INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 20 -22, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health-Ha, Inc. 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
May 22, 2009.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of employee records and training files during the onsite licensing inspection of April 20-22, 2009, the facility failed to ensure that all counselors met one of the qualification specified at 28 Pa. Code Chapter 704.7(b).
The findings include :
During the onsite licensing inspection, seven employee records and training records of counselors were reviewed. One counselor ( # 3) did not have documentation of an approved degree as required under Chapter 704. The counselor had documentation of a Bachelor of Science degree in Communications Media with a Psychology minor. The Clinical Supervisor was interviewed on 4/ 20/ 09 at 2:45 PM and acknowledged that the degree was not a human service degree, but thought a minor would meet the qualification requirements.
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Plan of Correction
CS #3 will immeadiately have direct supervision until completion of Master Degree upon completion of the Master Degree she will be considered a Master Level counselor assistant and will complete 3 months at that level with close supervision. This will be monitored by the Program Director and Clinical Supervisor. |
704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of the agency manual during the onsite inspection of April 20-22, 2009 the facility failed to document a training procedure which included who is responsible for implementing the training and what the timeframes for the required components were.
The findings include:
The agency training policy and procedure was reviewed during the annual licensing inspection.. The procedure did not document who, by job title, is responsible for the completion of the annual training plan. The procedure did not document timeframes for completion of each of the required components of the staff development program.
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Plan of Correction
The annual assessment will be completed by the clinical supervisor in coordination with the Program Director as in our policy pg 70. The associates will fill out training needs form to be completed by Jan 31 of the training year. The overall plan and the annual evaluation of the previous year will be completed by Jan 31 of the training year. Upon completion of trainings all associates will complete a training form that will be kept in a training binding. This will be monitored by the Clinical Supervior and Program Director.
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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.
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Observations
Based on a review of the employee training records during the onsite licensing inspection of April 20-22, 2009, the facility failed to document an individual training plan for each employee.
The findings include:
During the annual onsite licensing inspection of April 20 to 22, 2009, twelve employee records were reviewed . No individual training plan was documented in the record of employee # 1.
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Plan of Correction
An individual training plan will be developed for employee #1 to meet the requirements for the employee's position and which relate to the employee's skill level and interest. Upon completion this it will be posted on the intranet for access by the clinic and auditors. This will be completed yearly before the end of December for the following years training. This will be monitored by the program director. |
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 self report staffing forms completed by the facility staff and interviews with the facility director and clinical supervisor and a review of staff qualifications for the position of counselor, the facility failed to ensure that the staff to client caseload was maintained at 35:1 for each counselor.
The findings include:
Interviews were held with the facility director and clinical supervisor on April 20 and 21, 2009 regarding the completion of the staffing self report forms. Counselor # 3 was not qualified for her position and so her hours could not be counted effectively resulting in a caseload of 32:0 for her caseload. Counselor # 10 had a caseload computed at 36:1 based on the number of clinical hours documented by the clinical supervisor on the self report staffing form and utilizing the formula represented on that form for computation of the staff to client caseload.
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Plan of Correction
CS# 3 will be under direct supervision until completion of Master Degree. CS#10 has a special circumstance of being lead counselor and her caseload was out of compliance we will readjust her caseload to meet the formula to get her in compliance. This will be monitored by the Clinical Supervisor and The Program Director. |
709.22(e)(2) 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:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the 2007 annual report during the onsite licensing inspection of April 20 - 22, 2009, the facility failed to document a financial statement of income and expenses in the body of the report
The findings include:
The annual report was reviewed during the licensing inspection. No financial statement of income and expenses was documented.
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Plan of Correction
The was an ammendment to policy for the annual report to be completed in 180 days we still have 30 days remaining. Upon completion of the annual report it will include the financial statement of income and expenses in the body of the report. This will be monitored by the program director. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of the policy manual during the onsite licensing inspection of April 20-22, 2009, the facility failed to document a manual which addressed the requirements of 28 Pa. Code Chapter 709.
The findings include:
The policy and procedure for 709.26(b)(10) - Confidential maintenance of personnel records - did not document the method for the release of employee information from the record or indicate who, by job title, was responsible for maintaining the records.
709.28 (a)(1)- Confidentiality of client identity and records.- The policy and procedure documented inaccurate language, allowing for the re release of patient information, as it pertained to HIPAA but which is prohibited at 42 CFR Part 2. The language in this policy blends the two laws together when they are, in fact, distinct laws and must be addressed separately.
709.28(a)(2)- staff access to client records- The procedure does not document a method for accessing client records.
704.11(a)- Staff development policy- The procedure does not document who is responsible for formulating the training plan and does not document the timeframes for the completion of each component.
The policies and procedures contain generic language which does not document specific requirements as detailed in 28 Pa. Code Chapters 704 and 709 and is not specific to the provision of services in Pennsylvania. Specific examples are listed below:
page 61- " Each clinic will have a person designated to provide clinical supervision. This person will meet the clinical supervisor requirements for the State. Supervision will be provided to each counselor as required by state regulation and licensure requirements." This section is not specific to Pennsylvania.
page 118 - "Assessments will be conducted by qualified persons as determined by state regulations and standards." This section is not specific to Pennsylvania.
page 186- "In states where required, for minors, the release would include the dated signature of the patient's guardian." This section is not specific to Pennsylvania.
Page 207- "Individual plans will be reviewed periodically. At least annually or more frequently as required by state standards or as required by changes in the patients life situation and needs." This section is not specific to Pennsylvania.
The last section of the manual talks about providing co- occurring services . Discovery house programs in Pennsylvania are not providing co- occurring services and do not maintain the required dual licensure to do so .
This is a repeat deficiency from 2008
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Plan of Correction
The program director will discuss concerns of the state in regards to failure to document a mannual which addressed the requirements fo28 Pa. Code chapter 709. I will work with the policy advisor on the generic language which does not document specific requirements as detailed in 28 PA. Code 704 and 709. We will add a page to the policy addressing that Discovery House programs in Pennsylvania are not providing co-occurring services and do not maintain the required dual licensing to do so. All the citations in this will be addressed at our Pa Directors meeting to be held in July 09. We will discuss each citation and make the recommendations to our home office for our Pennsylvaina Facilitys. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative materials and staff interviews during the onsite licensing inspection of April 20 - 22, 2009, the facility failed to document an annual audit.
The findings include:
Administrative materials were reviewed on April 20, 2009 and the Facility Director and Clinical Supervisor were interviewed on this date at 12:45 PM. No audit was documented and the Facility Director and Clinical Supervisor acknowledged that this was the case.
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Plan of Correction
If we are denied the waiver we will arrange to have an annual audit done in 90 days. The program direcotor will follow up with home office. |
709.26(b)(1) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(1) Confidential maintenance of personnel records.
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Observations
Based on the review of the agency manual on April 20-22, 2009, the facility failed to document a complete policy addressing the confidential maintenance of personnel records.
The findings include:
The agency policy manual and Associate Handbook were reviewed during the onsite licensing inspection. The policy and procedure did not document, by job title, who is responsible for maintaining employee records or the procedure to follow if records of employees are to be released. This is a repeat deficiency from 2008.
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Plan of Correction
Our policy page 73 state all associate records will be maintained in a locked file. The Program Director will maintain exclusive access to file contents. There is no policy directed at release of associate records. I will propose to Home Office to have the policy ammended to add a release will be signed by associates to have any personal records released. Program Director will be responible. |
709.28(a)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(2) Staff access to client records.
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Observations
Based on a review of the agency policy manual, the facility failed to document a complete policy and procedure stating how staff may access patient records.
The findings include:
The procedure in the agency policy manual was reviewed during the onsite licensing inspection or April 20-22, 2009. The policy did not document the methods used by staff to access patient records.
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Plan of Correction
Operation and compliance will review and amend policy and proceed to clearly identify which associates (according to job title) have access to patient records. The method to obtain patient access to records will be included in policy review. Policy will also address who, by job title, has access to patient records from Smart Management, and Discovery House. Discovery House job titles include Program Director, Program Manager, Medical Director, Clinical Supervisor, Senior Counselor, Nurse Manager, Nurses, Counselors, Administrative Assistant, Case Manager/Administrative Assistant, Physician Assistant, Intake Coordinator. Smart Management Associates who have access include, President CEO, Chief Operating Officer, Director of Operations and Compliance, Operations and Compliance associate, Accounting Manager, Provider Relations Supervisor, Provider Relations Representatives, Global Customer Advocate, Quality Assurance Coordinator, Systems Analysis, Vice President of Software, Support Dept Supervisor, Assistant Director of Software, Support Representatives, System Network Admistrators, Executive Director/Clinical, Corporate Medical Director, Quality Assurance Analyst, Director of New Program Development, Accounts Receivable. Program Director will be responsible to ensure this citation is brought up to compliance with regulations.
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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 a review of patient records during the onsite licensing inspection of April 20-22, 2009 the facility failed to document psychosocial evaluations which provided a complete picture of each client in relation to the collected historical data.
The findings include:
At the time of the annual licensing inspection, a total of seventeen patient records were reviewed. Each patient record was required to document a comprehensive psychosocial evaluation. Nine of seventeen patient records failed to include documentation of coping mechanisms in the evaluation ( patient records # 4, 5, 6, 8, 9, 13, 15, 16, 17).
Four of seventeen patient records failed to document support systems available to the client. (patient records # 2, 3, 5, 15).
Patient record # 7 failed to document a complete psychosocial evaluation. The following components were not documented on the psychosocial evaluation in this patient record: identification of client needs, client assets/strengths, coping mechanisms, attitude toward treatment and clinical impressions.
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Plan of Correction
The proper documentation of the psychosocial evaluation at intake will be reviewed by the clinical supervisor with clinical associates in a meeting explaining psychosocial evaluation and the proper documentation of coping mechanisms, support systems, identifying client needs to provide a complete picture of the patient. This will be monitored by the clinical supervisor. |
709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
Based on a review of patient records during the onsite licensing inspection of April 20- 22, 2009, the facility failed to document client correspondence which documented the information released to insurance providers.
The findings include:
During the onsite licensing inspection seventeen patient records were reviewed. Ten of these patient records documented that services were funded by insurance providers . One of the ten applicable patient records was a recent admission and was not counted. Of the remaining nine patient records, seven failed to document the specific information which was released to insurance companies as mandated by 4 Pa. Code subsection 255.5(a)(10). These patient records were : # 1, 2, 3, 10, 12, 14, and 15.
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Plan of Correction
The MMR (methadone maintenance reports) containing the information released to the insurance company for authorization of coverage by our 3rd party will be filed in the patient chart for reference. This will be monitored by the Program Director. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records during the onsite licensing inspection of April 20-22, 2009 the facility failed to document aftercare plans within the timeframes specified in the documented agency policy.
The findings include:
Seventeen client records were reviewed during th onsite licensing inspection. Fifteen of these records were in treatment long enough to require aftercare plans, which was within fourteen days of admission as stated in agency policy. During an interview with the facility director and Clinical Supervisor on 4/20/09 at 12:45 PM, it was determined that actual practice is generally to have the plan done within 30 days. Nine of the applicable records did not document aftercare plans within the timeframes specified in documented agency policy.
Patient record #2 admitted 9/26/08- aftercare plan dated 10/21/08
Patient record #3- admitted 2/5/09- aftercare plan dated 2/26/09
Patient record #4- admitted 2/28/09 - aftercare plan dated 3/20/09
Patient record #6 admitted 2/10/09 - aftercare plan dated 3/3/09
Patient record #8 admitted 11/5/08 - aftercare plan dated 12/3/08
Patient record #10 admitted 8/14/08 - aftercare plan dated 9/15/08
Patient record #12 admitted 10/21/08 - aftercare plan dated 11/21/08
Patient record # 16 admitted 4/9/09 - no plan documented as of 4/20/09
Patient record # 17 admitted 11/15/08 - aftercare plan dated 12/3/08
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Plan of Correction
The policy has been discussed with our home office stating the policy needs to be ammended to read aftercare plans to be completed within 30 days. The policy will be ammeded to read completed in 30 days. This will be monitored by the Program Director and Clinical Supervisor. |