INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 1-2, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Wes Corporation 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 March 6, 2010.
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Plan of Correction
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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 the review of personnel records, the facility failed to document a minimum of 4 hours of TB/STD training in one of seven records.
The findings include:
Eight personnel records were reviewed on February 1, 2010. Seven of the eight records required documentation of TB/STD training. The facility did not document 4 hours of TB/STD training in personnel record # 5.
Counselors are required to complete 4 hours of TB/STD training within the first year of employment. Personnel # 5, who is a counselor, was hired in October 2007, but 4 hours of TB/STD training was not documented at the time of review on February 2, 2010. The facility director confirmed that personnel record # 5 did not have documentation of TB/STD training.
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Plan of Correction
At the time of the on-site inspection there was no documentation present in the staff files. Since that time therapist has provided documentation of that training and a copy has been placed in the staff training files. Three (3) copies of all training certificates will be submitted to program director. One will be placed in training file that is kept on the unit, one will be sent to Human Resources and one will be submitted to the Training and Staff Development Director to insure that there is sufficient documentation of all trainings. The program director or designee will monitor for compliance. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of personnel records, the facility failed to document CPR and first aid training was provided to a sufficient number of staff persons so that at least one person trained in these skills is onsite during the project's hours of operation.
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The findings include:
Eight personnel records were reviewed on February 1, 2010. The facility did not document CPR and first aid training to a sufficient number of staff persons.
The facility did not document CPR and first aid training for their van driver.
The facility director confirmed that the driver did not have current documentation for CPR and first aid.
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Plan of Correction
According to the regulations there Was a sufficient number of staff trained in CPR/FA so that at least one person trained in these skills is onsite during program operations;However the van driver has been scheduled for
CPR/FA on 3/9/10 so that he may provide CPR when he is offsite. In the future all new staff will be scheduled for CPR within the first 30 days of employment. This will insure that all staff are trainined in CPR/FA and able to provide these skills on and off-site.
The Program Director or designee will monitor for 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 four counselor's personnel records, the facility failed to document a minimum of 25 hours of training in one of four records reviewed.
The findings include:
Four counselors's personnel records were reviewed on August 18-20, 2009. All four records required documentation of 25 clock hours of training annually. Personnel record # 4 documented only 11 of the required 25 training hours for the 2009 training year. The facility director confirmed that personnel record # 4 documented less than 25 hours of training for the 2009 training year.
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Plan of Correction
The therapist will received the required 25 hours of training. She will receive trainings @ BHTEN as well as WES to insure that she receives the required # of hours. A higher priority will be placed on insuring that the clinicians receive training during the first 6 months of the training year. The WES Institute which is held in August for one week should adequately address any additional training hours that are needed. The Program Director or designee will monitor for compliance.
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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation during a tour of the facility ' s physical plant, the facility failed to ensure that hallways and exits from the facility are unobstructed.
The findings include:
A tour of the physical plant was conducted on February 1, 2010 at approximately 1:00 PM. The facility was required to ensure that all exits remain unobstructed. The interior walkway of the emergency exit ramp was obstructed by leaves and debris at the time of inspection.
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Plan of Correction
The interior walkway of the emergency ramp will continue to be swept and kept clean on a regular basis as part of normal housekeeping duties. Housekeeping staff will ensure that any debris that has gathered at the bottom of the walkway is immediately
cleaned and the exit is unobstructed. Facility Director will perform ongoing checks of this exit to ensure that this occurs on a regular basis as part of the physical plant inspection conducted by agency staff.
QA Director and/or Facility Director will monitor for compliance. |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on observation during a tour of the facility ' s physical plant, the facility failed to clearly indicate exits by the use of signs.
The findings include:
A tour of the physical plant was conducted on February 1, 2010 at approximately 1:00 PM. The facility was required to clearly indicate exits by the use of signs. There were not exit signs at the bottom of the emergency exit ramp to indicate where to exit the building.
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Plan of Correction
On 2/1/10 a total of seven (7) new "Exit" signs were strategically
placed at the bottom of the exit walkway and the adjoining hallway
that is accessed upon exiting the bottom of the exit ramp from the
second floor clearly identifying where the Emergency Exits are located. The facilities director will survey the entire building to insure that all exits are clearly identified with proper signage. The facilities manager or designee will monitor for compliance.
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to document a drug and alcohol history in seven of seven client records.
The findings include:
Seven client records were reviewed on February 2, 2010. All seven records required documentation of a drug and alcohol history. The facility did not document a drug and alcohol history in client records # 1, 2, 3, 4, 5, 6 and 7.
The facility ' s policy titled " Comprehensive Bio-Psychosocial History " states:
" WES will ensure that a comprehensive biopsychosocial evaluation is developed on each consumer. The evaluation must provide a composite picture of the individual in relation to the data collected and must identify possible causes leading to the consumer ' s current situation. The consumer ' s assigned program therapist must complete the biopsychosocial evaluation within 30 days following the consumer ' s admission and registration process. "
Client records # 1, 2, 3, 5, 6 and 7 did not document a drug and alcohol history to include prior drug/alcohol treatment episodes.
Client records # 1, 2, 3, 5, 6 and 7 did not document a drug and alcohol history to include the client ' s perception of the effect substances have had on his/her social, physical and mental state.
Client records # 1, 2, 3, 5, 6 and 7 did not document a drug and alcohol history to include any substance abuse history within the client ' s family or that of significant others.
The admission date for client # 4 was 9/2409, but a drug and alcohol history was not documented at the time of review on 2/2/10.
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Plan of Correction
All client charts will have a complete drug and alcohol history. A meeting was held on 3/1/10 with the program director, medical director, director of Assessment and Evaluation Unit and the QA director to revise the current comprehensive biopsychosocial evaluation to insure that all areas of client's substance abuse history are documented. The revision will clearly identify client's perception of the effect substances have had on his/her social, physical and mental state. The revisions will also document and substance abuse history within the family or that of the significant others. In the event that a client's psychosocial cannot be completed within the 30 day timeframe, a note shall be placed in the client record explaining the reason that it was not completed. All clinical staff will be trained on the completion of the revised form. The program director or designee will complete chart reviews randomly and during supervision sessions to insure that clinicians are adhering to the documentation protocol.
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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
Based on the review of client records, the facility failed to document a personal history in seven of seven client records.
The findings include:
Seven client records were reviewed on February 2, 2010. All seven records required documentation of a personal history. The facility did not document a personal history in client records # 1, 2, 3, 4, 5, 6 and 7.
The facility ' s policy titled " Comprehensive Bio-Psychosocial History " states:
" WES will ensure that a comprehensive biopsychosocial evaluation is developed on each consumer. The evaluation must provide a composite picture of the individual in relation to the data collected and must identify possible causes leading to the consumer ' s current situation. The consumer ' s assigned program therapist must complete the biopsychosocial evaluation within 30 days following the consumer ' s admission and registration process. "
Client records # 1, 2, 3 and 4 did not document a personal history to include the client ' s legal history.
Client records # 1, 2, 3, 5, and 7 did not document a personal history to include the client ' s employment/vocation history.
Client records # 1, 2, 3, 5 and 6 did not document a personal history to include the client ' s recreational history.
The admission date for client # 4 was 9/24/09, but a personal history was not documented at the time of review on 2/2/10.
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Plan of Correction
The current biopsychosocial evaluation is being revised to insure that a complete personal history is documented on each client that will include the client's legal history, employment/vocational history and the client's recreational history. All clinical staff will receive training on the completion of the revised form. The program director or designee will monitor for compliance by completing chart reviews both randomly and during supervision sessions.
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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
Based on the review of client records, the facility failed to document a psychosocial evaluation in three of seven client records.
The findings include:
Seven client records were reviewed on February 2, 2010. All seven records required documentation of a psychosocial evaluation. The facility did not document a psychosocial evaluation in client records # 1, 6 and 7.
The facility ' s policy titled " Comprehensive Bio-Psychosocial History " states:
" WES will ensure that a comprehensive biopsychosocial evaluation is developed on each consumer. The evaluation must provide a composite picture of the individual in relation to the data collected and must identify possible causes leading to the consumer ' s current situation. The consumer ' s assigned program therapist must complete the biopsychosocial evaluation within 30 days following the consumer ' s admission and registration process. "
The admission date for client # 1 was 9/1/09, but a biopsychosocial evaluation was not documented at the time of review on 2/2/10.
The admission date for client # 6 was 7/22/09; the discharge date was 11/30/09, but a biopsychosocial evaluation was not documented at the time of review on 2/2/10.
The admission date for client # 7 was 7/28/09; the discharge date was 11/20/09, but a biopsychosocial evaluation was not documented at the time of review on 2/2/10.
The facility director confirmed that client records # 1, 6 and 7 did not have a psychosocial evaluation documented at the time of review on 2/2/09.
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Plan of Correction
All client records will have a completed psychosocial evaluation. As per the policy and procedure all psychosocial evaluations will be completed within 30 days of admission. If the psychosocial cannot be completed due to client's failure to keep scheduled appointments or other reasons this will be clearly documented in the client record. All staff will receive additional training to insure that policies and procedures are adhered to. Program Director or designee will conduct regular chart reviews to insure that clinicians are documenting accordingly. Training will be provided on an on-going basis to insure that all staff and specifically new staff understand and are following the procedure. |
709.92(a) 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:
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Observations
Based on the review of client records, the facility failed to document an individualized treatment plan in four of seven client records.
The findings include:
Seven client records were reviewed on February 2, 2010. All seven records required documentation of an individual treatment plan. The facility did not document an individualized treatment plan in client records # 1, 2, 3 and 6.
The facility ' s policy titled " Treatment and Rehabilitation Plan " states:
" The Preliminary treatment plan will be completed within fifteen (15) days of admission; The Comprehensive Treatment plan will be completed within thirty (30) days of admission; Treatment plan updates occur every (60) days thereafter. "
The admission date for client # 1 was 9/1/09, but a treatment plan was not documented at the time of review on 2/2/10.
The admission date for client # 6 was 7/22/09, but a treatment plan was not documented at the time of review on 2/2/10.
The treatment plan in client record # 2 documented on 9/9/09 was identical to the treatment plan in client record # 3 documented on 9/11/09.
The facility director confirmed that client records # 1, 2, 3 and 6 did not have an individual treatment plan documented at the time of review on 2/2/09.
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Plan of Correction
An individual treatment and rehabilitation plan shall be developed with each client within the timeframes specified in the policy and procedures manual. If the treatment plan cannot be completed within the prescribed timeframes the reasons will be clearly documented in the client record. The clinical staff will be re-trained on the treatment plan process. The current treatment plan will be revised to include clear documentation of the client's progress made towards each treatment goal. The program director or designee will meet with clinicians during supervision and random chart reviews will be completed to insure that treatment plans are in compliance.
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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
Based on the review of client records, the facility failed to document a treatment plan update in five of five client records.
The findings include:
Seven client records were reviewed on February 2, 2010. Five of the seven records required documentation of a treatment plan update. The facility did not document a treatment plan update in client records # 2, 3, 4, 5 and 7.
The facility ' s policy titled " Treatment and Rehabilitation Plan " states:
" The Preliminary treatment plan will be completed within fifteen (15) days of admission; The Comprehensive Treatment plan will be completed within thirty (30) days of admission; Treatment plan updates occur every (60) days thereafter. "
In client record # 2, a comprehensive treatment plan was documented on 9/9/09, but the treatment plan update was not documented until 12/31/09.
Additionally, the treatment plan update documented on 12/31/09 did not include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan.
In client record # 3, the comprehensive treatment plan was documented on 9/11/09, but a treatment plan update was not documented at the time of review on 2/2/10.
In client record # 4, the comprehensive treatment plan was documented on 10/24/09, but the treatment plan update documented on 12/31/09 did not include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan.
In client record # 5, the comprehensive treatment plan was documented on 10/20/09, but the treatment plan update was not documented until 1/11/10.
Additionally, the treatment plan update documented on 1/11/10 did not include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan.
In client record # 7, the comprehensive treatment plan was documented on 8/25/09, but the treatment plan update documented on 10/28/09 did not include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan.
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Plan of Correction
A preliminary treatment plan will be developed with the client within 15 days of admission into the program. A comprehensive treatment plan will be developed 30 days after the date of admission and treatment plan updates will be completed every 60 days thereafter. In the event that a treatment plan cannot be completed within the prescribed timeframe due to the client's non-compliance documentation will be placed in the client record indicating the specific reason(s). The current treatment plan is being revised to more clearly indicate the client's progress towards each goal outlined in their treatment plan. To insure that all treatment plans are completed within the prescribed timeframes and that they are completed accurately all clinical staff will be re-trained on the documentation protocol. Additionally the program director or designee will conduct chart reviews randomly and during supervision sessions to monitor for compliance. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document a case consultation note in five of seven client records.
The findings include:
Seven client records were reviewed on February 2, 2010. All seven records required documentation of a case consultation. The facility did not document a case consultation every 90 days, as stated in their policy manual, in client records # 1, 2, 3, 6 and 7.
The facility ' s policy titled " Case Conference " states:
" A Case Conference is due every 90 days within date of admission. "
Client # 1 was admitted to the program on 9/1/09, but a case consultation was not documented at the time of review on 2/2/10.
Client # 2 was admitted to the program on 8/12/09, but a case consultation was not documented at the time of review on 2/2/10.
Client # 3 was admitted to the program on 8/13/09, but a case consultation was not documented at the time of review on 2/2/10.
Client # 6 was admitted to the program on 7/22/09 and discharged on 11/23/09, but a case consultation was not documented at the time of review on 2/2/10.
Client # 7 was admitted to the program on 7/28/09 and discharged on 11/20/09, but a case consultation was not documented at the time of review on 2/2/10.
The facility director confirmed that client records # 1, 2, 3, 6 and 7 did not have a case consultation documented at the time of review on 2/2/09.
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Plan of Correction
Case consultation notes will be documented on each client every 90 days. To insure that this occurs all clients will be reviewed during weekly treatment team meetings to determine when their case consultation is due. Case consultations will be completed at that time. Program director or designee will also review clients in need of case consultations during clinical supervision as well as during random chart reviews to monitor for compliance. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in one of two client records.
The findings include:
Seven client records were reviewed on February 2, 2010. Two of the seven records required documentation of follow-up information. The facility did not document follow-up information within 30 days from the date of discharge, as stated in their policy manual, in client record # 7.
The facility ' s policy titled " Follow-Up " states:
Follow-up will occur on clients who successfully complete treatment within seven (7) days. Clients terminated and not referred will be followed up in thirty (30) days. The therapist or case manager will be responsible for contacting the client.
Client # 7 was admitted to the program on 7/28/09 and discharged on 11/20/09, but follow-up was not documented at the time of review on 2/2/10.
The facility director confirmed that client record # 7 did not have follow-up information documented at the time of review on 2/2/09.
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Plan of Correction
A follow-up contact will be documented on all clients discharged from the program. Follow-up will occur within seven (7) days of discharge for those clients who have successfully completed treatment. For unsuccessful discharges there will be a follow-up within 30 days of discharge. To insure that this occurs the Program Director or designee will conduct weekly chart reviews both randomly and during clinical supervision to insure that documented follow-up is occurring. Discharges will also be discussed during weekly treatment team meetings. Clinical staff will also be re-trained on follow-up documentation protocol. Program Director or designee will monitor for compliance |