INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 27-29, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Home Nursing Agency Community Services 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 April 1, 2008.
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Plan of Correction
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on the review of administrative documentation during the onsite licensing inspection of February 27-29, 2008, the facility failed to identify the appropriate staff member as the project director. The project director requirements identified in the Licensing Alert issued May 2005 were not met by the staff member currently identified as project director.
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Plan of Correction
Project Director
The agency currently identifies Robert Packer, CEO of Home Nursing Agency, as the Project Director. We will request that our board approve a request to waive the requirements for the Project Director to have mandatory trainings or will request approval from the board to have Donna Hartford, Executive Director, report directly to the board regarding the Drug & Alcohol program by April 24, 2008.
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the agency manual and employee training records, the facility failed to consistently document training evaluation forms in four of nine employee records, specifically records #1, 3, 4 and 7.
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Plan of Correction
704.11 (a) (3) ? Staff Development Program
THE CREATOR OF THE INSERVICE PROGRAM WILL:
A. Identify a minimum of two and a maximum of seven instructional objectives for the in-service
program, ensuring that the objectives are appropriate and measurable.
B. Insert the instructional objectives into the Education Program Evaluation (form #680) or
Independent Learning Module/Program (form #678).
C. Provide copies of the completed Evaluation form to the presenter or include it with the
materials given directly to the participants, if the program is an independent learning module.
II. THE PRESENTER WILL:
A. Instruct the participants to complete the evaluation form.
B. Return the completed forms to the creator of the in-service.
III. THE PARTICIPANT WILL:
A. Complete the evaluation form as follows:
Procedure 2025.02
1. Record the date of the program, program title, instructor (if applicable), name
(optional) and discipline/position.
2. Evaluate if each of the instructional objectives were not met, partially met or met.
3. Evaluate each aspect of the presentation/teaching method as very poor, poor, fair,
good, or very good.
4. Complete the Additional Comments section.
B. Return the completed form to the presenter or to the designated person, if the program was an
independent learning module.
IV. THE CREATOR OF THE INSERVICE WILL:
A. Tabulate the data.
1. Instructional Objectives ? calculate the percentage that was not met, partially met, or
met for each objective. Calculate an overall percentage of the instructional objectives that
were not met, partially met or met. Items which received no response are ignored in the
calculations.
2. Presentation/Teaching Method ? calculate a weighted mean score for each item, using
the following weights: very poor=0, poor=25, fair=50, good=75, and very good=100.
Calculate an overall mean score. Items which received no response are ignored in the
calculations.
3. Additional Comments ? record the comments noted by the participants.
B. Create a summary of the data.
C. Distribute the summary to the presenter, as appropriate.
D. Forward a copy of the summary to:
1. If required for All staff ? Secretarial Services
2. If program specific ? the appropriate program
E. Create additional programs if the instructional objectives were not met.
F. Incorporate the comments and summary information into future programs.
V. SECRETARIAL SERVICES OR THE PROGRAM SECRETARY WILL:
A. File In-service Program Description and attendance list in the In-service Manual.
Procedure 2025.02
B. Maintain in-service records indefinitely for topics related to Infection Control and Safety and
for at least 5 (five) years for all other topics, unless longer time frames are required by specific
program, regulatory or accreditation guidelines.
Currently in place; 3/26/08
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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 documentation reviewed in agency training records during the onsite inspection held February 27-29, 2008, employee (#7) did not have the minimum number of training hours for the last training year. Only 9 hours of documented training was found in the training record.
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Plan of Correction
704.11 (f) (2) ? Training Requirements for Counselors
The Counselor will attend Training 4/8/2008 on 'Cultural Competency' and on 4/16/08 on 'Addiction & Mental Health' in Altoona PA. This will total 25 annual training hours approved by the Department of Drug & Alcohol.
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709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. 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 a review of client records during the onsite licensing inspection held February 27-29, 2008, the facility failed to document a detailed drug and alcohol history in records # 4, 9 and 11. The sample consisted of four records.
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Plan of Correction
Partial Hospitalization
709.81 (b) (3) (ii) ? Drug or Alcohol History, or both
Admissions Supervisor met with staff on 3/13/08 to educate the assessment counselors on the drug & alcohol history documentation for the substance most frequently abused, the length and patterns of use, prior to treatment episodes. Included in the assessment will be the client's perception of the effect his/her substance use has had on his/her social, physical and mental state. In addition, any other substance abuse history within the family or that of a significant other will be noted. Admissions staff will continue to monitor charts quarterly and Admissions Team Manager will review audits and discuss needed corrections as they arise.
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709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records during the onsite licensing inspection held February 27-29, 2008, the facility failed to collect detailed personal histories in records # 2, 4, 9 and 11. The sample was four records
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Plan of Correction
709.81 (b) (3) (iii) ?Personal History Partial Hospitalization;
Admissions Supervisor met with staff on 3/13/08 to educate the assessment counselors on how to document the historical and current personal data including: family, legal, employment/vocational, educational, military, recreational, sexual, and others where appropriate.
Admissions staff will continue to monitor charts quarterly and Admissions Team Manager will review audits and discuss needed corrections as they arise.
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709.81(b)(6) LICENSURE Intake and admission
709.81. 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 on February 27-29, 2008, the facility failed to address the required components of the psychosocial evaluation in the following client records: #2, 4, 9 and 11. The record sample consisted of four client records.
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Plan of Correction
709.81 (b) (6) ? Psychosocial Evaluation,Partial Hospitalization;
Admissions Supervisor met with staff on 3/13/08 to educate the assessment counselors on a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. This evaluation will include:
A clear description of the client's presenting and underlying problems; Client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment; Client strengths that can contribute to the resolution of identified problems; the client supports; negative factors that might affect treatment; client's coping mechanisms; conclusion regarding the client's appearance, behavior and reactions during the intake process; and conclusions regarding the client's attitude toward and ability to participate in the recommended treatment.
Admissions staff will continue to monitor charts quarterly and Admissions Team Manager will review audits and discuss needed corrections as they arise.
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709.83(a)(9) LICENSURE Client records
709.83. 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:
(9) Progress notes.
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Observations
Based on a review of client records during the onsite licensing inspection held February 27-29, 2008, the facility failed to consistently write individualized progress notes which addressed all required components in two of four client records, specifically # 2 and 11.
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Plan of Correction
709.83 (a) (9) ? Client Records/Progress Notes
Partial Hospitalization;
Drug and Alcohol Services Manager met with clinical staff on 3/10/08, to educate on the progress notes. Information to be presented on the content of the data, assessment and plan format. The data to include information presented by the client during the counseling session, counselor observations and information about the client from other sources. The assessment to be based on the interpretative statements based upon both new and previous information and includes the counselor's analysis of and conclusions regarding the client's current situation or status. The Plan to reflect the counselor's actions to be taken in light of the evaluation and indicate the direction of treatment and include action steps, counselor plans and client assignments.
Drug and Alcohol Services Manager to continue with ongoing chart audits on a quarterly basis to assess for any further deficiencies and address immediately.
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709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) 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:
(2) Specific information disclosed.
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Observations
Based on the review of client records at the onsite licensing inspection held February 27-29, 2008, the facility failed to list the specific information that would be released. Emergency contact consents did not specify what information would be released in the event of an emergency. Specific information to be released was identified only as "Emergency Contact" in client records # 1, 4, 5, 6, 7, 10 and 11. Specific information to be disclosed was unclear or missed in client records # 6, 7 and 8. The consent to release information form required by the Single County Authority, and executed by the agency, incorrectly contained the language "release to /receive from" in client records # 1, 3, 4, 5, 6, 7, 9 and 11. The sample consisted of eleven records.
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Plan of Correction
709.28 (c) (2) ? Release of Information
Admissions Supervisor met with staff on 3/13/08 to educate them on the Releases to Emergency contacts to include the specific parameters of the information that is to be released in the case of an emergency.
Have obtained new release form from the SCA that contains the correct language ?. This form to be implemented immediately.
Admissions staff will continue to monitor charts quarterly and Admissions Team Manager will review audits and discuss needed corrections as they arise.
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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 a review of client records during the onsite licensing inspection held February 27-29, 2008, it was determined that the facility failed to document a detailed drug and alcohol history in records # 1, 3, 5, 9 and 11. The sample consisted of eight records.
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Plan of Correction
Outpatient
709.91 (b) (3) (ii) ? Drug or Alcohol History, or both
Outpatient;
Admissions Supervisor met with staff on 3/13/08 to educate the assessment counselors on how to document the substance most frequently abused, the length and patterns of use, prior to treatment episodes. Also to include in the assessment the client's perception of the effect his/her substance use has had on his/her social, physical and mental state. In addition, any other substance abuse history within the family or that of a significant other will be noted.
Admissions staff will continue to monitor charts quarterly and Admissions Team Manager will review audits and discuss needed corrections as they arise.
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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 a review of client records during the onsite licensing inspection held February 27-29, 2008, the facility failed to collect detailed personal histories in client records # 1, 3, 5, 6, 7, 8, 9 and 10. The outpatient record sample was eight records.
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Plan of Correction
709.91 (b) (3) (iii) ? Personal History
Outpatient;
Admissions Supervisor met with staff on 3/13/08 to educate the assessment counselors on how to document the historical and current personal data including: family, legal, employment/vocational, educational, military, recreational, sexual, and others where appropriate.
Admissions staff will continue to monitor charts quarterly and Admissions Team Manager will review audits and discuss needed corrections as they arise. |
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 on February 27-29, 2008 the facility failed to address the required components of the psychosocial evaluation in the following client records: #1, 3, 5, 6, 7, 8, 9 and 10. The record sample consisted of eight records .
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Plan of Correction
709.91 (b) (6) ? Psychosocial Evaluation
Outpatient;
Admissions Supervisor met with staff on 3/13/08 to educate the assessment counselors on how to provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. This evaluation to include: A clear description of the client's presenting and underlying problems; Client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment; Client strengths that can contribute to the resolution of identified problems; the client supports; negative factors that might affect treatment; client's coping mechanisms; conclusion regarding the client's appearance, behavior and reactions during the intake process; and conclusions regarding the client's attitude toward and ability to participate in the recommended treatment.
Admissions staff will continue to monitor charts quarterly and Admissions Team Manager will review audits and discuss needed corrections as they arise. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records during the onsite licensing inspection held February 27-29, 2008, the facility failed to consistently write individualized progress notes which addressed all required components in four of eight client records, specifically # 3, 5, 6 and 7.
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Plan of Correction
709.93 (a) (5) -- Client Records/Progress Notes
Outpatient;
Drug and Alcohol Services Manager met with clinical staff on 3/10/08, to educate on the progress notes. Information presented on the content of the data, assessment and plan format. The data to include information presented by the client during the counseling session, counselor observations and information about the client from other sources. The assessment to be based on the interpretative statements based upon both new and previous information and includes the counselor's analysis of and conclusions regarding the client's current situation or status. The Plan to reflect the counselor's actions to be taken in light of the evaluation and indicate the direction of treatment and include action steps, counselor plans and client assignments.
Drug and Alcohol Services Manager to continue with ongoing chart audits on a quarterly basis to assess for any further deficiencies and address immediately.
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