INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 4-5, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, MCP/Caring Together 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 April 5, 2009.
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Plan of Correction
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the review of personnel files, the facility failed to meet the minimum required hours in one of two files reviewed.
The findings include:
Four personnel files were reviewed on March 4, 2009. A minimum of 12 training hours were required in two personnel files. The facility did not document training hours in personnel file # 2.
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Plan of Correction
Program Manager in consultation with Program Director will develop strategy for insuring that training hour minimum (12) be met going forward through careful consideration of available training options and adjustments to employee schedule/responsibilities to allow for same. Program Manger will review progress towards training hours with staff and Program Director on a bimonthly basis to ensure compliance. |
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 the review of administrative documentation, the facility failed to ensure each counselor completed at least 25 clock hours of annual training.
The findings include:
Administrative documentation that included training hours for four clinical personnel , was reviewed on March 4, 2009. At least 25 clock hours were required in two personnel files. Personnel # 3 did have sufficient hours, but not related to drug and alcohol. Personnel # 4 had only 18 of the required 25 hours completed.
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Plan of Correction
Program Manager with review with staff the required amount of training hours, will increase opportunities for staff to attend trainings, and will more closely monitor status of training hours for staff throughout the training year. |
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 the review of administrative documentation and staff interviews, the facility failed to set off an alarm or smoke detector during each fire drill.
The findings include:
The fire drill log was reviewed on March 5, 2009; fire drills were required to be conducted monthly. The setting off of the fire alarm or smoke detector was not documented for seven of the prior ten months reviewed.
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Plan of Correction
At recommendation of state inspector, the Program Manager shall request in writing an exception regarding the monthly testing of smoke alarms (given their physical location)to allow agency to continue to test smoke alarms when access is available as currently practiced. If this exception is not granted, Program Manager will pursue obtaining a ladder for program use to check smoke detectors monthly. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in four of four client records.
The findings include:
Six client records were reviewed on March 4-5, 2009. Psychosocial evaluations were reviewed in four client records. Client # 1 was re-admitted on May 23, 2008 and a new psychosocial evaluation was not completed. In client records #2, 5 and 6 the psychosocial evaluation was based on client reported comments and did not provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
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Plan of Correction
Program Manager will review/retrain with staff the requirements for doing a new psychosocial for re-admits. Program Manager will also retrain staff regarding appropriate procedure/documentation on evaluation section of psychosocial. Program Manager will then do random monthly spot checks to ensure compliance. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on the review of client records, the facility failed to document aftercare plans in two of two client records.
The findings include:
Six client records were reviewed on March 4-5, 2009. Aftercare plans were required in two client records. The facility did not document aftercare plans in client records # 3 and 4.
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Plan of Correction
Program Manager will review/retrain counseling staff regarding aftercare policy and procedure and will do monthly spot checks of client records to ensure compliance. |
711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies 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:
(i) Confidentiality of client identity and records.
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Observations
Based on a physical plant inspection and review of administrative documentation, the facility failed to maintain the confidentiality of client records.
The findings include:
Administrative documentation that included the program's policy and procedure manual, was reviewed on March 4, 2009. The policy regarding the maintenance of client confidentiality included a process of keeping all files in locked containers. A physical plant inspection was conducted at approximately 10:30 AM on March 5, 2009. There were two large filing cabinets located in the hall area near the locked file room, both were not locked and contained client files.
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Plan of Correction
Program Manager will ensure that file cabinets containing confidential information are kept locked at all times, review agency confidentiality policy and procedure with staff and post reminder signs to further enhance compliance. |