INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 21, 2007 through February 23, 2007 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 April 4, 2007.
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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
There was no documentation available during the inspection to demonstrate monthly supervisory meetings with the two newest clinical supervisors and their supervisor.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
There was no documentation available for six hours of HIV/AIDS training and four hours of TB/STD and other communicable diseases training for employees #1 and 2.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
One counselor failed to obtain 25 hours of training for the previous training year. Employee #2 obtained only 19.5 hours of training for the previous training year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.81(b)(3)(i) LICENSURE Medical History
711.81. 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 missing or incomplete in client records # 1, 2, 3, 4, 5, 6, 7, 10 and 11. Documentation of symptoms and illnesses, except for psychiatric symptoms, was inconsistent.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.81(b)(3)(iii) LICENSURE Personal History
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The personal history was missing from client record #6. The personal histories were incomplete, providing for poorly documented family history, education and vocational history and sexual history in client records # 1, 2, 9, 10 and 11.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.81(b)(4) LICENSURE Consent to Treatment
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
The drug and alcohol treatment facility is using the University of Pittsburgh Medical Center general consent to treatment form. This form is designed for general hospital use and fails to acknowledge the behavioral health aspects of the treatment that will be provided. This form also contains language that could be interpreted as a general consent to release information, which is inappropriate for use in a drug and alcohol treatment facility.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.82(c)(2) LICENSURE Type/Frequency of Treatment
711.82. Treatment and rehabilitation services.
(c) 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 partial hospital treatment plans do not provide for the type and frequency of treatment that will be provided. Instead, the treatment plans in client records # 3, 5, 8 and 9 listed only that it was partial hospital treatment instead of indicated the frequency of individual, group, and family treatment sessions that would occur.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.82(f)(1) LICENSURE Ind Counseling - 2X WK
711.82. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Individual counseling was not provided at least twice per week in client records # 3, 7 and 9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.82(g)(3) LICENSURE Legal Support Services
711.82. Treatment and rehabilitation services.
(g) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
The facility was unable to provide documentation demonstrating its ability to assist clients in obtaining legal support services.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.82(g)(6) LICENSURE Vocational Support Services
711.82. Treatment and rehabilitation services.
(g) The project shall assist the client in obtaining the following supportive services when necessary:
(6) Vocational.
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Observations
The facility was unable to provide documentation demonstrating its ability to assist the client in obtaining vocational support services.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.83(a)(7) LICENSURE Follow-up Information
711.83. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Documentation of follow up attempts on discharged clients was missing from client records #3 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.83(c)(2) LICENSURE Informed/Voluntary Consent
711.83. Client records.
(c) Confidentiality.
(2) 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
General consents to release information were found to be an intrinsic part of the University of Pittsburgh Medical Center consent to treatment form. The use of general consents to release information are prohibited directly by 42 CFR Part 2, Subpart C, subsection 2.32 and indirectly at subsection 2.31 and in this state regulation.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.83(c)(2)(ii) LICENSURE Specific Information Disclosed
711.83. Client records.
(c) Confidentiality.
(2) 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:
(ii) The specific information disclosed.
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Observations
The releases of information identified in client records #3, 4 and 7 exceeded the limits imposed at 4 Pa. Code Subsection 255.5(b), where the releases of information were made to third party payers, government officials, criminal justice entities and/or their agents.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.85(b) LICENSURE Efficient Retrieval of Data
711.85. Uniform Data Collection System.
(b) A data collection shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
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Observations
The electronic record keeping system, which works in conjunction with a hard copy record keeping system, was not efficient at the time of the review. Licensing specialists were locked out of the system frequently during the inspection and resulted in lost time for the licensing specialists. Informal interviews with WPIC employees who must use this system have confirmed that there a flaws in the system that have yet to be solved.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.91(b)(3)(i) LICENSURE Medical History
711.91. 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 missing or incomplete in client records # 1, 2, 5, 6, 10 and 11. Documentation of symptoms and illnesses, except for psychiatric symptoms, was inconsistent.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.91(b)(3)(iii) LICENSURE Personal History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The personal histories were incomplete, providing for poorly documented family history, education and vocational history and sexual history in client records # 1, 2, 8, 10 and 11.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.91(b)(4) LICENSURE Consent to Treatment
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
The drug and alcohol treatment facility is using the University of Pittsburgh Medical Center general consent to treatment form. This form is designed for general hospital use and fails to acknowledge the behavioral health aspects of the treatment that will be provided. This form also contains language that could be interpreted as a general consent to release information, which is inappropriate for use in a drug and alcohol treatment facility.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Documentation of follow up attempts on discharged clients was missing from client records #3 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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
General consents to release information were found to be an intrinsic part of the University of Pittsburgh Medical Center consent to treatment form. The use of general consents to release information are prohibited directly by 42 CFR Part 2, Subpart C, subsection 2.32 and indirectly at subsection 2.31 and in this state regulation.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. Client records.
(c) Confidentiality.
(2) 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:
(ii) The specific information disclosed.
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Observations
The releases of information identified in client records #3, 4 and 7 exceeded the limits imposed at 4 Pa. Code Subsection 255.5(b), where the releases of information were made to third party payers, government officials, criminal justice entities and/or their agents.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.95(b) LICENSURE Efficient Retrieval of Data
711.95. Uniform Data Collection System.
(b) A data collection system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
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Observations
The electronic record keeping system, which works in conjunction with a hard copy record keeping system, was not efficient at the time of the review. Licensing specialists were locked out of the system frequently during the inspection and resulted in lost time for the licensing specialists. Informal interviews with WPIC employees who must use this system have confirmed that there a flaws in the system that have yet to be solved.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |