INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 3, 2008 and September 4, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital Outpatient Treatment Program 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 October 8, 2008.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
The hospital failed to supervise a counselor assistant with a high school diploma during the first two weeks of employment in one of two employee records where required.
Findings:
Based on a review of the counselor assistant's assigned records, staff development training files, personnel files, supervision notes and a discussion with the facility director on Septometer 4, 2008, the hospital failed to provide documentation of direct observation of the counselor assistant for the period of August 18, 2008 through September 4, 2008. A counselor assistant with a high school diploma may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment.
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Plan of Correction
Since September 4th, 2008, when the Director of the Kensington Hospital Methadone Maintenance Program was instructed that the Counselor Assistant who has only a high school degree must be observed whenever, she provides counseling for a client, either he or the senior counselor have observed the counseling done by this counselor assistant. The Senior Counselor has an office which is adjacent to the Counselor Assistant's office and both he and the Director have offices on the same floor as the Counselor Assistant. Therefore, the Counselor Assistant frequently provides counseling for her clients under the direct supervision and observation of the Director. The Director has trained the Senior Counselor on the proper procedure for observing the counseling provided by the Counselor Assistant when the Director is unabailable to do so. The Director reviews, and signs off on all progress notes written by the Counselor Assistant and also documents in the supervision log all counseling sessions provided (and therefore observed) by the Counselor Assistant. All of the above began on September 4th, and will continue for the counselor Assistant first 3 months of employment for the next 9 months, the counselor Assistant will only be permitted to counsel clients under the close supervision of the Senior Counselor or the Director (Clinical Supervisor). |
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
The project and facility director failed to complete an annual evaluation of the staff development program for 2007.
Findings:
Based on a review of the facility policy and procedure manual on September 3, 2008, procedures require an evaluation of the staff development program be documented annually by the end of the calender year. An interview with the facility director and administrative assistant on September 4, 2008 verified the evaluation for the calender year 2007 had not been completed. Additional discussion with the detoxification unit facility director on September 9, 2008 provided additional verification that the evaluation has not been completed for the outpatient program.
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Plan of Correction
Although the project and facility director failed to complete an annual evaluation of the staff development program for 2007, this process is presently underway and will be fully completed by November 14th, 2008, in preparation for evaluation of the staff development for 2008 before January 1st, 2009. The Project Director(Hospital CEO) will ensure that this is done for both the methadone Maintenance program and the Detox Unit, and will also ensure that any training necessary for thoughtful, through and professional completion of these evaluations will be provided for the staff involved.
Completion Date: November 14th, 2008. |
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
The hospital failed to meet the general training requirements for one of three medical support staff.
Findings:
Based on a review of the staffing requirements facility summary report of September 2, 2008 and a discussion with the Facility Director on September 4, 2008, one of three medical support staff did not acquire 6 hours of HIV/AIDS training. There was no documentation that Employee number 1, hired on November 24, 2003, had obtain this mandatory training as of September 4, 2008.
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Plan of Correction
The hospital failed to meet the general training requirements for one of the three medical support staff, the Director of Nursing and the Medical Director will both ensure that all medical staff will, henceforth, 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 (furthermore, counselors and counselors assistants shall complete the training within the first year of employment, and all other staff will complete the training within the first two years of employment).
Training provided will be documented to ensure that it is completed by 01/01/09. |
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 of three counselors failed to complete twenty- five hours of training for the January 1, 2007 through December 31, 2007 training year.
Findings:
Based on a review of the staffing requirements facility summary report completed on September 2, 2008, a review of three personnel records and three staff development files on September 3, 2008 and a discussion with the facility director on September 4, 2008, counselor # 4 failed to acquire twenty -five hours of training during the 2007 training year.
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Plan of Correction
All counselors will receive 25 hours of training and counselor assistants 40 hours of training by the methadone maintenance program director (i.e., Facility Director of Methadone Unit) or by approved professional trainers, by December 31st, 2008 in areas directly related to provision of competent services to opiate dependent clients (such as recordkeeping, confidentiality, pharmacology, treatment planning, counseling techniques, drug and alcohol assessment, professional boundaries, ethics, cultural awareness, interaction of addiction and mental illness and etc.
Completion Date: 12/31/08 |
705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
The non-residential facility failed to maintain all structures on facility grounds.
Findings:
Based on a tour of the building and a discussion with the Facility Director on September 4, 2008 the facility failed to clean floors and walls. Carpeting on all three levels of the facility were torn, worn, dirty and/or stained during the inspection of the physical plant. Walls and ceilings were either stained, dirty and in need of repair and paint. Wood trim throughout the three levels was also worn and in need of repair and paint.
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Plan of Correction
During the tour of the building with the Facility Director on September 4th, 2008, the Licensing Inspector observed that; "The facility failed to clean floors and walls; carpeting on all three levels of the facility were torn, worn, dirty and/or stained; walls and ceilings were either stained, dirty and in need of repair and paint; wood trim throughouot the three levels was also warn and in need of repair and paint". The Project Director through the building and maintenance supervisor, will ensure that all floors and walls are cleaned every week; that torn, worn, dirty and/or stained carpents are replaced; that walls and celings and wood trim are all cleaned, repaired and painted, etc., by January 1st, 2009. The building and maintenance supervisor will provide all necessary training to ensure that these tasks are completed satisfactory.
Completion Date: December 31st, 2008. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The hospital failed to provide complete treatment and rehabilitation plan updates every 60 days. The treatment plan updates did not include an assessment of the patients' progress in relationship to the stated goals of the comprehensive treatment plan in five of seven patient records reviewed.
Findings:
Based on a review of seven patient records on September 4, 2008, the treatment plan updates in five of the seven client records did not include documentation of an assessment of the patients progress in relationship to the stated goals of the comprehensive treatment plan. This documentation was missing from patient records # 1, 2, 3, 5 and 6.
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Plan of Correction
The Methadone Maintenance Program Director (Methadone Unit Facility Director) will ensure that all counseling staff henceforth provide complete treatment and rehabilitation plan updates every 60 days, and will provide both training and supervision to ensure that such updates include an assessment and documentation of the patients' progress in relationship to the stated goals of the comprehensive treatment plan.
Completion Date: November 14th, 2008. |