INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on August 21-23, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Lebanon Treatment 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(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the staff development and training documentation, the facility failed to provide an evaluation of the training activities for the previous training year.
The finding includes:
The staff development plan for the facility was reviewed during the onsite licensure renewal inspection of August 21-23, 2012. The annual evaluation of the overall training plan consisted of a summary of the training received by facility staff but failed to evaluate the extent to which the plan addressed the identified training needs, including a determination of the extent to which implementing the plan eliminated or satisfied the identified training needs for the facility staff.
The finding was reviewed with the Facility Director and Clinical Supervisor and was not disputed.
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Plan of Correction
The Clinical Supervisor and/or Campus Director is responsible to ensure that an evaluation of the training activities for the previous training year is collected from each employee. An annual evaluation of the overall training plan will be completed by each employee and maintained in the employee training file. Each individual assessment will then be compiled into a report which addresses the past years training plan for the entire facility and the extent to which the plan met the facility's identified needs. This will take effect for the 2012 training year and will be on-going. Completion date of 12/31/12. |
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
Based on the review of the staff training records, the facility failed to ensure that the Project Director received a minimum of 12 hours of training for 2011.
The finding included:
The staff training records for the facility were reviewed on August 21-23, 2012. Training records for eleven staff were requested. Ten records were presented for review. No training record was presented for the Project Director. An interview with the Facility Director verified that the Project Director did not have an individual training plan for 2011 nor did he receive the required minimum training hours for the 2011 training year.
The findings were reviewed with the Facility Director and Clinical Supervisor and were not disputed.
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Plan of Correction
The Project Director is responsible to ensure that he has the mandated training hours and the annual training plan is available. The Project Director will ensure that the annual training plan is available and that the required training hours are completed by the end of this training year, 12/31/2012. This will be on-going on an annual basis. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Report" completed by the Facility Director, the facility failed to ensure that a caseload of 35:1 or less was maintained for each counselor.
The finding includes:
The "Staffing Requirements Facility Summary Report" for the facility was reviewed during the renewal inspection of August 21-23, 2012. The form was completed by the facility director at the time of the inspection and reflected the client to counselor caseloads for eight clinical staff.
Employee # 2 - The client to counselor caseload for this employee was 37:1.
Employee # 4- The client to counselor caseload for this employee was 36:1 .
Employee # 5- The client to counselor caseload for this employee was 36:1.
Employee # 8- The client to counselor caseload for this employee was 37:1.
Employee #11 - The client to counselor caseload for this employee was 37:1.
The finding was reviewed with the Clinical Supervisor and Facility Director and was not disputed.
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Plan of Correction
A new counselor has been hired at this time, thus bringing Lebanon Treatment Center back into compliance regarding the 35:1 ratio. This staffing pattern will be on-going and is the responsibility of the Clinical Supervisor and or Clinic Director. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the facility policy and procedure manual and other administrative materials including the annual report, the facility failed to make the annual report available to the public.
The finding includes:
The annual report was reviewed during the inspection of August 21-23, 2012. The facility director was asked if the report had been made available to the public in any way . He indicated that he could not document notification of availability to the public of the annual report.
The finding was reviewed with the Facility Director and was not disputed.
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Plan of Correction
The Clinic Director will ensure that the Annual Report is made available to the public thru local newspaper as in years past. This will take place for the 2012 Report as soon as report is completed, an no later than July 1st, 2013. |
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, the facility failed to adhere to documented facility policy and procedure by completing individual treatment plans within the timeframes specified in policy in 5 of 12 client records reviewed.
The finding includes:
Twelve client records were reviewed during the renewal inspection of August 21-23, 2012. Facility policy required that the individual comprehensive treatment plan be completed within 30 days of admission. Five of twelve client records reviewed did not include documentation of the comprehensive treatment plan within the 30 day period after admission.
Client record # 1- The client was admitted on 11/10/11. The individual comprehensive treatment plan was completed on 12/22/11.
Record # 2- The client was admitted on 3/8/12 . The individual comprehensive treatment plan was completed on 5/9/12.
Record # 4- The client was admitted on 1/4/12. The individual comprehensive treatment plan was completed on 4/26/12.
Record # 10- The client was admitted on 11/18/11. The individual comprehensive treatment plan was completed on 12/22/11.
Record # 12- The client was admitted on 10/31/11. The individual comprehensive treatment plan was completed on 12/5/11.
The findings were reviewed with the facility director and the clinical supervisor and were not disputed.
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Plan of Correction
Clinical Supervisor is responsible of ensuring that all comprehensive treatment plans be in place and reviewed by patients within 30 days of admission. Clinical Supervisor will address this thru weekly supervision and chart audits. This is immediate and on-going. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to adhere to facility policy and procedure by completing individual treatment plan updates within the timeframes specified in policy in 4 of 8 client records reviewed.
The finding includes:
Twelve client records were reviewed during the licensure renewal inspection of August 21-23, 2012. Eight client records were due to include treatment plan updates. Facility policy requires treatment plan updates every 60 days. Four of eight client records reviewed failed to include documentation of the treatment plan update within 60 days.
Client record # 3- The client was admitted on 5/18/12. The individual comprehensive treatment plan was completed on 6/14/12. A treatment plan update would have been due by 8/14/12. No update was documented in the record at the time of the inspection.
Client record # 4- The client was admitted on 1/4/12. The individual comprehensive treatment plan was completed on 4/26/12. One treatment plan update was documented on 6/14/12. No update for August 2012 was documented at the time of the record review.
Client record # 9- The client was admitted on 1/12/12. The individual comprehensive treatment plan was completed on 1/24/12. The facility took 70 days to document the treatment plan update on 4/12/12. The facility took 87 days to document the treatment plan update on 7/9/12.
Client record # 12- The client was admitted on 10/31/11. The individual comprehensive treatment plan was completed on 12/5/11. A treatment plan update was documented on 12/31/11. The facility took 97 days to document the next treatment plan update on 4/6/12.
The findings were reviewed with the facility director and the clinical supervisor and were not disputed.
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Plan of Correction
Clinical Supervisor is responsible for ensuring that all treatment plans are updated and reviewed with patients every 60 days. Clinical Supervisor will address this with clinical team members in weekly supervision sessions and regular chart audits. This correction is immediate and on-going. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to adhere to facility policy and procedure by completing case consultations within the timeframes specified in policy in 6 of 7 client records.
The finding includes:
Twelve client records were reviewed during the licensure renewal inspection of August 21-23, 2012. Seven clients were in treatment long enough to require documentation of a case consultations. Facility policy required that case consultations be completed every 90 days. Five of seven client records due for case consultations failed to include documentation of case consultations within the 90 day period specified in facility policy.
Client record # 1- The client was admitted on 11/10/11. The individual comprehensive treatment plan was completed on 12/22/11. The first case consultation in this record was not documented until 4/11/12.
Client record # 3- The client was admitted on 5/18/12. The individual comprehensive treatment plan was completed on 6/14/12. There was no documentation of a case consultation as of 8/23/12.
Client record # 4- The client was admitted on 1/4/12. The individual comprehensive treatment plan was completed on 4/26/12. The first case consultation was not documented until 8/8/12.
Client record # 7- The client was admitted on 2/5/11. The treatment plan was documented on 2/21/11. The last case consultation was documented on 12/6/11. There was no further documentation of case consultations as of 8/23/12.
Client record # 10- The client was admitted on 11/18/11. The individual comprehensive treatment plan was completed on 12/22/11. The first case consultation was dated 2/9/12. The facility took 112 days to document the case consultation dated 5/31/12.
The findings were reviewed with the facility director and the clinical supervisor and were not disputed.
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Plan of Correction
The Clinical Supervisor is responsible for ensuring that case consultations are being completed every 90 days. Clinical Supervisor will address this in weekly supervisions with members of the clinical team and thru engaging in regular chart audits. This correction is immediate and on-going. |