INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northern Tier Counseling, Inc. 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.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of administrative documentation, the facility failed to provide an assessment of needs for the current training year, an overall training plan for the current training year, and an evaluation of the plan for the previous training year.
The finding includes:
The staff development plan for the facility was reviewed during the onsite licensure renewal inspection. The document failed to contain an assessment of the staff training needs and an overall plan to address the needs identified for the current training year. An evaluation of the overall training plan for the previous year was not documented.
The findings were reviewed with the Facility Director and confirmed.
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Plan of Correction
704.11 (a) Staff Development Procedure
All staff within the Drug and Alcohol program received an Individual Performance Evaluation which notes areas of strength and weakness yearly. Also within the Performance Evaluation includes an area noting training plan for the upcoming year. The Clinical Director has established a second form to accompany each Performance Evaluation that specifically outlines "Assessment of staff training needs" as well as "NTC plan for addressing those needs". This form will be completed with the Clinical Director and the D&A staff person within 2 weeks of their employment or if a current employee the form will be completed during the month of October 2013. The completed form will be kept in the Staff person's Human Resource file, a copy with Clinical Director and copy with the Staff person. A summary of the overall training needs and outcome of the identified plan will be noted in addition to the staff person's performance evaluation that is done at 90 days of employment and again annually during the month of June. Additional goals will be added as appropriate. Human Resources will note the "Assessment of Staff training needs" form as part of all new hire paperwork for staff working in the Drug and Alcohol facility. Human Resources and the Clinical Director will track that the form is completed within the first two weeks that an employee agrees to provide Drug and Alcohol Services. Human Resources will request and maintain a copy of the training assessment in the employee's Human Resource file. Both Human Resources and Clinical Director can assess and ensure that the Assessment of Training needs has been completed by day 90 of the employees' initial orientation. Employee Human Resource charts will be audited quarterly by the Human Resource Manager and the Clinical Director to ensure that if Assessment of Staff Training needs forms are completed and filed appropriately.
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704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of personnel and training records, the facility failed to provide documentation of individual training plans that were drug and alcohol specific in three of three records reviewed.
The findings include:
Four personnel training records were reviewed during the onsite licensure renewal inspection. Three records required an individual training plan for the 2013-2014 training year. The individual training plans were focused on improvement of job performance. The training plans failed to include drug and alcohol specific training in personnel records, # 1, 2 and 3.
The findings were reviewed with the Facility Director and confirmed.
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Plan of Correction
704.11 (b) (2) & (3)
All staff within the Drug and Alcohol program will complete a yearly Drug and Alcohol Training Plan within 2 weeks of accepting a position within the Drug and Alcohol Program. Within the Employee Training Plan form required trainings will be noted i.e., HIV 6 hour training and STD 4 hour training and CPR as deemed necessary by Clinical Director. The form will include and Assessment of Staff Training Needs, the NTC Plan for addressing those training needs. The Mechanism to collect feedback on completed trainings will also be included with this form, via a Drug and Alcohol Training Feedback form. Recommended training topics are noted on the Employee Training Plan and will include Drug and Alcohol Specific Trainings. All original Drug and Alcohol Training feedback forms will be kept within the staff person's Human Resource file with Clinical Director maintaining a copy as well as the staff person maintaining a copy. The Employee Training plan will be reviewed yearly in June. Additional goals will be added as appropriate. The Assessment of Training needs form notes acceptable Drug and Alcohol training topics. The required hours of training for counselor and supervisor are noted on the form. The Clinical Manager will be tracking the number of hours of completed Drug and Alcohol training related topics during monthly supervision with each employee and will be noted on the employee supervision and education form. This information will be forwarded to the Human Resource manager as the employee completes the training feedback form allowing Human Resources to track CEU's. Employee Human Resource charts will be audited quarterly by the Human Resource Manager and the Clinical Director to ensure that the Assessment of Staff Training needs forms are completed and filed appropriately.
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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
Based on a review of personnel and training records, the facility failed to provide documentation of HIV/AIDS training in one of four records reviewed.
The findings include:
Four personnel records were reviewed during the onsite licensure renewal inspection. Per regulation, staff persons shall receive a minimum of four hours of TB/STD training and six hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first two years of employment.
Employee #3 was hired by the facility on 3/23/2011 and moved to their current position as a counselor on 6/13/2011. This employee was required to obtain HIV/AIDS and TB/STD training by 6/13/2012. Employee #3 failed to obtain the training as of the date of the inspection.
The findings were reviewed with the Facility Director and confirmed.
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Plan of Correction
704.11 (c) (1) Mandatory Communicable Disease Training
Training has been scheduled on November 26th 2013, from 8am-4pm with the Pennsylvania Department of Health. The training will take place at the Northern Tier Counseling office in Towanda and will include staff that are currently providing Drug and Alcohol treatment as well as two staff that are anticipated to provide Drug and Alcohol treatment, as well as the Clinical Director. Human Resources will note the "Assessment of Staff training needs" form as part of all new hire paperwork for staff working in the Drug and Alcohol facility. Human Resources and the Clinical Director will track that the form is completed within the first two weeks that an employee agrees to provide Drug and Alcohol Services. Human Resources will request and maintain a copy of the training assessment in the employee's Human Resource file. Both Human Resources and Clinical Director can assess and ensure that the Assessment of Training needs has been completed by day 90 of the employees' initial orientation. The Clinical Director will be responsible for scheduling the HIV 6 hour training and STD 4 hour training for new staff in the Drug and Alcohol Facility. The trainings will be scheduled within the first 6 months of the staff's employment in the Drug and Alcohol Facility. The Clinical Director will note the date and time of the completed trainings on the Assessment of Staff Training needs form. The Assessment of Training needs form will be housed in the employee's Human Resource folder. The Human Resource charts of all Drug and Alcohol staff will be audited quarterly by the Human Resource Manager and the Clinical Director to ensure that the Assessment of Staff Training needs forms are completed and filed appropriately.
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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 the Staffing Requirements Facility Summary Report form completed by the facility on September 24, 2013, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed during the onsite licensing renewal inspection. The outpatient caseload computation sheet listed one counselor. The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 37.5 hours per week.
Based the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week 37.5, and the total number of clients assigned to the following employee on September 24, 2013 employee # 3 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by the facility's standard workweek.
The number of hours per week devoted by Employee # 3 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 18.75 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee #3 had 20 active clients.
Employee # 3 (18.75/35 = .54 FTE 20 clients/.54 FTE = 37:1 caseload)
The findings were reviewed with the Facility Director and confirmed.
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Plan of Correction
704.12 (a) (6) Outpatient Caseload
Northern Tier Counseling is currently training 2 new staff to work within the Drug and Alcohol department. The ratio of 35:1 became out of compliance due to a resignation of staff in August 2013. Moving forward the Clinical Director will complete the Staffing Requirements Summary Report on a quarterly basis to ensure that all staff are within compliance with the 35:1 staffing ratio. This Staffing Requirements Summary Report will be reviewed quarterly by the Compliance Manager.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
The fire drill logs were reviewed during the onsite licensing renewal inspection. The time period reviewed included October 2012 through August 2013. The facility did not document any alternate exits used during fire drills. The front, side and back exit routes were used during every fire drill that took place during this time period.
The findings were reviewed with the Facility Director and confirmed.
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Plan of Correction
705.28 (d) (5) Fire Safety
Fire Drills will be conducted throughout the week on a monthly basis and monitored by Clinical Director. Beginning in the month of October 2013 each drill will be conducted noting that an alternative exit was used during the fire drills. The fire drill log will be reviewed monthly by the Compliance Manager and Clinical Director.
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills were conducted during different times of the day.
The findings include:
The fire drill logs were reviewed during the onsite licensing renewal inspection. The time period reviewed included October 2012 through August 2013. The facility's hours of operation are Monday, Tuesday, Thursday and Friday from 8 a.m. to 4 p.m. and Wednesday from 8 a.m. to 8 p.m. The facility documented fire drills between the hours of 12 p.m. and 3:30 p.m. The facility failed to conduct morning or evening fire drills.
The findings were reviewed with the Facility Director and confirmed.
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Plan of Correction
705.(d) (6) Fire Safety
Fire Drills will be conducted throughout the week on a monthly basis and monitored by the Clinical Director. Beginning in the month of October 2013 drills will be conducted during random days and random times with specific attention focusing on Fire Drills that occur during the morning hours as well as the evening hours. The fire drill log will be reviewed monthly by the Compliance Manager and Clinical Director.
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709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on a review of personnel records, the facility failed to provide documentation of that informed personnel of their employee rights in two of two records reviewed.
The findings include:
Four personnel training records were reviewed during the onsite licensure renewal inspection. Two records required documentation of informing employees of their rights. The document used by the facility to demonstrate that employees are advised of their rights was consistently missing from the personnel records and was not documented elsewhere, # 2 and 4.
The findings were reviewed with the Facility Director and confirmed.
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Plan of Correction
709.26 (e) Personnel Management
All staff hired by Northern Tier Counseling attends an Orientation completed by the CEO of the organization within the first 60 days of their employment. It is during that time that the CEO will specifically note policies on employee rights. All staff attending this Policy Orientation sign in that they attended this training and the sign in sheets are kept with Human Resources. All staff are educated by Human Resources on the date of hire as to the location they may find all policies on line on the companies intranet. Hard copies of all policies can be obtained through the Human Resource Department. All staff will sign a Policy Acknowledgement form and this form will be filed within the employees Human Resource file within a timely manner. The Human Resource charts of all Drug and Alcohol staff will be audited quarterly by the Human Resource Manager and the Clinical Director to ensure that the Assessment of Staff Training needs forms are completed and filed appropriately.
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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 the client records, the facility failed to document consents to release information which identified the specific information to be disclosed in one of five client records. Additionally, the consents to release information exceeded Federal and State regulations in two of five records.
The findings include:
Five client records were reviewed during the onsite licensing renewal inspection.
Client # 1 was admitted on February 20, 2013. A release of information was signed on February 20, 2013 for a government agency. A letter addressed to the government agency dated February 20, 2013 included evaluation completion, recommendations, a specific diagnosis and the schedule of treatment sessions. The information disclosed exceeded the limitations imposed by Pa Code 255.5 (b).
Client #3 was admitted on March 20, 2013. A release of information was signed on May 8, 2013 for an employer that included progress, prognosis and treatment recommendations. The information disclosed exceeded the limitations imposed by Pa Code 255.5 (b).
Client # 5 was admitted on June 17, 2013. A release of information form was signed on June 17, 2013 for an insurance company. The facility failed to specify what information was to be released on the consent form. A release of information was signed on June 17, 2013 for "other agencies" that did not identify the agency or the information to be released on the consent form.
The findings were reviewed with the Facility Director and confirmed.
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Plan of Correction
709.28 ( c) Confidentiality
All Drug and Alcohol charts will be audited at the time of intake, randomly during current services and again at time of discharge. The Clinical Director and the Compliance Committee will be conducting these audits. With respect to the releasing information that "exceeded the limitations" imposed by PA Code 255.5; the clinical director will review with all staff the appropriate items that may be released with the appropriate/completed release of information. In addition, the Clinical Director will review all documentation that may be provided to another agency to ensure compliance in this area. The Clinical Director will review and co-sign all correspondence. The Clinical Director will randomly review Drug and Alcohol charts at time of intake, during active treatment and at discharge, the Clinical Director will review all releases to ensure that they specify what information was to be released on the consent form. Drug and Alcohol charts will also be audited randomly by the Compliance Committee to ensure accuracy in this area. The Compliance Committee will review all findings with the Clinical Director. The Clinical Director will complete In Service with all Drug and Alcohol staff on the PA Code 255.5 during the month of October 2013. Signed documentation relating to in service will be placed in the employees Human Resource file.
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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
Based on a review of client of records, the facility failed to document complete records in four of five records reviewed.
The findings include:
Five client records were reviewed during the onsite licensing inspection. Three client records were reviewed for case consultations and record of services. Two records were reviewed for discharge summaries.
Client # 3 was admitted on March 20, 2013. The record of service documentation ended on July 23, 2013. The progress notes documented sessions up to September 19, 2013.
Client # 5 was admitted on June 17, 2013. The record of service documentation ended on August 14, 2013. The progress notes documented sessions up to September 4, 2013. A case consultation is required every 90 days per regulation. A case consultation was due September 17, 2013. A case consultation was not documented in the client record at the time of the inspection.
Client #1 was admitted on February 20, 2013 and discharged on April 20, 2013. The discharge summary is due within 7 days of discharge per regulation. The discharge summary was due by April 27, 2013. The discharge summary was documented on August 28, 2013.
Client # # 2 was admitted on April 16, 2013 and discharged on June 1, 2013. The discharge summary is due within 7 days of discharge per regulation. The discharge summary was due by June 8, 2013. The discharge summary was documented on August 12, 2013.
The findings were reviewed with the Facility Director and confirmed.
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Plan of Correction
709.93 (a) Client Records
All Drug and Alcohol charts will be audited at the time of intake, randomly during current services and again at time of discharge. The Clinical Director and the Compliance Committee will be conducting these audits. With respect to the Record of Service; the clinical Director will verbally and in writing educate all staff that provide Drug and Alcohol treatment that the record of service is to be completed at each client contact. The clinical director will ensure that all client contact services are noted within the Record of Service via random charts audits. The Clinical Director will review the Service History/Edit list to ensure the use of the Record of Service.
With respect to the case consultation documentation; the clinical Director will verbally and in writing educate all staff that provides Drug and Alcohol treatment that the case consultation documentation is due every 90 days. It will be noted that the case consultation form should be completed with the client, reviewed with the treatment team and filed in the chart by the date that it is due. The Clinical Director will review caseload reports, noting those clients in care for 90 days to ensure that the case consultations form/'s are being completed timely.
With respect to Discharge documentation; the clinical Director will verbally and in writing educate all staff that provides Drug and Alcohol treatment that the Discharge documentation is due within 7 days of discharge per regulation. The Discharge documentation should be completed during the last session or when treatment team determines that client is no longer intent on participating in services. The discharge documentation should be completed and sent to the Clinical Director prior to the 7 days to ensure that all paperwork have been reviewed and case closed within the 7 day requirement.
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