INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 18-19, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northwestern Human Services Of Delaware County 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 March 23, 2010.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on the review of personnel records, the facility failed to document an assessment of staff training needs in seven of seven personnel records.
The findings include:
Seven personnel records were reviewed on February 18, 2010. All seven records required an assessment of staff training need. The facility did not document a staff training needs assessment by September 1st of each year, as per facility policy, in personnel records # 1, 2, 3, 4, 5, 6 and 7.
The facility policy titled " Supervision Training and Staff Development " states:
An assessment of staff training needs is to be completed by September 1st of each year with their supervisor.
In personnel record # 2, the assessment of staff training needs was documented on 2/15/10.
In personnel record # 3, the assessment of staff training needs was documented on 2/10/10.
In personnel record # 4, the assessment of staff training needs was documented on 2/5/10.
In personnel record # 5, the assessment of staff training needs was documented on 2/8/10.
In personnel records # 1, 6 and 7, the assessment of staff training needs was not dated and was not signed at the time of review on February 18, 2010.
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Plan of Correction
Human Resource department will add assessment of training needs to anual performance evaluation. Human resources is responsible to alert the program director and supervisor that performance evaluations are due for completion. These are completed duing the month of July and August for all employees. Supervisor will complete training needs assessment with employee at time of performance evaluation review. These will be submitted to director for review and signature. Director submits to HR for entry into computer system and placed in employee file. HR files are reviewed by HR during August to assure all reviews are completed prior to September 1st. |
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 the review of personnel records, the facility failed to document an individual training plan for in seven of seven personnel records.
The findings include:
Seven personnel records were reviewed on February 18, 2010. All seven records required an individual training plan. The facility did not document a training plan by September 1st of each year, as per facility policy, in personnel records # 1, 2, 3, 4, 5, 6 and 7.
The facility policy titled " Supervision Training and Staff Development " states:
In conjunction with the assessment of staff training needs, each staff person will develop with their supervisor an Individual Training Plan (ITP) annually, by September 1, which will address their training and educational needs.
In Personnel record # 2, the individual training plan was documented on 2/15/10.
In personnel record # 3, the individual training plan was documented on 2/10/10.
In personnel record # 4, the individual training plan was documented on 2/5/10.
In personnel record # 5, the individual training plan was documented on 2/8/10.
In personnel records # 1, 6 and 7, the individual training plan was not dated and was not signed at the time of review on February 18, 2010.
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Plan of Correction
Human Resources will add individual training plan to the annual performance evaluation. HR will alert program director and spervisor at beginning of July that evaluations are due for completion, which includes needs assessment and training plan. These are completed by supervisor for all employees during July and August. When completed supervisor submits to director for review and signature. Director submits to HR for entry in computer system and placed in employee HR file. HR reviews all files to assure all employees files are complete prior to September 1st. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of personnel records, the facility failed to document CPR and First Aid training to a sufficient number of staff persons.
The findings include:
Seven personnel records were reviewed and an interview with the clinical supervisor was conducted on February 18, 2010. The facility did not document CPR and First Aid training to a sufficient number of staff persons. Current CPR and First Aid Certification were documented in only two of the seven personnel records reviewed.
The clinical supervisor was unable to provide additional information to demonstrate sufficient CPR and First Aid coverage during the facility ' s hours of operation.
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Plan of Correction
All FT and PT employees will be required to obtain CPR and first aid certification. All new hires recieve this during pre-service training. This will assure a sufficient number during all hours of operation are certified. Human Resources administers the pre-service training for new employees. Individuals are not allowed to start work without HR sign-off that all requirements have been met. The program director is responsible to obtain training times from HR for current employees to attend. This training is completed in-house by certified trainer monthly. |
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 Staffing Requirements Facility Summary Report, the facility failed to maintain counselors ' caseloads at or below 35 active clients.
The findings include:
The Staffing Requirements Facility Summary Report was reviewed on February 18, 2010. The facility was required to not exceed 35 active clients on any counselor ' s caseload. The Staffing Requirements Facility Summary Report indicated a counselor ' s caseload to have 38 active clients.
The facility director signed the Staffing Requirements Facility Summary Report on February 18, 2010 to attest to its accuracy, veracity, and authenticity.
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Plan of Correction
This was for a fee-for-service counselor for which hrs were prorated to derive caseload size. The counselor has added 4 hrs per week to accomodate the number of active cases.
Program director will establish caseload size for all part-time employees based on hours worked per week. Program director will check monthly active list for each counselor against maximum allowed to assure compliance. Counselors will be required to submit a written request to have a new case with discharge form attached to assure case load does not change. Counselor therefore won't be able to add anyone without discharging someone. The exception would be counselor can request an increase in work hours to accept new cases. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a tour of the facility ' s physical plant, the facility failed to ventilate all toilets and wash rooms by exhaust fan or window.
The findings include:
A tour of the facility ' s physical plant was conducted on February 19, 2010 at approximately 9:45 AM. The facility was required to ventilate all toilets and wash rooms by exhaust fan or window. The facility did not ventilate the bathroom for the male clients and the bathroom for the male staff members.
The clinical supervisor confirmed that ventilation was not provided in the two identified bathrooms.
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Plan of Correction
Program director will contact facilities department. Facilities department is responsible to install exhaust fans in all four bathrooms. Program director will add 'check bathroom ventilation is working' to monthly physical plant audit checklist. Program director is responsible for monthly physical plant audit. |
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 the review of administrative documentation, the facility failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility ' s administrative documentation was reviewed and an interview with the project director was conducted on February 18, 2010. The facility was required to document an annual audit of financial activities. The facility did not document a financial audit for the 2008-2009 fiscal year.
The project director confirmed that a financial audit had not yet been completed.
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Plan of Correction
Audit has been complete as of this date for 08-09. Fiscal department will request final finacial reconciliation from payer to be received no later than October. Fiscal department will assure auditors will completed audit by December 31st. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on a tour of the facility ' s physical plant, the facility failed to display a service fee schedule in a prominent place.
The findings include:
A tour of the facility ' s physical plant was conducted on February 19, 2010 at approximately 9:45 AM. A service fee schedule was required to be posted in a prominent place. The facility did not have a service fee schedule posted at the time of inspection.
The clinical supervisor confirmed that a fee schedule was not posted at the time of inspection.
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Plan of Correction
Oversite of facility during renovation of space. Fee schedule is now posted in waiting room. Program director will add this to monthy physical plant audit checklist. Program director performs physical plant audit monthy. Audits are maintained in a notebook at the site. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document a preliminary treatment and rehabilitation plan in three of seven client records.
The findings include:
Seven client records were reviewed on February 19, 2010. All seven records required documentation of a preliminary treatment and rehabilitation plan. The facility did not document a preliminary treatment plan at intake, as per facility policy, in client records # 1, 2 and 7.
The facility ' s policy titled " Management of Intake / Treatment / Rehab Services " states:
The Intake worker completes the Initial Treatment Plan. It covers the client in treatment for thirty days. The initial treatment plan should be based upon information derived from the initial interview and other evaluations. The treatment plan will be signed by the client and/or legal guardian as appropriate, to reflect agreement of the goals.
Client # 1 was admitted to the program on 11/10/09, but an initial treatment plan was not documented at the time of review on 2/19/09.
Client # 2 was admitted to the program on 10/2/09, but an initial treatment plan was not documented at the time of review on 2/19/09.
Client # 7 was admitted to the program on 2/12/09; discharged on 10/6/09, but an initial treatment plan was not documented at the time of review on 2/19/09.
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Plan of Correction
Intake workers have been re-trained regarding completion of all required documents at time of intake. We have implimented an electronic tracking system for required documents. Director and supervisor receive a weekly report of any outstanding documents and documents due to expire. Supervisor is responsible to follow-up with staff. Progressive discipline will be administered to any staff not completing paperwork in timely manner. |
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
Based on the review of client records, the facility failed to document a treatment plan update in six of seven client records.
The findings include:
Seven client records were reviewed on February 19, 2010. All seven records required documentation of a treatment plan update. The facility did not document a treatment plan update to include an assessment of the client ' s progress, as per facility policy, in client records # 1, 2, 4, 5, 6 and 7.
The facility ' s policy titled " Management of Intake / Treatment / Rehab Services " states:
The counselor completes the Treatment Plan Update every sixty days, following the Comprehensive Treatment Plan. The plan will list the problems that will be worked on during the next sixty days of treatment and identify the behavioral tasks the client will perform to accomplish their short term goals. The Treatment Plan Update should also include an assessment of the client ' s progress (or lack of) in relationship to the stated goals of the Comprehensive Treatment plan.
Client # 1 was admitted to the program on 11/10/09; the comprehensive treatment plan was dated 12/14/09, but the treatment plan update that was documented on 2/1/09 did not include an assessment of the client ' s progress.
Client # 2 was admitted to the program on 10/2/09; the comprehensive treatment plan was dated 11/3/09, but the treatment plan update that was documented on 12/29/09 did not include an assessment of the client ' s progress.
Client # 4 was admitted to the program on 9/22/09; the comprehensive treatment plan was dated 10/22/09, but the treatment plan update that was documented on 12/3/09 did not include an assessment of the client ' s progress. Additionally, another treatment plan update had not been completed 60 day later.
Client # 5 was admitted to the program on 9/21/09; the comprehensive treatment plan was dated 12/1/09, but the treatment plan update that was documented on 12/28/09 did not include an assessment of the client ' s progress.
Client # 6 was admitted to the program on 2/5/09; the comprehensive treatment plan was dated 3/4/09, but the treatment plan update that was documented on 6/10/09 did not include an assessment of the client ' s progress.
Client # 7 was admitted to the program on 2/12/09; the comprehensive treatment plan was dated 3/11/09, but the treatment plan updates that were documented on 4/23/09 and 6/9/09 did not include an assessment of the client ' s progress.
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Plan of Correction
Counselors have been re-trained on completion of treatment plans with an emphasis on completing all fields and how these relate to service delivery per regulation and policy. Supervisor will review for completion when submitted for signature. Electronic tracking of due dates has been implimented to assure timely completion. Progressive discipline will be administered for all non-compliance. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document counseling services provided according to the individual treatment plan in five of seven client records.
The findings include:
Seven client records were reviewed on February 19, 2010. All seven records required documentation of counseling services provided according to the treatment plan. The facility did not document counseling services according to the treatment plan in client records # 2, 4, 5 and 7.
In client record # 2, the treatment plan dated 11/3/09 and the treatment plan update dated 12/29/09 state individual counseling sessions one time weekly, but at the time of review, individual counseling sessions were only documented on November 3, 5, 10, 19, December 8, February 2 and 9.
In client record # 4, the treatment plan dated 10/22/09 and the treatment plan update dated 12/3/09 state individual counseling sessions one time weekly, but at the time of review, individual counseling sessions were only documented on December 1, 3, 10 and January 7.
In client record # 5, the treatment plan dated 12/1/09 and the treatment plan update dated 12/28/09 state individual counseling sessions two times monthly, but at the time of review, individual counseling sessions were only documented on December 2 and January 6.
In client record # 7, the treatment plan updates dated 4/23/09 and 6/9/09 state individual counseling sessions two times weekly, but at the time of review, only one individual counseling session had been documented on February 14, 2009.
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Plan of Correction
Re-training on treatent plan requirements per regulation and policy with attention to relationship between plan and service delivered. When client does not show for appointment a note must be written indicating why frequency requirement has not been met. If frequency of visits has changed a new plan will be written. Supervisor will audit a sample monthly to assure frequency of visits matches plan or notes supporting deviation. Discipline will be administered for non-compliance. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document a case consultation in four of seven client records.
The findings include:
Seven client records were reviewed on February 19, 2010. All seven records required documentation of a case consultation. The facility did not document a case consultation at least quarterly, as per the facility ' s policy, in client records # 1, 2, 3 and 5.
The facility ' s policy titled " Management of Intake / Treatment / Rehab Services " states:
A Case Conference Note is completed quarterly during the first year of treatment and once annually thereafter by the counselor. It outlines the progress made and the roadblocks toward recovery. The case consult will include the names of those present and summary of discussion and disposition.
Client # 1 was admitted to the program on 11/10/09, but a case consultation was not documented at the time of review on 2/19/10.
Client # 2 was admitted to the program on 10/2/09, but a case consultation was not documented at the time of review on 2/19/10.
Client # 3 was admitted to the program on 10/19/09, but the only case consultation was documented on 2/15/10.
Client # 5 was admitted to the program on 9/21/09, but a case consultation was not documented at the time of review on 2/19/10.
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Plan of Correction
Staff re-trained regarding consultation notes. Counselor will submit case consultation note during supervision to be reviewed. Supervisor will have all notes entered for tracking to assure all clients have appropriate number and frequency dependent upon length as active client. |
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
Based on the review of client records, the facility failed to document follow-up information in two of two client records.
The findings include:
Seven client records were reviewed on February 19, 2010. Two of the seven records required documentation of follow-up information. The facility did not document follow-up information within 30 days from the date of discharge, as per their policy, in client records # 6 and 7.
The facility ' s policy titled " Management of Intake / Treatment / Rehab Services " states:
The Clinical Supervisor follows up on all transferred clients within 7 days; documented in follow-up section of discharge summary.
Client refuses treatment and walks off - Medical records staff mails a 30 day follow-up letter to the client within 30 days.
Completed treatment - Counselor may arrange several phone call contacts; Medical records staff mails a 30 day follow-up letter to the client within 30 days.
Client # 6 was admitted to the program on 2/5/09 and discharged on 7/20/09, but follow-up was not documented at the time of review on 2/19/10.
Client # 7 was admitted to the program on 2/12/09 and discharged on 10/6/09, but follow-up was not documented at the time of review on 2/19/10.
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Plan of Correction
Discharges will be submitted to supervisor who will forward to medical records for letter to be sent to client. Copy of letter with date will be placed on medical record. Monthly audit of random sample of discharges will be completed by supervisor to assure timely mailing of follow-up letter. |