INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 20 - 21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Freedom Healthcare Services, LLC 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 February 17, 2010.
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Plan of Correction
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of personnel records and an interview with the project/facility director and Chief Executive Officer of the facility, the facility failed to ensure that the staff person appointed to the position of project director would be responsible for the overall management of the project and staff, as defined at 28 Pa. Code subsection 701.1.
The findings included:
On January 20, 2010, five personnel records were reviewed. One personnel record pertained to the project/facility director. The regulations at 28 Pa. Code 709.22(d)(1) require a drug and alcohol treatment project to have a project director responsible for the overall management of the project and staff; including the authority to execute contracts, establish wage scales, approve personnel policies and manage fiscal matters. The facility failed to provide documentation that the project director is responsible for the overall management of the project and staff in employee record # 1.
Employee # 1 was hired on July 28, 2008. On October 21, 2009, employee # 1 was promoted to the positions of the project and facility director. The project/facility director was interviewed on January 21, 2010 at approximately 9:30 AM. The project/facility director reports her job duties include overall management of the staff and stated her duties are mainly clinical in nature. The project/facility director currently maintains a small caseload of clients. The project/facility director confirmed that she is not responsible for the overall management of the project and does not manage fiscal matters. The Chief Executive Officer was interviewed on January 21, 2010 at approximately 11:30 AM. He also confirmed that the project/facility director is not responsible for the fiscal matters of the project and that the project director does not have the authority to hire and fire employees or set wage and salary scales. The Chief Executive Officer reported that he manages fiscal matters along with the Chief Financial Officer of the project. The duties, responsibilities and authorities of the employee currently identified as the project director do not rise to the level required by the Pennsylvania Code and as clarified at Licensing Alert 05-05.
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Plan of Correction
The Chief Executive Officer and Chief Financial Officer will review staffing requirements for Project Director. They will either turn over fiscal management to the named Facility Director or will appoint a new Project Director. Within 30 days from plan of correction, the Chief Executive Officer and Chief Financial Officer, along with the Board of Directors, will decide the position of the Project Director and will submit for approval immediately to all licensing agencies. |
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy and procedure manual and an interview with the project/facility director, the facility failed to document an assessment of staff training needs.
The findings include:
On January 20, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, each employee will have their training needs assessed on their anniversary date and a summary of training needs within 30 days. The regulation requires an assessment of staff training needs to be completed as a component of a staff development program. The facility failed to document the completion of a staff training needs assessment.
The project/facility director was interviewed on January 20, 2010 at approximately 1:30 PM. The project/facility director confirmed that a needs assessment was not completed on each employee, nor was a summary of training needs completed for each employee. The project/facility director reports this policy will be reviewed and changed to complete training needs assessments once per year rather than on the anniversary dates of each employee.
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Plan of Correction
The Project/Facility Director will review and revise the current policy on needs assessment and summary of needs assessment at Freedom Healthcare within 1 week from submission of plan of correction. Upon hire of a new employee, staff will have a needs assessment completed either by the Clinical Supervisor or the Facility Director. All staff will have a training needs assessment completed by the end of December for the following year along with the summary of the needs assessment since hire date. The Facility Director and/or Clinical Supervisor will complete training needs assessment once per year thereafter rather than on the employee's anniversary date. Current staff will have a needs assessment completed on them by the Facility Director 2/22/2010 and will have the summary of needs assessment completed atthe end of the year.
In order to ensure that this deficiency does not reoccur, the Project Director/Facility Director will review a new hire's personnel file with Clinical Supervisor within the week of initial hire. The Project/Facility Director will also review all personnel files on a quarterly basis with the Clinical Supervisor. |
704.11(a)(2) LICENSURE Overall Training 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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy and procedure manual and an interview with the project/facility director, the facility failed to document an overall plan for addressing training needs.
The findings include:
On January 20, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, a training plan will be completed after the summary of staff training needs. The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. The facility failed to document the completion of an overall training plan.
The project/facility director was interviewed on January 20, 2010 at approximately 1:30 PM. The project/facility director confirmed that a plan for addressing training needs of staff was not completed. The project/facility director reports this policy will be reviewed further to see if any changes need to be implemented regarding the completion of an overall training plan.
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Plan of Correction
The Project Director/Facility Director will review and revise Freedom Healthcare's policy regarding the overall training plan for staff. The Project Director/ Facility Director will complete an overall training plan for staff and revise policy by 3/1/2010. The Project/Facility Director will ensure this corrective action is implemented.
In order to ensure that this deficiency does not reoccur, the overall training plan for staff thereafter will be completed by the Project/Facility Director prior to January 31st of each year. |
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 policy and procedure manual and an interview with the project/facility director, the facility failed to document an annual evaluation of the overall training plan, as required by regulation.
The findings include:
On January 20, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, an annual review of the training plan will be completed within one year of the original training plan. The regulation requires an annual evaluation of the overall training plan to be completed as a component of a staff development program. The facility failed to document the completion of an annual evaluation of the overall training plan.
The project/facility director was interviewed on January 20, 2010 at approximately 1:30 PM. The project/facility director confirmed that an annual evaluation of the overall training plan was not completed. The project/facility director reports this policy will be reviewed further to see if any changes need to be implemented regarding the time frames for completion of the annual evaluation of the overall training plan.
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Plan of Correction
The Project Director/Facility Director will review and revise Freedom Healthcare's policy regarding the annual evaluation of the overall training plan within 1 week from submission of plan of correction. Project Director/Facility Director will complete overall training plan for this current year by 3/1/2010 and the annual review of this overall training plan will be completed prior to the end of December. The annual review of the overall training plan will be completed once per year prior to December 31st by the Project Director/Facility Director hereafter. |
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.
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Observations
Based on a review of personnel records, CPR/first aid certification cards and an interview with the project/facility director, the facility failed to ensure that a sufficient number of staff persons were trained in CPR and first aid.
The findings include:
Five personnel records and employee CPR/first aid certification cards were reviewed on January 20, 2010. Per regulation, 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. Only two employees have current CPR certification and first aid training. The facility is open on Mondays and Thursdays until 9 PM for clients in the intensive outpatient treatment track. The two employees with CPR certification and first aid training do not work on these evenings. The project/facility director was interviewed on January 21, 2010 at approximately 9:30 AM. The project/facility director confirmed that there are no employees with documentation of CPR certification and first aid training who work on Monday and Thursday evenings. The project/facility director reported the physician works on Monday evening and has CPR certification; but she did not have documentation of the CPR certification.
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Plan of Correction
The Project Director/Facility Director will schedule CPR/first aid training within the next 60 days. Freedom Healthcare's nursing staff, clinical staff including the Intensive Outpatient Therapist and two members of management staff will be required to attend and obtain CPR/first aid training by 4/30/2010. The Project Director/Facility Director will ensure the at least two staff will be trained in CPR/first aid during each shift. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of personnel records, the facility staffing form and an interview with the project/facility director, the facility failed to provide one Full Time Equivalent (FTE) counselor for every 35 active clients.
The findings include:
Five personnel records and the facility staffing form were reviewed on January 20 - 21, 2010. FTE counselor caseloads for counseling in outpatient programs may not exceed 35 active clients. The facility failed to maintain counselor caseloads at 35 active clients to one FTE counselor.
Employee # 2 is a counselor and was hired on December 2, 2009. Employee # 2 has a caseload of 55 active clients to one FTE counselor.
Employee # 3 is a counselor and was hired on September 28, 2009. Employee # 3 has a caseload of 40 active clients to one FTE counselor.
One counselor has been on medical leave since December of 2009. This counselor had 28 active clients, who have not been assigned to another counselor.
The project/facility director was interviewed on January 20 and January 21, 2009. The project/facility director confirmed that there are 28 clients who have not been assigned to a counselor. The project/facility director reports other counselors have provided services to these clients, as needed. The project/facility director reports there has been a turnover of clinical staff.
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Plan of Correction
Freedom Healthcare hired an additional counselor that began employment on 1/28/2010. Also, the counselor that was out on medical leave returned as of 1/25/2010. Each counselor is now at a 35:1 caseload ratio.
The Project Director/Facility Director will have weekly meetings with the Clinical Supervisor to review and update each of the counselor's caseloads. Ongoing interviews for counselors will be scheduled and conducted by both the Clinical Supervisor and the Project/Facility Director. New intakes will be placed on hold until a new counselor can be hired to manage the new clients. The Clinical Supervisor will monitor this on a weekly basis by monitoring the intakes versus the discharges via the computer system and meetings with the intake coordinator. The Clinical Supervisor will meet and discuss this with the Project/Facility Director on a weekly basis. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative polices and procedures and an interview with the project/facility director, the facility failed to document the annual update of a written manual delineating project polices and procedures.
The findings include:
The administrative policies and procedures were reviewed on January 20, 2010. The project director failed to document the annual update of the written project policies and procedures, as required by regulation.
The project/facility director was interviewed on January 20, 2010 at approximately 1:30 PM. The project/facility director reports that she has not documented the annual update of the policy and procedure manual. The project/facility director reviewed the policy and procedure manual to determine if the previous project director had completed an annual update; and could not find documentation that this had occurred.
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Plan of Correction
Due to the issue of the Project Director position being unresolved currently, the Facility Director has reviewed the policy and procedure manual for the annual update as of 1/28/2010 and documented this. When the new Project Director is named, the policy and procedure manual will be reviewed by him or her and that review will be documented immediately within the first week of their employment as Project Director. The Project Director/Facility Director will review the policy and procedure manual at the beginning of each year within the month of January. |
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 a review of client records and an interview with the project/facility director, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in seven of seventeen client records.
The findings include:
Seventeen client records were reviewed on January 20 - 21, 2010. Seventeen client records were required to include documentation of an informed and voluntary consent from the client prior to the disclosure of information; as required by regulation. Client records # 9, 10, 11, 13 and 14 did not include documentation of an informed and voluntary consent for the release of information to insurance companies for billing purposes, though insurance companies were billed for services provided.
Client # 9 was admitted on September 25, 2009. The client signed a verification of insurance form on September 25, 2009. There was no documentation of an informed and voluntary consent form allowing for the disclosure of information to the insurance company for billing purposes.
Client # 10 was admitted on August 18, 2009. The client signed a verification of insurance form on August 18, 2009. The client record contained copies of the client's insurance card. There was no documentation of an informed and voluntary consent form allowing for the disclosure of information to the insurance company for billing purposes.
Client # 11 was admitted on August 25, 2009. The client signed a verification of insurance form on August 25, 2009. The client record contained copies of the client's insurance card. There was no documentation of an informed and voluntary consent form allowing for the disclosure of information to the insurance company for billing purposes.
Client # 13 was admitted on August 10, 2009. The client signed a verification of insurance form on August 10, 2009. The client record contained copies of the client's insurance card. There was no documentation of an informed and voluntary consent form allowing for the disclosure of information to the insurance company for billing purposes.
Client # 14 was admitted on July 9, 2009. The client signed a verification of insurance form on July 9, 2009. The client record contained copies of the client's insurance card. There was no documentation of an informed and voluntary consent form allowing for the disclosure of information to the insurance company for billing purposes.
Client # 16 was admitted on October 9, 2009. The client signed a verification of insurance form on October 9, 2009. The client record contained copies of the client's insurance card. There was no documentation of an informed and voluntary consent form allowing for the disclosure of information to the insurance company for billing purposes.
Client # 17 was admitted on November 9, 2009. The client signed a verification of insurance form on November 9, 2009. The client record contained copies of the client's insurance card. There was no documentation of an informed and voluntary consent form allowing for the disclosure of information to the insurance company for billing purposes.
The project/facility director was interviewed on January 21, 2010 at approximately 9:30 AM. The project/facility director reported she could not locate the informed and voluntary consent forms for these clients. The project/facility director confirmed that the insurance companies had been billed for payment of services for these clients.
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Plan of Correction
Starting as of 1/25/2010, all the clients that were reviewed during the audit have been explained the purpose of a release of information for their insurance companies and have signed them. The clinical staff was advised on 1/21/2010 that they were to explain to all of their clients who were paying by private insurance the purpose of a release of information and have each of those clients sign releases in order to bill. The intake coordinator, as of 1/25/2010, has begun to complete all releases of information, including a client's insurance company, at intake. The client's primary counselor will then monitor the expiration as well as the renewal of any necessary releases for each of their clients on a regular basis. The Project/Facility Director will monitor this progress during regular reviews of charts. |
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 a review of client records, the administrative policy and procedures manual and an interview with the project/facility director, the facility failed to document psychosocial evaluations that included a clinical assessment of the client in eight of seventeen client records, as required by regulation.
The findings include:
Seventeen client records were reviewed on January 20 - 21, 2010. Seventeen client records required the completion of psychosocial evaluations, per regulation. Eight client records did not include a clinical assessment of the client; and only included client historical information. The facility failed to document a psychosocial evaluation that included a clinical assessment in client records # 7, 8, 9, 11, 12, 13, 14, and 17.
Client # 7 was admitted on August 25, 2009. The date of the psychosocial evaluation is unknown as it was not documented on the form. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 8 was admitted on August 18, 2009. The date of the psychosocial evaluation is unknown as it was not documented on the form. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 9 was admitted on September 25, 2009. The psychosocial evaluation was completed on September 28, 2009. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 11 was admitted on August 25, 2009. The psychosocial evaluation was completed on September 2, 2009. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 12 was admitted on November 25, 2009. The psychosocial evaluation was completed on November 25, 2009. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 13 was admitted on August 10, 2009. The psychosocial evaluation was completed on August 14, 2009. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 14 was admitted on July 9, 2009. The psychosocial evaluation was completed on July 13, 2009. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 17 was admitted on November 9, 2009. There is no documentation that the psychosocial evaluation was completed. The project/facility director could not find documentation of the psychosocial assessment.
The project/facility director was interviewed on January 21, 2010 at approximately 1:30 PM. The project/facility director reviewed these psychosocial evaluations and agreed that they did not include a clinical assessment of the client.
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Plan of Correction
Prior to audit, the counselor primarily responsible for the majority of the charts reviewed had been let go. Currently, Freedom Healthcare has an intake coordinator that completes all of the psycho-social evaluations on each of the new clients. The Project Director/Facility Director reviewed audit findings with all staff on 1/21/2010 including the intake coordinator. The intake coordinator has begun turning in all completed psycho-social evaluations to Project Director/Facility Director for review. Any necessary training with the assessment portion of the psycho-social evaluation is done at that time between the Project Director/Facility Director and intake coordinator. |
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 client records and an interview with the project/facility director, the facility failed to document a case consultation in two of eight client records, as required by regulation.
The findings include:
Seventeen client records were reviewed on January 20 - 21, 2010. Case consultations were required in eight client records. Case consultations were not required in nine client records; due to the client not being in treatment the length of time required. Per agency policy, case consultations will be completed at least quarterly. The facility did not document a case consultation in client records # 10 and 11.
In active client record # 10, the client was admitted on August 18, 2009. A case consultation was due no later than December 31, 2009. There was no documentation of a case consultation.
In active client record # 11, the client was admitted on August 25, 2009. A case consultation was due no later than December 31, 2009. There was no documentation of a case consultation.
The project/facility director was interviewed on January 21 at approximately 9:30 AM. The project/ facility director confirmed that no documentation of a case consultation could be located.
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Plan of Correction
The Project Director/Facility Director and clinical supervisor reviewed with staff on 1/25/2010 how case consultions must be completed. The counselors have begun creating and utilizing their own individual tracking systems so that case consultations will be completed in a timely manner. Reviews of each of the counselors clinical charts will be completed by the clinical supervisor and/or the Project/Facility Director on a regualr basis. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on an interview with the project/facility director and the review of client census information, the facility failed to comply with the maximum approved capacity for the outpatient treatment activity.
The findings include:
On January 21, 2010, client census material provided by the project/facility director and an interview with the project/facility director confirmed that the current census for active clients receiving outpatient other chemotherapy was at 142. The maximum approved capacity on the day of the inspection for outpatient other chemotherapy clients was 50.
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Plan of Correction
All intakes for buprenorphine were placed on hold as of 1/21/2010 and a waiting list was developed. The Project Director/Facility Director was advised during the audit to submit for an increase in maximum capacity to the department. A letter was drafted and faxed on 1/29/2010 explaining that Freedom Healthcare had acquired a physician private practice in 1/09 and currently have another physician working with us. The Project Director/Facility Director requested at the minimum to have our current caseload of 142 clients covered and at maximum 200 clients as defined by the DEA cap guidelines for our physicians. The Project Director/Facility Director received verbal verification that exception was granted and is awaiting the hard copy letter.
In order to ensure this does not reoccur, the Project Director/Facillity Director will monitor the intakes versus discharges on our buprenorphine patients via the computer system on a daily basis. As Freedom Healthcare reaches their capacity, the Project/Facility Director will place a hold on intakes for buprenorphine and a waiting list will be developed. |