INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24 - 26, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Health Masters, 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 and a plan of correction is due on March 23, 2009. .
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Plan of Correction
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative policies and procedures and an interview with the facility director, the facility failed to document a written agreement with a licensed hospital or physician, for 24 hour emergency medical coverage.
The findings include:
The administrative policies and procedures were reviewed on February 24, 2009. The facility did not document a written agreement with a licensed hospital or physician, for 24 hour emergency medical coverage. The project director reports the facility has been unable to obtain a signed agreement with the local hospital.
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Plan of Correction
1. The program has been in the process of securing a 24 hour service agreement
for emergency medical and psychiatric care with the Medical Center of Beaver, Heritage Valley, as previous agreement was with Commonwealth Medical Center that has shut down. Facility Director has been in pursuit of Administration of Heritage Valley to sign an agreement, but has not been able to obtain a finalized, signed copy for records. Facility Director will continue, along with Board of Directors of Health Masters, to seek agreement with Medical Center, as it is the appropriate and obvious provider of the necessary services in the geographic area. Compliance with standard and securing of agreement will be attained by April 30, 2009.
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document annual staff work performance evaluations in four of six personnel records.
The findings include:
Six personnel records were reviewed on February 24, 2009. Annual staff work performance evaluations were required in six personnel records. The facility did not document annual staff work performance evaluations in personnel records # 1, 3, 5 and 6.
Employee # 1 was hired on August 4, 2004. The annual work performance evaluation for 2008 was due by August 4, 2008. The facility failed to document an annual work performance evaluation.
Employee # 3 was hired on December 12, 2004. The annual work performance evaluation for 2008 was due by December 12 , 2008. The facility failed to document an annual work performance evaluation.
Employee # 5 was hired on February 13, 2006. The annual work performance evaluation for 2008 was due by February 13, 2008. The facility failed to document an annual work performance evaluation.
Employee # 6 was hired on September 2, 2006. The annual work performance evaluation for 2008 was due by September 2, 2008. The facility failed to document an annual work performance evaluation.
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Plan of Correction
2. The facility will begin utilizing an employee form, obtained through Department of Health, that will serve as a "checklist" of required documentation for employees initiating with date of hire. Annual Work Performance Evaluation will be included in checklist, which will be maintained with personnel files. It will be the duty of Facility Director and Administrative Assistant to review checklist at the conclusion of weekly staff meeting, particularly the first weekly meeting of each month, and schedule the proper evaluations for the month. A copy of each "checklist" will be maintained in a separate file for review monthly. Compliance with process will begin during the month of April, 2009, with Facility Director and Administrative Assistant compiling checklists for all staff members and bringing all requirements up to date. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in two of two client records.
The findings include:
Twenty-two client records were reviewed on February 25 - 26, 2009. Two records were required to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client records # 19 and 20.
In client record # 19, the client was involuntarily terminated from the project on November 24, 2008. There was no documentation of written notification to the client.
In client record # 20, the client was involuntarily terminated from the project on November 6, 2008 . There was no documentation of written notification to the client.
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Plan of Correction
3. Facility director will schedule an in-house review for all clinical staff members regarding program policy on involuntary termination. Policy requires the notification of termination, in writing, to patient on a form that is currently in place. Facility Director will require all involuntary terminations be discussed in staff meetings with Narcotic Treatment Physician, and Involuntary Termination Form be attached to Discharge Summary for completion of documentation. Training of staff and compliance with process to be effective by April 30, 2009. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to provide written documentation of the proposed type of support services, in the individual treatment and rehabilitation plans, in four of eleven client records.
The findings include:
Twenty-two client records were reviewed on February 25 - 26, 2009. The individual treatment and rehabilitation plans were required to document support services in eleven client records. The facility did not document support services in client records # 3, 4, 5 and 8.
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Plan of Correction
4. Facility director will review with counseling staff during weekly staff meeting
the standards regarding inclusion of support services in individual treatment planning. Services offered in the area will be reviewed, and a copy of listing will be supplied to each counselor. Clinical Supervisor will be responsible for the inclusion of support services in all individual treatment plans, and will not approve any individual treatment plan that does not include a proposed type of service. Those counselors consistently submitting individual treatment plans without inclusion of support services will be required to attend additional training, either in-house or through another provider, on the topic of support and effective treatment plan formulation. Review with counseling staff will be held prior to April 30, 2009.
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of personnel records, the facility failed to provide documentation of the clinical supervisor completing a core curriculum in clinical supervision, in one of one personnel records.
The findings include:
Six personnel records were reviewed on February 24, 2009. The core curriculum in clinical supervision was required in one personnel record. The facility did not document completion of a core curriculum in clinical supervision in personnel record # 1.
Employee # 1 is a clinical supervisor and was hired for this position on September 1, 2006. Employee # 1 did not have two years of experience in clinical supervision. There is no documentation that employee # 1 completed the required core curriculum in clinical supervision.
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Plan of Correction
5. Health Masters shall place in the position of clinical supervisor an individual
who meets the qualifications of a clinical supervisor under the standard, or will have an individual assigned as clinical supervisor receive core curriculum training. Facility Director will attempt to have clinical supervisor attend training being offered by BDAP on the dates of 5/4/09 through 5/8/09. It will be the responsibility of the Facility Director to ensure that the clinical supervisor position is held by staff member who meets the qualifications of the standards, with compliance by 5/31/09.
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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 records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in one of six personnel records.
The findings include:
Six personnel records were reviewed on February 24, 2009. Six personnel records were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training in personnel record # 3.
Employee # 3 is a counselor and was hired December 12, 2004. HIV/AIDS and TB/STD training was due to be completed by December 12, 2005. The facility failed to provide documentation of TB/STD training.
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Plan of Correction
6. The facility will begin utilizing an employee form, obtained through Department of Health, that will serve as a "checklist" of required documentation for employees initiating with date of hire. HIV/AIDS and STD/TB trainings will be included on this checklist. It will be the duty of Facility Director and Administrative Assistant to review checklist at the conclusion of weekly staff meeting, particularly the first weekly meeting of each month. A copy of each "checklist" will be maintained in a separate file for review monthly. Compliance with process will begin during the month of April, 2009, with Facility Director and Administrative Assistant compiling checklists for all staff members and bringing all requirements up to date. Counselor whose record was incomplete during recent survey has been scheduled to attend STD/TB training on March 25, 2009 at Gateway Rehabilitation Center. |