this training will satisfy the requirement for (12) total hours; as well as, 1/2 of those hours would be provided externally. This workshop will take place in Frederick, Maryland and will be presented by CompuMaster. |
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 documentation reviewed in agency training files it was determined that two employees (#7, 8) did not have the minimum number of training hours for the last training year. Less than 25 hours of appropriately documented training was found in the training file for employees # 7 ( 23.5) and 8 (23)..
|
Plan of Correction
All of the counselors achieved the required total of training hours, however, three staff members were deficient by 1,2 and 4 hours due to the fact that the Training Evaluation Report did not have a signature of the fellow staff member who provided the internal training or instruction, and therefore were rejected. In the future, upon counselors submitting the Training Evaluation report for any internal trainings, the full-time Support Staff person at the Lemoyne office will confirm that they are signed at the bottom by the staff member who provided the instruction in-house. If this feedback for is not signed at the bottom, the Support Staff person will forward it to the staff member who conducted the training and have them sign-off before inserting the report in the binder of annual trainings. During the quarterly review of status of staff trianing hours by the Executive Director, the full-time Support Staff person in Lemoyne will be responsible for reconciling the binder with the automated monitoring report and confirm that all Training Evaluation Reports have the appropriate signature. This aciton will be completed by December 31st, 2007. |
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 an inquiry by Division staff to the Project Director, it was determined that this regulation was not met because trash is picked up only bi-weekly. This regulation requires that trash be removed weekly.
|
Plan of Correction
Due to the fact that we cannot terminate our current contract with Waste Management untill November, 2008 and refuse to pay an additional $200.00 per month for a weekly pickup, we are having a second dumpster installed. We have contracted with another waste removal company (IWS Interstate) who will place a 2nd dumpster and service on a weekly basis. This company only charges $50.00 month to service monthly, so our cost is only an additional $50 a month, instead of a $200 additional cost. This task is being addressed by the Assistant Director and will be completed by November 1st, 2007. |
709.81(b)(5) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
|
Observations
Based on a review of client records it was determined that the facility failed to meet the requirements of its own policy regarding physical exams. The policy indicated that a physical examination needed to be obtained prior to admission if no physical exam had been completed within the past year. Physical examinations should have been documented in client records #1, 3, 9 and 10. No documentation was found in these records. The sample consisted of 4 records for this activity.
|
Plan of Correction
The Executive Director will revise the policy that requires a physical examination prior to being admitted to our program. The revised policy will provide guidelines for counseling staff to make a recommendation to see a physician, but not mandate as a condition for admission. This policy revision will take place by September 30th, 2007. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
|
Observations
Based on a review of client records it was determined that the facility failed to meet the requirement for treatment plan updates in 1 of 2 applicable client records. Client records should have had updates done every 30 days. The treatment plan update in client record # 9 was late.
|
Plan of Correction
The Clinical Supervisor will review with the clinical staff at the staff meeting on 10/3/07 the policies on time frames for individual treatment plan updates for clients in partial hospitalization, IOP and Outpatient counseling. One chart for each clinician will be randomly audited by the Clinical Supervisor every two weeks during clinical supervision to monitor for compliance with treatment plan time frames. |
709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on client record reviews it was determined that the facility staff failed to comply with 4 PA. Code subsection 255.5(b). The information identified for release on the consent to release information forms in client records # 2, 8 and 9 were not clear and specific as to what was being released and, hence, did not meet the conditions for an informed consent. Examples of phrases used included : " visitation and calls" and "emergency information". Client record # 1 exceeded the limitations imposed by this regulation by releasing more information than is permitted to the employer, [(see 4 Pa. Code Subsection 255.5(a)(6)] who is only permitted to receive information related to presence in treatment. In client record # 3 information was released to parents without the clients written consent. These errors were found in 5 of 10 records in the sample.
|
Plan of Correction
The Clinical Supervisor will review with the clinical staff at the staff meeting on 10/3/07 what specific information can be released by signed consent in accordance with Code subsection 255.5. In addition, those charts that were in violation with Code subsection 255.5 will be reviewed at the staff meeting and more specific and appropriate wording for the purpose of release of information will be reviewed and those charts that are active will be rectified. The clinical supervisor will randomly review one of each clinician's charts every two weeks during clinical supervision to monitor for compliance. A standardized consent specific for release of information to family members will be developed by the clinical supervisor by 9/28/07 and reviewed with the Executive Director. Clinical staff will be oriented to the consent to release information during the staff meeting on 10/3/07. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on a review of a sample of client records, the facility failed to meet the requirements for this regulation because histories lacked detail on family dynamics and interactions in client records # 1, 2, 3, 4, 5, 7, 9 and 10. Details were lacking on sexual histories in client records # 2 and 4. The facility failed to provide for complete educational information in client records # 2 and 9. These deficiencies were noted in 8 of 10 records reviewed.
|
Plan of Correction
The Clinical Supervisor will review at the staff meeting on 10/3/07 New Insights Bio-psycho-social profile with the clinical staff and what specific details are expected in each section. All the charts that were found to be in violation will be reviewed with the clinicians by the Clinical Supervisor as to why they were in violation and those that are still active will be rectified. The Clinical Supervisor will randomly audit one chart of each counselor every two weeks during clinical supervision to monitor for compliance. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
|
Observations
The facility failed to meet the requirements of its own policy regarding physical exams. The policy indicated that a physical exam needed to be obtained prior to admission if no physical examination was completed within the past year. Physical examinations should have been documented in client records #2, 4, 8, 9 and 10. No documentation was found in these records. The sample consisted of 8 records for this activity.
|
Plan of Correction
The Executive Director will revise the policy that requires a physical examination prior to being admitted to our program. The revised policy will provide guidelines for counseling staff to make a recommendation to see a physician, but not mandate as a condition for admission. This policy revision will take place by September 30th, 2007. |
709.93(b) LICENSURE Client records
709.93. Client records.
(b) The project shall develop and maintain client records on standardized project client record forms.
|
Observations
Based on a review of client records, it was determined that the facility failed to meet the requirement for treatment plan updates in 2 of 3 applicable client records. Client records # 2 and 9 should have had updates done every sixty days. The update in client record # 2 was missing and the update in client record # 9 was late.
|
Plan of Correction
The Clinical Supervisor will review with the clinical staff at the staff meeting on 10/3/07 the policies on time frames for individual treatment plan updates for clients in partial hospitalization, IOP and Outpatient counseling. One chart for each clinician will be randomly audited by the clinical supervisor every two weeks during clinical supervisor to monitor for compliance with treatment plan time frames. |
709.14(a) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
|
Observations
Based on a review of administrative documentation it was determined that the facility failed to meet the requirement for this regulation as noted on the staffing form completed by the Project Director. The form reflected a census of 92 in the outpatient activity. The maximum capacity authorized by the Division for this activity is 80 .
|
Plan of Correction
The Executive Director will formally notify the Division of Drug and Alcohol Program Licensing if the Lemoyne facility's Outpatient capacity has increased from 80 to 100. this will take place by September 14th, 2007. |