INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the March 15-16, 2011 licensure renewal inspection. The follow-up inspection was conducted on September 20, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Open Door Counseling At Mazzoni Center 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(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 personnel records and an interview with the project director, the facility failed to document at least 25 clock hours of training annually in one of two personnel records.
The findings include:
On March 16, 2011 two personnel records identified as counselors during the 2010 training year were reviewed for documentation of 25 clock hours of training. The facility did not document 25 hours of training during the 2010 training year in personnel record #5.
Personnel record #5 documented only 12 hours of training for the 2010 training year.
An interview with the facility director on March 16, 2011, confirmed that personnel record #5 did not contain at least 25 hours of training for the 2010 training year.
This was still out of compliance at the time of the follow-up conducted on September 20, 2011.
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Plan of Correction
Staff #5 has registered for and received training in the specified areas that will be completed at the conclusion of this calendar year which will total the requisite 25 hours.
At the time of the recent site inspection, Staff #5's personnel record was not available for inspection; however, 20 training hours have been logged and 5 more will be completed before the end of 2011.
Program Director will continue to instruct and advise on appropriate training areas and ensure staff completes the required number of training hours. HR will monitor for ongoing ocmpliance. |
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 and facility policy and procedures, the facility failed to document client psychosocial evaluations in accordance with facility policy and procedures.
The findings include:
The facility's psychosocial evaluation policy states: "Comprehensive Biopsychosocial History and Evaluation (to be completed on or before 4th session)".
On September 20, 2011, psychosocial evaluations in two client records were reviewed, specifically records # 1 and 6. The facility did not document a psychosocial evaluation on or before the 4th session, as per facility policy, in client records # 1 and 6.
Client # 1 was admitted on 5/3/11. The psychosocial evaluation in client # 1's record was not signed or date by the counselor, so it was not possible to determine if the psychosocial evaluation had been complete by the 4th session.
Client # 6 was admitted on 6/23/11. Progress notes and the record of service in client # 2's record state individual counseling sessions occurred on 6/23/11, 8/2/11, 8/9/11, and 8/30/11. A psychosocial evaluation was due to be completed on or before 8/30/11, but the record did not contain a psychosocial evaluation as of the date of this inspection.
An interview with the director on September 20, 2011 confirmed the findings.
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Plan of Correction
To correct the recent findings, the counselor will correct Client #1's psychosocial evaluation by signing and dating in order to accurately reflect completion of this documentation. This will bring the psychosocial evaluation into compliance.
Staff will complete a psychosocial evaluation for Client #6 in order to meet program requirements.
Staff is aware of the requirement to complete psychosocial evaluation prior to 4th session. Program Director has conducted a meeting with staff on 10/5/11 in which we reviewed documentation requirements. Program Director and Clinical Supervisor will continue to monitor on a quarterly basis for compliance. Program Director will hold quarterly meetings with staff to review documentation in order to ensure compliance. |
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 and the facility's policies and procedures manual, the facility failed to document a treatment plan in accordance with facility policy and procedures.
The findings include:
The facility's treatment plan policy states: "Initial Treatment Plan (to be completed before the 5th session)".
On September 20, 2011 one client record requiring documentation of a treatment plan was reviewed. The facility did not document a treatment plan before the 5th session, as per facility policy, in client record # 1.
Client # 1 was admitted on 5/3/11. Progress notes and the record of service in client # 1's record state individual counseling sessions occurred on 5/3/11, 6/22/11, 6/29/11, 7/13/11, 7/27/11 and 8/10/11. The Initial treatment plan in client # 1's record was dated 8/10/11, which was the 6th session.
An interview with the director on September 20, 2011 confirmed the findings.
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Plan of Correction
While facility has made progress in this area, we need to continue to develop consistency among staff in meeting documentation deadlines. Program Director met with staff on 10/5/11 to reiterate program policies and procedures regarding documentation. Supervisor will review charts on a monthly basis and report any identified progblems or patterns to PD. Program Director will hold quarterly meetings to refresh and review policies with staff and also to review charts for compliance on a quarterly basis. |