INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19-21, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on October 20, 2006.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
No documentation was presented to verify that the required meetings occurred during the past year for the clinical supervisor who assumed his role as of 6/20/05.
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Plan of Correction
Clinical Supervisor will document all meetings. Program Director will do regular monitoring to ensure compliance and continue on a regular basis. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
The required semi annual performance evaluation was not documented for the counselor assistant who assumed her role as of 7-12-05. (File #9).
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Plan of Correction
Clinical Supervisor will record a performance evaluation. Semi annual performance evaluations will be completed by the Clinical Supervisor. Program Director will monitor to ensure compliance. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
No documentation was presented to verify that the counselor assistant (file # 9) had the required supervision completed during the past year.
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Plan of Correction
Clinical Supervisor will document the required supervision that was completed during the past year. Program Director will monitor to ensure compliance. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Documentation presented to verify the mandatory communicable disease training did not meet the requirements of this Chapter. Acceptable training documentation may include: training certificates, dated attendance sheets signed by the trainer and the individual, and transcripts.
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Plan of Correction
Medical Director has provided the mandatory Communicable Disease Training.
A dated and signed attendance sheete will be kept on file. |
704.12(b) & (c) & (d) LICENSURE Counselor Asst/Exceptions
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(b) Counselor assistants. Counselor assistants may be included in determining FTE ratios when the counselor assistant is eligible for a caseload.
(c) Exemption for transitional living. Specific client/staff ratios are not required for transitional living facilities.
(d) Exceptions. A project director may submit to the Department a written petition requesting an exception to the client/staff and client/counselor ratios in this section. The petition shall describe how the characteristics of the program and its client mix support the request for the exception and shall be approved by the governing body. Granting the petition shall be at the discretion of the Department. Long-term residential facilities and halfway houses which include a client's participation in schooling or employment as part of a treatment day are examples when requests for exceptions will be considered.
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Observations
The counselor assistant was not able to be counted in the caseload because the required supervision was not documented.
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Plan of Correction
Clinical Supervisor will document the required supervision that was completed during the past year. Program Director will monitor to ensure compliance. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
The exhaust fan in one of the client bathrooms was not operating at the time of the inspection. A second client bathroom had no exhaust fan or window. Both of these bathrooms were located on the first floor lobby area.
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Plan of Correction
Both bathrooms will be brought to compliance. Program Director will monitor to ensure compliance. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
A space heater was in use in one of the counselor offices on the first floor. Only heaters which are permanently mounted or installed may be used.
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Plan of Correction
Space heater has been removed. |
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
The documentation of fire safety training was dated beyond the time allowed. Instruction may be included in the employee orientation, but must occur no later than seven days from the date of employment.
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Plan of Correction
Form developed to provide documentation of training upon hire. Program Director and Health and Safety Captain will monitor to ensure compliance. |
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
Emergency training was not documented for all staff reviewed. This must be documented within seven days for new hires.
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Plan of Correction
New hires will receive Health and Safety packet upon hire. Program Director and Health and Safety Captain will monitor to ensure compliance. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The fire drill log did not address whether the fire alarm or smoke detector was operative. If an alternate procedure is used it must be approved by the Division before it is implemented.
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Plan of Correction
The Project will seek departmental approval for an alternative procedure. Program Director and Health and Safety Captain will monitor to ensure compliance. |
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
Documentation was not presented for the fire alarm/smoke detector being set off during each fire drill. If the facility does not feel it can pull the alarms, the director would need to provide documentation that the facility has an alternate method for alerting the staff of a fire alarm. In addition, the facility would need to submit the alternative method to the division, explaining the process, and await approval by the Division before implementing the alternate procedure. No documentation of such approval was presented.
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Plan of Correction
The Project will seek departmental approval for an alternative procedure. Program Director and Health and Safety Captain will monitor to ensure compliance. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
No documentation was presented to verify that the annual report was made available to the public for the year ended December 2005.
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Plan of Correction
Document will be present to demonstrate that the annual report is made available. Project Director will ensure compliance. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
No documentation of income and expenses was noted in the annual report.
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Plan of Correction
A financial statement of income and expenses will be made available. Project Director and Program Director will monitor to ensure compliance. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
No documentation was presented to demonstrate that the Governing Body and the Project Director collaborated on the formulation of goals and objectives with final approval given by the Governing Body.
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Plan of Correction
Will be documented in Board of Directors meeting minutes and made available. Project Director will monitor to ensure compliance. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply 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:
(1) Confidentiality of client identity and records.
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Observations
The agency policy on client confidentiality was incomplete and contained inaccuracies. The language in the policies and procedures did not distinguish between HIPAA and 42 CFR Part 2, Subparts A through E. The policy and procedure gives the impression that the project staff do not recognize the distinction in the various applicable laws and regulations.
The requirements of this regulation stipulate that written procedures comply with 4 Pa. Code subsection 255.5. The procedures as presented at the inspection address only subpart (b) of subsection 255.5. The patient confidentiality notice form incorrectly states that revocations must be put in writing by the client. Clients may revoke consents to release information verbally and staff must then document the revocation in the client record. This notice also incorrectly states that client information can be released without consent to obtain legal or financial services or to another medical facility. The same form also states that Discovery House need not agree to any restrictions on disclosures of information requested by the client. All releases of information must be voluntary unless otherwise excepted by the applicable section of 42 CFR. The section of the confidentiality procedure entitled "Prohibition on Redisclosure" on page 191 of the manual is blank.
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Plan of Correction
Policy will be amended to reflect distinctions between 42 CFR Part 2 and HIPAA regulations. Forms will be changed to comply with cited regulations. Program Director will monitor to ensure compliance. |
709.28(a)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply 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:
(2) Staff access to client records.
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Observations
The Discovery House policy on staff access to client records lacked sufficient detail. The policy should identify by name or position who may access client records. The method of access should be outlined. Since the project has an electronic system for keeping client identifying information, a detailed policy and procedure which addresses all of the requirements of the Licensing Alert of May 2005 relating to Electronic Clinical records must be developed.
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Plan of Correction
Policy will be amended to include language regarding access restriction. An attachment will be available that details by position. Program Director will monitor to ensure compliance. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
The storage area for active client records was not locked or staffed at the time of the inspection. File cabinets were not secured.
A second floor storage area contained an abundance of client identifying information which was not secured. This information included old client records and billing information.
Client records must be kept secure at all times.
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Plan of Correction
Client records will be secured in a locked filing cabinet and maintained throughout the day. Will be monitored by the Keeper of the Records and Program Director will ensure compliance. |
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
One agency form presented did not comply with the intent of this regulation. The form entitled "Patient Agreement to Pay for Treatment If Third Party Coverage is denied" contains language which indicates information will be released but the form does not specify what specific information will be sent to third party sources. This constitutes a general consent to release information which does not comply with the requirements of the law.
Releases without informed consent were found in client records # 2, 9 and 14.
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Plan of Correction
Form will be changed to comply with regulation. Program Director will monitor to ensure compliance. |
709.28 (c)(1) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The name of the person, agency or organization to whom information was to be released was missing from consents found in client records # 3 and 5.
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Plan of Correction
Audits will be conducted by Clinical Supervisor quarterly. Program Director will monitor to ensure compliance. |
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
Specific information to be disclosed was missing or exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b) in client records # 4 ,6 ,8 ,9 ,12 ,and 14.
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Plan of Correction
Program Manager will conduct in-service training on proper way to do all releases. Emphasis will be on specific information that can be released according to regulations. Program Director will monitor to ensure compliance. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
The purpose of disclosures to be made was not identified in consents found in client records # 5, 11 and 12.
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Plan of Correction
Program Manager will conduct in-service training on proper way to do all releases. Emphasis will be on specific information that can be released according to regulations. Program Director will monitor to ensure compliance. |
709.28(c)(6) 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:
(6) Expiration date of the consent.
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Observations
Expiration dates were missed on consents found in client records # 2, 3, 5, and 12.
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Plan of Correction
Program Manager will conduct in-service training on proper way to do all releases. Emphasis will be on specfic information that can be released according to regulations. Program Director will monitor to ensure compliance. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Family medical histories were incomplete in client record # 1, 5, 6, 9 and 10.
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Plan of Correction
Responsible medical staff have been trained in proper procedure for completing form. Program Director will conduct audits of documentation to ensure that form is completed thouroughly and address as needed. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories were incomplete in all files reviewed. Personal histories should collect as much personal information about a client as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated.
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Plan of Correction
Training will occur and chart audits will be completed. Clinical Supervisor will monitor for compliance. |
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
Psychosocial evaluations did not consistently address coping mechanisms in files reviewed. Clinical impressions were not consistently detailed or individualized to identify the treatment needs of each client. Staff have a tendency to use rote phrases which appeared throughout the documents reviewed. In one client record reviewed there was a section of the clinical evaluation which was cut and pasted from the file of one client into the file of another client.
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Plan of Correction
There will be regular trainings on psychosocial evaluation. Clinical Supervisor will monitor to ensure compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Updates did not consistently address progress in relation to the stated goals of the treatment plan. The treatment plan update should include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan. The following issues should be considered:
Have problems or issues that have been identified in the comprehensive treatment plan been impacted upon through treatment?
Do the goals need to be revised or restated?
Do the treatment strategies or action steps need to be modified?
Is closure reflected when goals have been achieved?
Treatment plan updates should be signed and dated by the primary counselor and it is recommended that it be countersigned and dated by the supervisory counselor.
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Plan of Correction
Training will be occur and chart audits will be completed. Clinical Supervisor will monitor for compliance. |
709.93(a) 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:
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Observations
Client records presented were not complete. There is, in essence, a two record system used at the agency. Part of the record is electronic and part of the record is paper. This regulation requires that a complete client record be kept. It should contain all of the required components specified under this Chapter. If the agency plans to continue to use this type of system, minimally, the entire discharged record should be completed in paper copy . The agency policy states on page 202 of the manual, "The paper copy of the record will be the main record". If the project intends to have a complete electronic file, policies and procedures should be developed to describe how this will occur in accordance with the Licensing Alert of May 2005 relating to Electronic Records.
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Plan of Correction
Memo will be distributed to all staff instructing them that a complete patient record must be printed at discharge. Program Director will monitor to ensure compliance. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Records of service were not complete in the client records reviewed. There were discrepancies in the services provided noted when comparing the paper record of service with the electronic listing of services provided. The services record should be a chronological listing (separate from progress notes) of the various specific services provided to the individual client. This listing should also include the date, the provider(s), and the duration of the service.
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Plan of Correction
Program Director will give a memo to all Discovery House staff instructing them to print a copy of the patients entire record in the computer when a patient is discharged. This will become part of the discharge file as required in this regulation. Clinical Supervisor will monitor to ensure compliance. |
709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
Client related correspondence was incomplete in records reviewed. It was noted in documentation provided that documents were being sent out to various agencies but no copies of the information sent were kept on file for review in accordance with 4 Pa. Code subsection 255.5(a)(10).
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Plan of Correction
In-service training will be held to ensure compliance. Clinical Supervisor will monitor to ensure compliance. |