INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from May 14, 2007 through May 17, 2007 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 June 14, 2007.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Supervisory meeting documentation did not address the supervisor's duties and performance for their position for employees #3 and 4 .
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Plan of Correction
We had two staff people promoted to the role of clinical supervisor following the death of our Associate Director. Due to the reason for the promotions and the difficulties of the past few months, it was not properly documented that supervision of these staff was indeed taking place. Supervision notes were available for review, but did not address specifics of their abilities and difficulties on the job. Supervision notes continue to be written on both staff members, but now include specifics on how staff members are doing in their new roles. Supervision notes will include any issues or problems the staff members are having in their current role as well as what they are doing well. Changes in the supervision notes have already taken place so, this plan of correction is already being implemented. |
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
Employee #8 earned only 15 of the 25 required hours for the 2005-2006 training year. Employee #11 earned only 5 hours for the 2005-2006 training year.
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Plan of Correction
This year we had two employees who did complete their required number of training hours. Staff is made aware of the need to attend 25 hours of training per fiscal year. We have implemented a new tracking system for our staff's training hours. Training hours will now be monitored monthly by one person, who will email staff who are low on training hours and copy this to facility director. We believe this system will allow administration to more effectively monitor the training hours of all staff and to assure that staff is completing trainings as required. This new system was put into effect several months ago and as training hours that were reviewed were for the 05/06 fiscal year, we believe this issue has already been resolved. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
The showers in five of ten bathrooms did not have slip resistant surfaces, specifically bathrooms located in bedrooms # 202, 203, 221, 222 and 226.
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Plan of Correction
Several of the resident bathrooms did not have adequate slip resistant surfaces. These wear off quickly and were not replaced in a timely fashion. Maintenance has been made aware of this problem and will install new slip resistant pads in all bathrooms as needed |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Eating utensils were not stored in an enclosed area.
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Plan of Correction
Our eating utensils are not currently covered. We were unaware of the need to cover utensils in the cafeteria. Our short term plan is to cover the utensils with plastic wrap after each meal. Our maintenance director and coordinator of residential services are looking into a more long term solution, ie: a covered cart that we would purchase to eliminate this issue. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
A space heater was observed in a counselor's office.
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Plan of Correction
A space heater was observed in one counselor's office. This space heater has been removed. An all staff email will be sent to remind staff of the fact that space heaters are not allowed in any area of the recovery center. Facility director will oversee this. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Fire drills were not documented for September, October, November, December 2006, February 2007 and April 2007.
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Plan of Correction
Several fire drills were not documented in the fire drill log. Maintenance has been notified via e-mail of the need to assure that fire drills are completed at least one time a month and that these fire drills are properly documented in the log book. Maintenance director will oversee this. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The facility failed to present documentation that fire drills were conducted during the sleeping hours in the past year.
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Plan of Correction
There were no documented fire drills taking place during sleeping hours. Maintenance director is aware of the need to conduct fire drills during sleeping hours and will work with Recovery Center staff to assure that this happens. Maintenance Director will oversee this procedure. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
The facility failed to document the exit routes utilized during fire drills.
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Plan of Correction
Fire drills that were documented did not use the correct form that was created last year to address what exit was used during the fire drill. The new form does exist, it was used for other departments in Penn Foundation. It appears as though the new form was inadvertently overlooked at the Recovery Center and not utilized. The old form will be destroyed and Maintenance Director will oversee that the correct form is used from now on. |
709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The drug and alcohol history did not include the client's perception of their use as it pertained to the effect it has had on their social, mental, and physical state in two of three records reviewed, # 13 and 14.
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Plan of Correction
Biopsychosocial evaluation did not adequately address client's perception of use as it pertains to the effect it had on social, mental and physical state. Clinicians and assessors will be made aware at the weekly staff meeting of the need to include this information in all evaluations. Clinical supervisors of inpatient and outpatient levels of care will oversee this meeting and will periodically review evaluations to assure this information is being included in all records |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluation was missing in one of three records reviewed, #14. Evaluations included check boxes, statements from clients and a repeat of historical data instead of the counselor's assessment of the client in one of two client records reviewed, #13. Support systems were not assessed for their potential impact on the client in one of two client records reviewed, #13.
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Plan of Correction
Biopsychosocial evaluations that were reviewed did not contain an adequate assessment of the client. At the weekly team meeting, staff will be made aware of the need to interpret the data in the evaluation, not just repeat it back. Staff will shown examples of integrated summaries that were reviewed to be satisfactory and staff will be expected to incorporate interpretations in their evaluations. Staff will be reminded of the need to address support systems that are in place for all clients. Clinical supervisors of inpatient and outpatient programs will oversee the team meeting and will periodically review charts to assure quality of the evaluations. |
709.82(a)(1) LICENSURE Treatment and rehabilitation services
709.82. 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:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Treatment plans goals did not include measurable criteria in two of three client records reviewed, #14 and 27.
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Plan of Correction
Treatment plans did not include measurable goals in two of the three charts that were reviewed. Treatment plans will need to be updated to be assure that the goals are measurable and individualized for each client. Staff will be directed on what constitutes a measurable goal and will be expected to use measurable goals on all treatment plans that they complete. Facility Director will oversee this process. |
709.83(a)(11) LICENSURE Client records
709.83. 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:
(11) Follow-up information.
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Observations
The facility failed to document follow up information in one of two client records reviewed, #27.
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Plan of Correction
Follow up was not adequately documented in one chart that was reviewed. Staff will be reminded of our facility's follow up policy and reminded of the importance of completing all follow ups in a timely fashion. Staff will be reminded of this policy and procedure at the upcoming staff meeting. Inpatient and Outpatient clinical supervisors will oversee this policy and procedure to assure that follow ups are being completed. |
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
The facility failed to identify the fiscal year on the announcement to the community regarding the availability of the annual report.
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Plan of Correction
Our facility was unaware of the need to have the year of the annual report on our web site, we just had it announced that the annual report was available for review. Our public relations department has been made aware of the need to update our website to include the year of the annual report. Facility Director will oversee to assure this is added to our website. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
The performance report summarizing the progress for the 2005 - 2006 year did not address all of the goals and objectives identified by the project.
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Plan of Correction
Our facility does an annual summation of program goals. This year, the summation of goals did not include a status report of all proposed goals for the year. We now understand there needs to be a direct correlation between these two documents and starting at the end of this fiscal year, we will give a report on all goals that were listed the beginning of the year. Facility Director will be responsible for this and will assure that all program goals are updated annually in the summation of goals report. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The written procedures for the completion of the client's personal history, psychosocial evaluation and comprehensive treatment plan were not congruent and were in contrast to the current practice. The procedures did not indicate that the partial hospitalization and outpatient programs have an "assessment phase" that occurs prior to the actual admission date in which the clinical team completes the history and psychosocial evaluation.
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Plan of Correction
The written policy and procedure did not accurately describe our current practice of an assessment phase in outpatient and partial hospital levels of care. It was also unclear how many sessions we allow to complete the biopsychosocial evaluation. A new policy and procedure will be written that accurately describes our current practices. Old policy and procedure will be discarded so there is no further confusion. Facility Director will oversee the writing and implementation of this new policy and procedure. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
The physician's signatures for verbal orders did not include a date to verify that the orders were signed within 24 hours from the time the order was given.
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Plan of Correction
Physicians were not dating verbal orders when they were signing them, making it impossible to verify that they were being signed within 24 hours. Our lead nurse spoke with both our medical doctor and our psychiatrist and explained the need for them to date the orders in addition to signing them. Doctors agreed to do this. Lead nurse is aware of the need to consistently check to assure that they continue to date their signatures. |
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.
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Observations
The drug and alcohol history did not include the client's perception of their use as it pertained to the effect it has had on their social, mental, and physical state in two of two records reviewed, # 1 and 6.
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Plan of Correction
Biopsychosocial evaluation did not adequately address client's perception of use as it pertains to the effect it had on social, mental and physical state. Clinicians and assessors will be made aware at the weekly staff meeting of the need to include this information in all evaluations. Clinical supervisors of inpatient and outpatient levels of care will oversee this meeting and will periodically review evaluations to assure this information is being included in all records. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations were missing in two of two client records reviewed, #1 and 6.
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Plan of Correction
Psychosocial evaluations were missing in two of the records. It is our belief that these were in fact completed and in the computer system, but neglected to be printed out. Support staff responsible for chart check has been talked to about the importance of assuring that clinical records are complete and include all paperwork that is done. Inpatient clinical supervisor will oversee this process to assure that clinical records are complete. |
709.64(d) LICENSURE Aftercare policy
709.64. Project management services.
(d) The project shall develop a written client aftercare policy.
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Observations
The aftercare plan policy for the detoxification program did not address when the plan should be created or the person responsible for completing the plan.
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Plan of Correction
Aftercare policy for detox did not include who was responsible for completing the form and when the form was to be completed. A new policy and procedure will be written to address this missing information. Facility Director will be responsible for writing and implementing this policy and procedure. |
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.
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Observations
The drug and alcohol history did not include the client's perception of their use as it pertained to the effect it has had on their social, mental, and physical state in three of four records reviewed, # 2, 3, and 4.
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Plan of Correction
Biopsychosocial evaluation did not adequately address client's perception of use as it pertains to the effect it had on social, mental and physical state. Clinicians and assessors will be made aware at the weekly staff meeting of the need to include this information in all evaluations. Clinical supervisors of inpatient and outpatient levels of care will oversee this meeting and will periodically review evaluations to assure this information is being included in all records. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Evaluations included check boxes, statements from clients and a repeat of historical data instead of the counselor's assessment of the client in four of four client records reviewed, # 2, 3, 4, and 5.
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Plan of Correction
Biopsychosocial evaluations that were reviewed did not contain an adequate assessment of the client. At the weekly team meeting, staff will be made aware of the need to interpret the data in the evaluation, not just repeat it back. Staff will shown examples of integrated summaries that were reviewed to be satisfactory and staff will be expected to incorporate interpretations in their evaluations. Staff will be reminded of the need to address support systems that are in place for all clients. Clinical supervisors of inpatient and outpatient programs will oversee the team meeting and will periodically review charts to assure quality of the evaluations. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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
The treatment plan was missing in one of six client records reviewed, #5. Treatment plans were not completed within the time frame identified by the facility (72 hours) in five of six client records reviewed, # 2, 3, 4, 9 and 10.
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Plan of Correction
Treatment plans were late in the majority of the records that were reviewed. One treatment plan was missing. The missing treatment plan was completed but was not printed out and signed. In the past we have had one person primarily responsible for printing out the treatment plans and getting them signed. This person was out on medical leave for several months and although this job was given to others, it was not implemented properly. We are making changes in our system making sure there are checks and balances to assure that if this staff person is out again, that treatment plans will still be signed in the appropriate time frame. We have put codes on the computer program to alert staff if the treatment plan is in danger of being late. We feel this will help us avoid this problem in the future. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
709.52. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Treatment plans goals did not include measurable criteria in five of five client records reviewed, # 2, 3, 4, 9 and 10.
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Plan of Correction
Treatment plans did not include measurable goals in all of the charts that were reviewed. Treatment plans will need to be updated to be assure that the goals are measurable and individualized for each client. Staff will be directed on what constitutes a measurable goal and will be expected to use measurable goals on all treatment plans that they complete. Facility Director will oversee this process. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
The facility failed to document follow up information in two of four client records reviewed, #10 and 12. Follow up information was not documented within the required time frame in one of four records reviewed, #9.
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Plan of Correction
Follow up was not adequately documented in two charts that were reviewed. Staff will be reminded of our facility's follow up policy and reminded of the importance of completing all follow ups in a timely fashion. Staff will be reminded of this policy and procedure at the upcoming staff meeting. Inpatient and Outpatient clinical supervisors will oversee this policy and procedure to assure that follow ups are being completed. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The drug and alcohol history did not include the client's perception of their use as it pertained to the effect it has had on their social, mental, and physical state in six of eight records reviewed, # 15, 16, 18, 19, 21, and 22.
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Plan of Correction
Biopsychosocial evaluation did not adequately address client's perception of use as it pertains to the effect it had on social, mental and physical state. Clinicians and assessors will be made aware at the weekly staff meeting of the need to include this information in all evaluations. Clinical supervisors of inpatient and outpatient levels of care will oversee this meeting and will periodically review evaluations to assure this information is being included in all records. |
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
Evaluations included check boxes, statements from clients and a repeat of historical data instead of the counselor's assessment of the client in six of eight client records reviewed, # 15, 16, 19, 20, 21, and 22.
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Plan of Correction
Biopsychosocial evaluations that were reviewed did not contain an adequate assessment of the client. At the weekly team meeting, staff will be made aware of the need to interpret the data in the evaluation, not just repeat it back. Staff will shown examples of integrated summaries that were reviewed to be satisfactory and staff will be expected to incorporate interpretations in their evaluations. Staff will be reminded of the need to address support systems that are in place for all clients. Clinical supervisors of inpatient and outpatient programs will oversee the team meeting and will periodically review charts to assure quality of the evaluations. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Treatment plans goals did not include measurable criteria in seven of eight client records reviewed, # 15, 16, 17, 18, 20, 21 and 22.
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Plan of Correction
Treatment plans did not include measurable goals in seven of the eight charts that were reviewed. Treatment plans will need to be updated to be assure that the goals are measurable and individualized for each client. Staff will be directed on what constitutes a measurable goal and will be expected to use measurable goals on all treatment plans that they complete. Facility Director will oversee this process. |
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
Treatment plan updates did not provide an assessment of the client's progress in relationship to the stated goals from the prior treatment plan and did not state if goals had been met or if treatment strategies needed revised in six of seven client records reviewed, #15, 17, 18, 20, 21 and 22.
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Plan of Correction
Treatment plan updates did not address assessment of the client's progress in relationship to the stated goals from the prior treatment plan and did not state if goals had been met or if treatment strategies needed revised. Treatment team will be instructed on the correct use of the treatment plan update at the next team meeting. An example of an inpatient treatment plan update will be shown since they were well done. Outpatient coordinator will oversee this. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
The facility failed to document follow up information in five of six client records reviewed, #20, 21, 23, 24 and 25.
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Plan of Correction
Follow up was not adequately documented in five of the six charts that were reviewed. Staff will be reminded of our facility's follow up policy and reminded of the importance of completing all follow ups in a timely fashion. Staff will be reminded of this policy and procedure at the upcoming staff meeting. Inpatient and Outpatient clinical supervisors will oversee this policy and procedure to assure that follow ups are being completed. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
The follow up policy for clients who are not referred to another treatment program did not include the method and frequency of contact.
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Plan of Correction
Our current follow-up policy did not include the method and frequency of contact for clients who are not referred to another treatment program. Our follow up policy and procedure will be updated to include this important information. |