INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 29, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Addictive Diseases -Main Line Affiliates 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 November 30, 2009.
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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 a review of the "Staffing Requirements Facility Summary Report", the Project Director job description and an interview with the current Project Director, the facility failed to ensure that the person appointed as the project director reported to the Board of Directors.
The findings include:
The current Project Director does not report directly to the Board of Directors and does not have the authority to set wage and salary scales. The current Project Director reports to an intermediary, who in turn reports to the Chief Executive Officer, who then reports to the Board of Directors.
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Plan of Correction
An exception will be requested according to procedure. If an exception is not granted the CEO will be named Project Director. |
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 staff training records, the facility failed to ensure that each counselor completed at least 25 clock hours of training per year, where required.
Findings:
A review of eleven counselor training records was performed on October 29, 2009 during the facility ' s annual inspection. Of the eleven records, ten required documentation of at least 25 hours of training annually. Counselor training record #3 documented a total of 22 training hours and record #6 documented a total of 23.5 hours over the past training year.
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Plan of Correction
All counselor's will complete the required 25 credit per year requirement. All training credits will be evaluated by the Project Director in January. From the review written notification will go to each Counselor to inform them of how many they have, and how many are remaining for them to obtain. Another review will be performed by the Project Director in April and Counselors without the required trainings will be required to meet individually every other week with the Project Director until credits are obtained. |
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 the review of the facility's caseload and hours per week staffing report, the facility failed to comply with the client/counselor caseload requirements for an outpatient facility.
Findings:
On October 29, 2009 a review was made of the staffing report presented during the annual survey showing counselor caseloads and hours worked per week. Three of eleven counselor caseloads exceeded the maximum 35:1 counselor/client ratio. The Full Time Equivalent counselor case load for counselor #4 and #8 was 44:1 and for counselor #11 was 46:1.
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Plan of Correction
Clinical Director will work with the Counselors to maintain caseloads within the 35:1 ratio for all Counselors based on the full time equivalent of hours worked. This will be accomplished by assigning cases from one therapist to be covered by another with the covering therapist providing individual sessions periodically.
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711.91(b)(3)(i) LICENSURE Medical History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to document medical histories which included the family medical history and the clients' history of symptoms and illnesses in twelve of fourteen client records.
The findings include:
Fourteen client records were reviewed on October 29, 2009. Documentation of the client's family medical history was missing in client records # 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, 13 and 14. There was no documentation of the client's symptoms and illnesses in client records # 1, 6, 7, 8, 9, 10, 12, 13 and 14.
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Plan of Correction
A new medical screening tool will be developed and given to the clients upon evaluation which will include the family medical history. Additionally, The Clinical Director will review with all Counselors during team meeting on 12/1/2009 the expected documentation for the medical history, including family medical history. The Clinical Director will collect data on the completion of the family medical history during quarterly chart audits. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document psychosocial evaluations that included a description of client support systems, coping mechanisms and client needs in eight of fourteen client records.
The findings include:
Fourteen client records were reviewed on October 29, 2009. There was no documentation of the evaluation of the client's support systems, coping mechanisms and client needs in client records # 2, 4, 6, 8, 10, 12, 13 and 14.
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Plan of Correction
The Clinical Director will review with all counselors during team meeting on 12/1/2009 the expected documentation for the psychosocial evaluation including the clients' assets and strenghts, coping mechanisms and negative factors affecting response to treatment. The Clinical Director will collect data on the accurate completion of the psychosocial evaluations during quarterly chart audits. |