INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25-26, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pinnacle Treatment Centers Pa-V. 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 22, 2011.
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Plan of Correction
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704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to document the completion of at least 40 clock hours of annual training required for counselor assistants in one of one personnel record.
The findings include:
Eight personnel records were reviewed on January 25-26, 2011. One personnel record was reviewed as a counselor assistant. One personnel record required the completion of 40 clock hours of annual training the first year and 30 clock hours annually thereafter . The facility failed to document 40 clock hours of annual training in personnel record # 5.
Employee # 5 was hired as a counselor assistant on December 2, 2009 and promoted to a counselor on December 2, 2010. The counselor assistant was to have completed 40 hours of annual training the first year. The personnel record documented 27 training hours from December 2, 2009 to December 2, 2010.
The facility director was interviewed on January 26, 2011 and confirmed the counselor assistant had only 27 training hours documented.
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Plan of Correction
The Facility Director will ensure that all counselors and counselor assistants receive required training hours, at minimum. The facility director will provide counselors and counselor assistants recommended trainings and will aid in the registration process, when needed. The facility director will track all completed trainings by staff to ensure that all staff have received adequate training. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on observation and a physical plant inspection, the facility failed to provide for lighted interior stairs at all times.
The findings include:
A physical plant inspection was conducted on January 26, 2010 at approximately 2: 40 PM. The back stairs exit was not lighted at the time of the inspection. The light switch was turned off and on with no results.
The facility director was present during the plant inspection and confirmed the stairs were not lighted.
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Plan of Correction
The facility director has worked with the maintenance staff to ensure the light bulb in the stairwell has been changed and is remaining lit during dosing/patinet hours. The facility director will periodically check to ensure the light continues to work properly.
The facility director will work with the maintenance staff to ensure all fire exits are well lit during business hours and the safety committee will conduct quarterly reviews to ensure all exits are well lit and replace lighting as needed. The facility director is responsible for ongoing compliance in this area. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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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 treatment plan which identified long and short term treatment goals in eleven of twelve clients records, as required.
The findings include:
Twenty two client records were reviewed on January 25-26, 2011. Twelve client records included treatment plans which required long and short term treatment goals. Per regulation, an individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of short and long-term goals for treatment as formulated by both staff and client. The facility failed to document identification of the long and short term treatment goals in client records # 1, 2, 3, 4, 5, 6, 7, 9, 10, 12 and 13.
Client # 1 was admitted into treatment on September 9, 2010. A treatment plan was completed on October 6, 2010. The treatment plan did not identify the treatment goals as long or short term treatment goals.
Client # 2 was admitted into treatment on July 29, 2010. A treatment plan was completed on August 29, 2010. The treatment plan did not identify the treatment goals as long or short term treatment goals.
Client #3 was admitted into treatment on June 17, 2010. A treatment plan was completed on July 17, 2010. The treatment plan did not identify the treatment goals as long or short term treatment goals.
Client # 4 was admitted into treatment on November 12, 2010. A treatment plan was completed on December 12, 2010. The treatment plan did not identify the treatment goals as long or short term treatment goals.
Client #5 was admitted into treatment on December 7, 2010. A treatment plan was completed on December 27, 2010. The treatment plan did not identify the treatment goals as long or short term treatment goals.
Client # 6 was admitted into treatment on October 22, 2010. A treatment plan was completed on November 22, 2010. The treatment plan did not identify the treatment goals as long or short term treatment goals.
Client # 7 was admitted into treatment on August 31, 2010. A treatment plan was completed on September 17, 2010. The treatment plan did not identify the treatment goals as long or short term treatment goals.
Client # 9 was admitted into treatment on July 15, 2010. A treatment plan was completed on August 11, 2010. The treatment plan did not identify the treatment goals as long or short term treatment goals.
Client # 10 was admitted into treatment on June 15, 2010. A treatment plan was completed on July 12, 2010. The treatment plan did not identify the treatment goals as long or short term treatment goals.
Client # 12 was admitted into treatment on September 28, 2010. A treatment plan was completed on October 28, 2010. The treatment plan did not identify the treatment goals as long or short term treatment goals.
Client # 13 was admitted into treatment on November 19, 2010. A treatment plan was completed on Decameter 7, 2010. The treatment plan did not identify the treatment goals as long or short term treatment goals.
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Plan of Correction
The facility director and clinical supervisor will provide training to clinical staff regarding the need for both long term and short term treatment goals and the proper identification of the goals in the treatment plan. Ongoing clinical supervision and the regular chart auditing process will be utilized to gauge ongoing compliance and additional training as needed. The clinical supervisor is responsible for compliance in this area. |