INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 21- 23, 2006 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 September 19, 2006.
|
Plan of Correction
|
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
|
Observations
The Project Director does not meet the requirements of the position based on his Bachelor's Degree in Accounting. Also, he does not have direct service experience.
|
Plan of Correction
On 8/10/06, the Governing Body of White Deer Run, Inc. appointed the Acting Project Director/Acting Executive Director, during the interim in which a permanent Project Director/Executive Director is identified. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
|
Observations
(b) Employee #5 failed to document to the facility director that he is working toward counselor status.
(c) Employee #5 did not meet the requirements for the position of counselor within 5 years of his date of employment as a counselor assistant. Employee #5 was hired on 02/12/2000 and needed to meet the requirements for counselor by 02/12/2005.
|
Plan of Correction
Employee # 5 will be assigned to position of Case Manager under the supervision of the Program Director. The responsible party is the Program Director. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Individual training plans for all staff reviewed were incomplete. The individual plans failed to list the training, the time frames within which the training would be obtained and the resources that would be utilized.
|
Plan of Correction
704.11(b)(1) Individual Training Plan
The "Individual Training Plan" will be modified for use and distributed in November 2006 for the 2007 training calendar year. The modification will include a checklist of potential trainings to be offered in the upcoming year. The QI/Staff Development Department will also note on the checklist the proposed resource for training (for example, Ethics-BDAP Trainer), and the proposed time frame in which the training will be offered (for example, Summer 2007). The "Individual Training Plan" will then provide documentation of:
1. Training needs assessment
2. Identified resources in which to meet training needs
3. Proposed timeframes in which to meet those training needs
|
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.
|
Observations
Multiple employees, specifically #15, 20, 21, 28, 36, 77 and 82, do not have documentation of receiving the mandatory 4 hours of TB/STD/other health related issues training. In addition, employees #44 and 82, do not have documentation of receiving the mandatory 6 hours of HIV/AIDS training.
|
Plan of Correction
Dates for the STD/TB training and HIV/AIDS training are being verfied with a trainer today 9/22/06. Employees #15, 20, 21, 28, 36, 77, and 82 will recived the mandatory 4 hours of TB/STD/Other health related issues training. Employees #44 and 82, will recieve the mandatory 6 hours of HIV/AIDS training. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
|
Observations
New staff members did not receive fire extinguisher training within 7 days of hire per documentation presented.
|
Plan of Correction
The Human Resources Representative will coordinate the Fire Extinguisher training with the Maintenance Supervisor for all new hires. Training will occur within seven days of hire and will be documented in the employee's personnel file. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
New staff members were not trained in emergency procedures within 7 days of hire per documentation presented.
|
Plan of Correction
The Human Resources Representative will coordinate the Emergency Procedures training with the Maintenance Supervisor for all new hires. Training will occur within seven days of hire and will be documented in the employee's personnel file. |
709.32(c)(6) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(6) Inventories.
|
Observations
There was no documentation of the inventory for stocked medications used by the physician in standing orders.
|
Plan of Correction
An accurate inventory list of stock medications used by the Physician in standing orders will be kept in a binder in each of the nursing units. The Nurse Manager will be the responsible party who will provide a directive to the Nursing staff. Inventories will be initiated by 9/30/06. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
|
Observations
Client record #14 did not contain a notice of termination.
|
Plan of Correction
The Program Director/Asst. Program Director will review the policy of the Notification of Treatment Form with the Adult Counselors. This will be conducted in Clinical Staffing and will be reviewed with new hires. The Program Director/Asst. Program Director will conduct random audits on a monthly basis for three months. |
709.62(c)(3)(ii) LICENSURE D & A History
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
In 9 out of 15 client records reviewed, specifically #2, 5, 6, 7, 9, 11, 12, 13 and 14, the drug and alcohol history did not include lengths and patterns that attribute to progression of use. In addition, in client records #1, 2, 5, 10, 11, 12, 13 and 14, the client's perception of drug and alcohol use was either not documented or did not clearly indicate how drug and alcohol use/abuse affected specific areas of the client's life.
|
Plan of Correction
The Nurse Manager will provide an in-service on evaluative summary for all nursing staff that will address complete drug and/or alcohol history to include the client's perception of drug and alcohol use. The specific areas of their life affected by the drug use and the lengths and patterns that attribute to progression of use. At the in-service, the Nurse Manager will review appropriate completion of the nursing assessment in its entirety. The Nurse Manager will conduct random audits on a monthly basis for three months. |
709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
In 5 out of 6 client records reviewed, specifically #2, 11, 12, 13 and 14, the nursing assessment lacked detail in the areas of family, employment and sexual. Questions often contained one word answers. In addition, questions regarding military history were missing altogether.
|
Plan of Correction
The Nurse Manager will provide an in-service to all nursing staff to educate in completing Nursing Assessments. The Nursing Assessments must detail the areas of family, employment, and sexual as part of the in-service on completing the assessment. The military history is documented in the Psychosocial Assessment, which the clinicians complete. The Program Manager will be responsible for addressing military histories at a clinical staffing meeting to be held prior to 9/30/06. The Nurse Manager and Program Director will conduct random audits on a monthly basis for three months. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
|
Observations
In 6 out of 6 client records reviewed, specifically #1, 2, 11, 12, 13 and 14, the nursing assessment was not an evaluative summary, but rather a 2 to 3 sentence reiteration of the client's history.
|
Plan of Correction
The nursing department will be educated as to the role of the evaluative summary. Education will encourage nursing staff to expand on their professional perception of the client's use including elements such as their pertinent medical history, externa factors affecting recovery, relapse triggers, social stressors, and the potential for successful recovery.
An audit will be conducted within 30 days of education to assess nursing improvement in this assessment category. The issue will be re-audited until an overall compliance of 90% is achieved. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
In 9 out of 15 client records reviewed, specifically #2, 5, 6, 7, 9, 11, 12, 13 and 14, the drug and alcohol history did not include lengths and patterns that attribute to progression of use. In addition, in client records #1, 2, 5, 10, 11, 12, 13 and 14, the client's perception of drug and alcohol use was either not documented or did not clearly indicate how drug and alcohol use/abuse affected specific areas of the client's life.
|
Plan of Correction
The Nurse Manager will provide an in-service on evaluative summary for all nursing staff that will address complete drug and/or alcohol history to include the client's perception of drug and alcohol use, the specific areas of their life affected by the drug use, and the lengths and patterns that attribute to progression of use. At the in-service the Nurse Manager will review appropriate completion of the nursing assessment in its entirety. The Nurse Manager will conduct random audits on a monthly basis for three months. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
In 4 out of 12 client records reviewed, specifically #2, 5, 11 and 14, the personal histories were weak in detail regarding family and employment. Questions were often one word answers with no further follow-up.
|
Plan of Correction
The nursing department will be re-educated to the first step of the nursing process and the need for comprehensive value-added nursing assessments. Each nurse will be provided with the organization's policy, a sample "ideal" assessment, and will be required to complete a post test scoring at least 90%. Emphasis will be placed upon the level of detail required for the reader to understand the client's use history, as well as the expansion of a more comprehensive social history of the client's employment, living situation, vocational goals, family, children, in order to develop an individualized plan of care. A corrective action plan will be developed for individual nurses who do not achieve a 90%.
Within 30 days of training and post testing, a nursing audit will be completed to assess for nursing compliance via detail, completed questions, and elimination of one-word responses. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
In 4 out of 12 client records reviewed, specifically #2, 5, 12 and 14, the psychosocial evaluation (evaluative summary) was disjointed and read more like a summary of the client's history rather than the clinician's impressions and opinions. In addition, coping mechanisms and negative factors that may inhibit treatment were not addressed.
|
Plan of Correction
The Program Director/Assistant Program Director will provide an in-service for the Clinical Staff in completing Psychosocial Evaluations. The Evaluation will include the clinician's impressions and opinions, coping mechanisms, and negative factors that inhibit treatment. The Program Director/ Asst. Program Director will conduct random audits on a monthly basis for three months. |