INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 9-10, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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 17, 2008.
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Plan of Correction
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the staff development program on 10-9-08, the facility failed to provide an annual evaluation of the overall training plan for the 2007 -2008 training year.
Finding:
The facility failed to document the annual evaluation of the overall training plan for the 2007 -2008 training year. In accordance with the facility policy, this document was due to be completed by July 31, 2008.
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Plan of Correction
Because of the retirement of our long time compliance officer, this report was overlooked. A staff training checklist has been developed by both the new compliance officer and clinical supervisor, who are primarily responsible for overseeing the staffing documentation.
This checklist was completed October 13,2008. The on-going review for compliance will be the responsibility of the Compliance officer. |
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 eight training/personnel records on 10-9-08, the facility failed to provide the required fire extinguisher training at the time of employment. The fire extinguisher training was not documented in two of eight personnel records where required.
Finding:
The facility did not document fire extinguisher training in personnel records #4 and 6 for more than seven days from the hire date.
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Plan of Correction
Review of the use of fire extinguishers has been included as a part of the HR orientation given to all new drug and alcohol employees. This is in addition to Agency orientation provided during the first month of hire.
This is effective immediately and will be monitored by the compliance officer. |
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 eight training/personnel records on 10-9-08, the facility failed to provide the required emergency training at the time of employment. The emergency training was not documented in two of eight client records where required.
Finding:
The facility did not document the training in personnel records # 4 and 6 for more than seven days after the date of hire.
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Plan of Correction
The review of emergency procedures has been added to the HR orientation for new drug and alcohol hires. This is in addition to the agency orientation held during the first month of employment.
This is effective immediately(10/13/2008)and will be monitored by the Compliance Officer. |
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 a review of personnel record on 10-9-08, the facility failed to provide work performance evaluations for two out of four employees where required.
Finding:
The facility did not document work performance evaluations for the current year in personnel records #5 and 6.
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Plan of Correction
The policy currently in effect requires review at 45 and 90 days. This policy will be reviewed by HR and the the manager of the Drug and Alcohol Program to determine the practicality of this time frame and to change it if appropriate. This will be completed by 12/1/2008.
The missing evaluations were completed
10/2008.
The Compliance Officer and HR Director will be responsible to monitor adherence to the policy. |
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.
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Observations
Based on a review of six client records on 10-10-08, the facility failed to provide specific information to be disclosed to a funding agency in six of six client records where required.
Finding:
The facility failed to provide specific information to be disclosed to a funding agency. The consent to release information forms are standardized, and the specific information section documents "intake information" as the information to be disclosed. This was documented on the consent to release information forms in all six client records.
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Plan of Correction
As this is a standardized form, the wording of the information to be released has been changed to include only the five areas allowed funding sourses.This was rewritten into the software on 10/21/2008. The registration staff was informed of the change and its rationale on 10/22/2008.
On-going monitoring will be the responsibility of the Compliance Officer and included as a part of
regular chart audits on documentation. |
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 a review of six client records on 10-10-08, the facility failed to provide case consultations in two of two client records where required.
Finding:
The facility failed to provide case consultations in client records # 2 and 3.
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Plan of Correction
As our forms are housed with-in our software system, the case consult has been bundled with the treatment plan, to insure completion minimally at each treatment plan update. Additionally, review of the need to complete a consult on each case reviewed in treatment team due to a change in status was reviewed with the drug and alcohol team. Both of these were completed by 10/23/2008.
The Compliance Officer will be responsible for monitoring completion of the case consult as part of the documentation audit. Additionally, the clinical supervisor will include this as part of the supervision process which focuses on documentation. Both of these are effective 12/15/2008. |