INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 21, 2010 licensure renewal inspection. The follow-up inspection was conducted on August 30, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 September 30, 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 an interview with the facility director, the project failed to appoint a project director responsible for the overall management of the project and staff, as required.
The findings include:
The facility director was interviewed on August 30, 2010 at approximately 9:30 AM. Per regulation, 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. The facility director confirmed that the members of the corporation have not hired a project director to handle the overall management of the project and staff.
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Plan of Correction
The Facility Director reviewed with the Chief Executive Officer the staffing requirements for Project Director on 8/30/10. Facility Director was advised that if Chief Executive Officer was to be named Project Director then Freedom Healthcare would have to submit for approval for an exception to the staffing requirements. The President of the Board of Directors/Owner will submit a letter stating that he would like to name the Chief Executive Officer as the Project Director. Also, attached would be included the CEO's resume for review. The President/Owner of Freedom Healthcare shall submit for review by 10/10/10. Freedom Healthcare shall then wait for final approval from State department as to position of the Project Director. If the CEO does not become the project director, then Freedom Healthcare will hire a project director that meets the qualifications for the position. |
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 an interview with the facility director, the facility failed to document an assessment of staff training needs, as required.
The findings include:
On August 30, 2010, the facility director was interviewed. 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 facility director confirmed that the policy has been changed to reflect a training needs assessment will be completed annually. Per the January 21, 2010 plan of correction, the facility planned to complete a needs assessment for all staff by February 22, 2010 and also complete a needs assessment on each new employee hired. The facility director confirmed that a needs assessment was not completed on current or newly hired staff.
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Plan of Correction
Freedom Healthcare has revised the policy to reflect a training needs assessment to be completed annually. Based on the revised policy, all training needs assessments will be completed by the end of December for the following year along with the summary of the needs assessment. All new hires will have training needs assessment completed within one week of hire.
In order to ensure that this deficiency does not reoccur, the Project Director/Facility Director will review all new hire's personnel files within one week of hire. All personnel files will be reviewed on a quarterly basis to make sure all necessary paperwork is completed and filed.
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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 an interview with the facility director, the facility failed to document an annual evaluation of the overall training plan, as required.
The findings include:
On August 30, 2010, the facility director was interviewed. 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 facility director confirmed that the policy has been revised to complete the annual evaluation of overall training plan by December 31 of each year. The facility director confirmed that an overall training plan and the annual evaluation of the overall training plan was not completed in 2009.
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Plan of Correction
Due to the fact that an overall training plan was not completed for 2009, the annual evaluation of the overall training plan could not be completed. The policy has been revised to complete the annual evaluation of overall training plan by December 31st of each year. The Facility Director will complete an annual evaluation of the overall training plan by December 31, 2010. |
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 counselor caseloads and an interview with the facility director, the facility failed to provide one Full Time Equivalent (FTE) counselor for every 35 active clients, as required.
The findings include:
On August 30, 2010, counselor caseloads were reviewed. Per regulation, 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. One full time counselor had a caseload of 49 active clients. The facility director was interviewed on August 30, 2010 and confirmed that one counselor had a current active caseload of 49 clients. The facility director reported that the program is in the process of hiring a new counselor as soon as possible.
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Plan of Correction
Freedom Healthcare is currently reviewing resumes and interviewing to fill the position of counselor that is available. Once the position is filled, every counselor will be at 35:1 ratio again. Of the caseload that is at 49 patients, the Facility Director reviewed each patient file and assigned them temporarily to the other clinical staff under the 35 patient caseload. Once another counselor is hired, the 14 patients will be assigned permanently to the new counselor. The Facility Director will review and update each of the counselor's caseloads 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 an interview with the facility director, the facility failed to document an annual update of a written manual delineating project polices and procedures by the project director, as required.
The findings include:
The facility director was interviewed on August 30, 2010. Per regulation, the project director shall prepare and annually update a written manual delineating project policies and procedures. The facility failed to document the annual update of the written project policies and procedures by the project director. The facility director reported the members of the corporation have not hired a project director and therefore, have been unable to document an annual update of the policies and procedures.
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Plan of Correction
Due to fact that members of the corporation have not hired a Project Director, Freedom Healthcare has not been unable to document an annual update of the policies and procedures. The Facility Director has signed off on policy and procedures during the interim as per conversation with the department. Freedom Healthcare is to fill the position of Project Director by the end of October 2010. Therefore by the first week in November 2010, the new Project Director will review/update and sign off on all policy and procedures. |
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 client records and an interview with the project/facility director, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the specific information to be disclosed in two of five client records, as required.
The findings include:
Six client records were reviewed on August 30, 2010. Five client records included releases of information to the funding entity and were reviewed for the specific information disclosed. Per regulation, 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 specific information disclosed. The facility released specific client information that exceeded the limits imposed at 4 Pa. Code subsection 255.5 (b) in client records # 2 and 3.
Client # 2 was admitted to the program on March 26, 2010. On March 26, 2010 a consent to release information to the funding entity was signed by the client. The consent listed the specific information to be disclosed to the funding entity as follows: dosage level, prescriptions, and discharge summary. This specific information to be released to the funding entity exceeded the limits imposed by 4 Pa. Code subsection 255.5 (b).
Client # 3 was admitted to the program on May 14, 2010. On May 14, 2010 a consent to release information to the funding entity was signed by the client. The consent listed the specific information to be disclosed to the funding entity as follows: dosage level, prescriptions, case consults, psychosocial evaluation, blood work, progress notes, TB results, treatment plans, drug screening results and discharge summary. This specific information to be released to the funding entity exceeded the limits imposed by 4 Pa. Code subsection 255.5 (b).
On August 30, 2010, the facility director reviewed the consents to the funding entity in client records # 2 and 3. The facility director confirmed that the specific information listed on these consents exceeded the limitations imposed at 4 Pa. Code subsection 255.5 (b).
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Plan of Correction
The Facility Director reviewed the findings with clinical staff on 8/30/10. The Facility Director reviewed the limits imposed by 4 Pa. Code subsection 255.5 (b) and provided copies of the regulations for confidentiality for all the clinical staff. Of the patient charts that were reviewed, each of the primary counselors voided the releases and will complete new releases during next clinical session.
The Facility Director will continue to provide in house confidentiality training as well as BDAP approved confidentiality when available. All new patient charts are reviewed by the Facility Director which is when most releases are completed for funding source. The Facility Director will continue to review all patient charts on a regular basis.
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