INITIAL COMMENTS
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This is a report of the on-site licensure renewal inspection conducted on September 18 through 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 12, 2006.
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Plan of Correction
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Employee #1 is required to obtain 12 hours of training per year and did not receive any training during the 2005 training year.
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Plan of Correction
Explanation: Employee #1 not aware on-line training hours do not count toward required training hours. Now aware of required training hours and for 2006, has completed 12 hours to date. Project director will monitor and ensure compliance in future. |
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
Employee # 20 only had one hour of the required 25 hours of training for the 2005 training year.
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Plan of Correction
Explanation - Employee #20 did not fulfill training hours due to lack of monitoring system. Monitoring system in place by Facility Director. Employee #20 has fulfilled required training hours for 2006 to date. Facility director will continue to monitor and ensure compliance in the future for required training hours for clinical and non-clinical staff. |
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
Policies and procedures were missing the content of the consent to release information forms. The information to be released without patient consent in policy and procedure exceeded that allowed by regulation.
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Plan of Correction
Explanation - Facility Director needed further direction and clarification regarding excess information being released without consent with regard to confidentiality. Written policy has been modified to ensure compliance with regulation. Training will be provided to all staff with regard to policy change. Facility Director will monitor to ensure compliance in future. |
709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
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Observations
Physical examinations were missing vital signs in twelve of twelve records reviewed, # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.
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Plan of Correction
Initial Physician Exam indicated a review of latest vital signs by examining physician/CRNP. Form will be modified to include vital signs for all patients during history and physical. Medical Director has been informed of this change and will continue to monitor compliance in this area. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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) Discharge summary.
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Observations
Discharge summaries did not consistently contain the required components. The client's response to treatment plan goals was missing client record #23. The services provided were missing or incomplete in six records reviewed, #7, 8, 13, 14, 15 and 16. The reason's for treatment were not addressed in six records reviewed, #7, 8, 13, 14, 15 and 16.
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Plan of Correction
Counselors were not completing discharge summaries in the correct manner due to lack of formal training. Facility Director will provide an in-depth in-service/training with regard to discharge summaries and its required components, specifically patient's response to treatment, services provided and reason for treatment. Facility Director will monitor compliance in this area via chart checks, which will include discharge summaries. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Follow up information was not documented in two records reviewed, #7 and 8.
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Plan of Correction
Follow-up information was made to referral source rather patient him/herself. Policy will be modified to indicate that a follow-up call shall made to patient regardless of discharge type. A release will be obtained from patient allowing participation in follow-up program. Facility Director will provide in-service to Quality Improvement team, who are responsible for aftercare follow-up. Aftercare follow-up calls will be made to patient for discharges other than regular, specifically Against Medical Advice, AWOL, Transfer, Therapeutic. Facility Director will monitor for compliance. |
709.64(e) LICENSURE Follow-up policy
709.64. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
The follow up policy did not address all types of discharges.
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Plan of Correction
Policy indicated follow-up call were made made to referral source rather patient him/herself. Policy will be modified to indicate that a follow-up call shall made to patient for discharges that are specifically Against Medical Advice, AWOL, Therapeutic, Transfers. A release will be obtained from patient allowing participation in follow-up program. Facility Director will provide in-service to Quality Improvement team regarding policy change. Facility Director will monitor for compliance. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
The physical examinations did not include vital signs in twelve of twelve records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.
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Plan of Correction
Initial Physician Exam indicated a review of latest vital signs by examining physician/CRNP. Form will be modified to include vital signs for all patients during history and physical. Medical Director has been informed of this change and will continue to monitor compliance in this area. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The frequency of services to be provided were missing in six of six record reviewed, # 1, 2, 3, 4, 5 and 6.
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Plan of Correction
Treatment plans indicate frequency of activitiy specific to goal, but was missing frequency of services, specifically individual therapy, group therapy, workshops, lectures. Treatment plan forms will be modified to indicate frequency of all services for all patients. Facility Director will implement change, provide training to all counseling staff regarding treatment plan change and monitor compliance via daily chart checks. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
The reasons for this treatment experience were missing in six of six client records reviewed, #7, 8, 13, 14, 15 and 16.
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Plan of Correction
Counselors were not completing discharge summaries in the correct manner due to lack of formal training. Facility Director will provide an in-depth in-service/training with regard to discharge summaries and its required components, specifically patient's reason for treatment. Facility Director will monitor compliance in this area via chart checks, which will include discharge summaries. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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
Follow up information was not documented in three client records reviewed, # 13, 14 and 16.
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Plan of Correction
Follow-up information was made to referral source rather patient him/herself. Policy will be modified to indicate that a follow-up call shall made to patient regardless of discharge type other than regular. A release will be obtained from patient allowing participation in follow-up program. Facility Director will provide in-service to Quality Improvement team, who are responsible for aftercare follow-up. Aftercare follow-up calls will be made to patient for discharges other than regular, specifically Against Medical Advice, AWOL, Transfer, Therapeutic. Facility Director will monitor for compliance. |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
The follow-up policy did not address all types of discharges.
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Plan of Correction
Policy indicated follow-up call were made made to referral source rather patient him/herself. Policy will be modified to indicate that a follow-up call shall made to patient for discharges that are specifically Against Medical Advice, AWOL, Therapeutic, Transfers. A release will be obtained from patient allowing participation in follow-up program. Facility Director will provide in-service to Quality Improvement team regarding policy change. Facility Director will monitor for compliance |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Frequency of medication use was missing in four of four records, #17, 18, 19 and 20.
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Plan of Correction
Forms used did not require this information to be recorded. Form will be modified to include frequency of medications. Facility Director will provide an in-service regarding change to form. Facility Director will monitor compliance via open and closed chart checks. |