INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7, 2008 and August 8, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Turning Point II 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 5, 2008.
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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 review of 2 employee records on August 7, 2008, the facility failed to document HIV/AIDS or STD/TB training in one of two employee records.
Finding:
There was no documentation that employee #2 had obtained HIV/AIDS or STD/TB training.
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Plan of Correction
Employee # 2 was hired February 5, 2007, and failed to obtain the HIV/AIDS and STD/TB training by February 2008. The Project Director will schedule the mandated training for deficient employee and training will be completed by 10/31/08. |
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 review of 2 employee files on August 7, 2008, the facility failed to document training hours for two staff members.
Finding:
Employee #1 had less then 25 hours of training. Employee #2 had no hours of training documented in their training file.
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Plan of Correction
Seven and 1/2 (7.5) hours of training for Employee #1, scheduled for August 20 have been completed, thus expanding the cumulative overall training to 26 hours. The Project Director will ensure that future training years operate on a July-June cycle beginning July 2008 and that the prescribed total hours are completed.
The Project Director will ensure that required training is completed and corresponding documentation maintained for Employee #2 and all future employees by 6/30/2009.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on review of the fire drill logs, the facility failed to document that the fire alarm or smoke detector were used to initiate fire drills.
Finding:
There was no documentation to demonstrate that the facility set off the fire alarm or smoke detector to initiate the fire dill of July 17, 2008.
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Plan of Correction
To address compliance requirements, the Project Director has directed that an internal alert system be implemented for the Facility's Office Suite, #900, commencing in August 2008. This system will be "sounded" monthly to announce emergency drills, communicate evacuation routes, and designate a meeting space outside the structure. Documentation will be maintained by the Project Director.
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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 the physical plant inspection on August 7-8, 2008, the facility failed to secure confidential client information.
Finding:
The computer which contains client information is sitting in the waiting area and the screen, which could contain client identifying information, could be visible to people in the waiting room.
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Plan of Correction
At the direction of the Project Director, the computer in question has been placed, as of 8/12/08, in a secure interior office that will insure client confidentiality.
Future installations of computers containing client information will be made in secure offices. |
709.28(c) 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:
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Observations
Based on review of five client records on August 7-8, 2008, the facility failed to document informed and voluntary consents to release information forms in 2 of 5 client records.
Finding:
Two blank consent to release information forms were signed by the client and documented in client record #2. One consent to release information form in client record #1 fails to identify the relationship of the recipient to the client. Another consent to release information form in client record #1 failed to list the specific information that was to be released and instead listed a purpose for the release of information.
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Plan of Correction
Chart deficiencies have been corrected and procedures updated to prevent recurrence. The Project Director will insure all counseling staff are adequately trained with regard to proper client record maintenance and insure continued compliance through supervisiory follow-up.
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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.
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Observations
Based on review of 5 client records on August 7-8,2008 the facility failed to document complete personal histories in 3 of 4 client records where required.
Finding:
The family history, recreational history and sexual history were incomplete in client record # 1. The personal history was incomplete relative to the family history, employment history, educational history and sexual history in client record # 2. The personal history in client record #4 was incomplete relative to the family history, legal history, employment history, educational history, and recreational history.
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Plan of Correction
Chart history deficiencies for client # 1, # 2 and # 4 are being corrected as client contact permits and will be completed by 9/12/08. Corrected procedures are being updated and will be in place by 9/8/08. The Project Director will insure all counseling staff are adequately trained with regard to proper client record maintenance and insure continued compliance through supervisory follow-up.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of five client records on August 7-8, 2008, the facility failed to document legible treatment plans, and treatment plans that were developed with a client in 3 of 4 client records where required.
Findings:
The comprehensive treatment plan was not legible and the client signature was photocopied in client record #1. Comprehensive treatment plans had no client signatures in client records # 4 and 5 and there was no documentation to suggest that the treatment plans had been developed with the clients.
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Plan of Correction
Treatment Plan chart deficiencies will be been corrected and procedures updated to prevent recurrence by 9/12/2008. Inscription clarity is being improved via off-line electronic enhancements planned for completion by 10/17/2008.
The Project Director will insure counseling staff members are adequately trained by 9/12/2008 with regard to proper client record entries and signature requirements. Supervisory follow-up inspection by the Project Director will be implemented by 9/30/2008 to insure continued compliance.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of five client records on August 7-8, 2008, the facility failed to document client progress on the treatment plan updates in two of two records where updates were due.
Finding:
The treatment plan update on client record #2 failed to include a review of the client's progress. The treatment plan update was missing from client record #3.
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Plan of Correction
Treatment plan updates for Client #2 and client # 3 will be corrected/completed by 9/12/2008. The Project Director will insure all counseling staff are adequately trained with regard to proper client record maintenance and insure compliance by supervisory follow-up by 9/30/2008. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on review of 5 client records on August 7-8, 2008, the facility failed to document progress notes which evaluated or assessed the client's progress in relationship to the comprehensive treatment plans in 3 of 4 client records where the documentation was required.
Finding:
Progress notes were missing the assessment portion of the note in client records # 1, 2, and 3.
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Plan of Correction
Progress note updated assessments for Client Records #1, #2, #3 will be corrected/completed by 9/12/2008. The Project Director will insure all counseling staff are adequately trained with regard to proper client record maintenance and insure compliance through supervisory follow-up by 9/30/2008. |