INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the February 18-19, 2010 licensure renewal inspection. The follow-up inspection was conducted on October 26, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 November 30, 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 an interview with the facility director, the facility failed to document training needs assessments for training year 2010/2011.
The findings include:
An unannounced follow-up inspection and an interview with the facility director took place on October 26, 2010. In an interview, the facility director informed the licensing specialist that the training needs assessments were not completed as of October 22, 2010 for training year 2010/2011. The facility policy titled " Supervision Training and Staff Development " stated that an assessment of staff training needs was to be completed by September 1st of each year with their supervisor.
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Plan of Correction
Although the training needs assessments were not initially completed by September 1, 2010, they were completed on all staff on October 22,2010.
Going forward, each site now has a direct supervisor that will be responsible for creating a training needs assessment on the beginning date of each fiscal year. |
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 an interview with the facility director, the facility failed to document individual training plans for training year 2010/2011.
The findings include:
An unannounced follow-up inspection and an interview with the facility director on October 26, 2010. In an interview, the facility director informed the licensing specialist that the staff individual training plans were not completed as of October 22, 2010 for training year 2010/2011. The facility policy titled " Supervision Training and Staff Development " stated that an assessment of staff training needs was to be completed by September 1st of each year with their supervisor.
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Plan of Correction
Individual training plans were not completed by September 1, 2010, they were completed on all staff on October 22, 2010.
Going forward, each site now has a direct supervisor that will consturct the individualized training plans on the first date of the fiscal year. |
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 CPR certifications and an interview with the facility director, the facility failed to document CPR and First Aid training to a sufficient number of staff persons.
The findings include:
An unannounced follow-up inspection and an interview with the facility director took place on October 26, 2010. The facility did not document sufficient coverage by CPR and First Aid trained staff persons.
The facility director 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
To date, a sufficient number (at least two per shift) of staff have been trained in CPR/First AID as required. Director of program is now in possessionof all CPR/First AID that were not available at the time of the follow up inspection on 10/26/2010. A system is now being implemented to track this specific training. |
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 four of seven client records.
The findings include:
Fifteen client records were reviewed on October 26, 2010. Of the seven records reviewed, documentation of a treatment plan update was required in six. In records #2, 3, 6 and 7 did not include an assessment of the client's progress.
The facility's policy titled "Management of Intake/Treatment/Rehab Services" state:
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 record #2 comprehensive treatment plan was dated 6/3/10, but the treatment plan updates that were documented on 7/8/10, 8/6/10 and 10/12/10 did not include an assessment of the client's progress.
Client record #3 comprehensive treatment plan was dated 8/28/10, but the treatment plan updates that were documented on 9/25/10 did not include an assessment of the client's progress.
Client record #6 comprehensive treatment plan was dated 6/29/10, but the treatment plan updates that were documented on 8/6/10, 9/1/10 and 10/4/10 did not include an assessment of the client's progress.
Client record #7 comprehensive treatment plan was dated 7/6/10, but the treatment plan updates that were documented on 8/10/10 did not include an assessment of the client's progress. No treatment plan updated since last update dated 8/10/10.
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Plan of Correction
A re-training of all staff will be conducted on December 21, 2010 on the proper content of a treatment plan.
treatment plans will be given to the supervisor for her review and approval before being placed into the chart. A semi-annual training will take place to ensure that all staff are properly trained on the correct content required in a treatment plan. |
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 seven of seven client records.
The findings include:
Fifteen client records were reviewed on October 26, 2010. Six 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 #1, 2, 4, 5, 6 and 7.
In client record #1 the treatment plan, dated 8/20/10, and the treatment plan updates, dated 9/10/10 and 10/7/10, specified individual counseling sessions 2 times a month and group sessions 3 times a week, but at the time of review, individual counseling sessions were only documented on September 23, 2010 and October 21, 2010.
In client record #2 the treatment plan, dated 6/3/10, and the treatment plan updates, dated 7/8/10, 8/6/10 and 10/12/10, specified individual counseling sessions 2 times a month and group sessions 1 time a week, but at the time of review, individual counseling sessions were only documented on June 10, 2010, July 8, 2010.
In client record #4 the treatment plan, dated 7/7/10, and the treatment plan updates, dated 8/4/10, 9/1/10 and 9/22/10, stated individual counseling sessions 1 times a week/month and group sessions 1 times a week/month, but at the time of review, group sessions were only documented on July 6, 2010 and 7/19/10.
In client record #5 the treatment plan, dated 9/9/10, stated individual counseling sessions 2 times a week/month and group sessions 3 times a week/month, but at the time of review, group sessions were only documented on July 26, 2010, August 2, 2010 and August 9, 2010.
In client record #6 the treatment plan, dated 7/6/10, and the treatment plan update, dated 8/10/10, state individual counseling sessions 2 times a week/month and group sessions 3 times a week/month, but at the time of review, individual counseling sessions were only documented on June 28, 2010.
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Plan of Correction
As of 12/6/10, all counselors are documenting all completed and missed therapy sessions in the progress notes so that there is documentation consistant wit the treatment plan modality and frequency. The superviosr will ensure that there are progress notes present for all expected therapy sessions and that the progress notes indicate missed sessions. |
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:
Fifteen client records were reviewed on October 26, 2010. Six records were required documentation of a case consultation. The facility did not document a case consultation at least quarterly, as per facility policy, in client records #2, 3, 6 and 7.
The facility's policy titled "Management of Intake/Treatment/Rehab Services" stated that a "case conference note is completed quarterly during the first year of treatment and once annually thereafter by the counselor".
Client #2 was admitted to the program on 5/21/10, but a case consultation was not documented at the time of review on 10/26/10.
Client #3 was admitted to the program on 7/16/10, but a case consultation was not documented at the time of review on 10/26/10.
Client #6 was admitted to the program on 6/3/10/10, but a case consultation was not documented at the time of review on 10/26/10.
Client #7 was admitted to the program on 6/8/10, but a case consultation was not documented at the time of review on 10/26/10.
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Plan of Correction
A re-training with all staff has been conducted regarding the frequency of completion of the case conferences. Additionally, a new system has been put in place to track the case conferences completion. The supervisor will monitor the tracking system to ensure that all staff are following the procedures regarding case consultations. |
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 eight of eight discharge records reviewed.
The findings include:
Fifteen client records were reviewed on October 26, 2010. Of the fifteen records reviewed, eight required documentation of follow-up information. The facility did not document follow-up information within 30 days from the date of discharge, as per facility policy, in client records, # 8, 9, 10, 11, 12, 13, 14 and 15.
The facility's policy titled " Management of Intake/Treatment/Rehab Services " stated:
"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 days follow-up letter to the client within 30 days."
Client #8 was admitted to the program 3/12/10 and discharged on 7/24/10, but follow-up was not documented at the time of review on October 26, 2010.
Client #9 was admitted to the program 4/1/10 and discharged on 8/3/10, but follow-up was not documented at the time of review on October 26, 2010.
Client #10 was admitted to the program 7/16/09 and discharged on 6/12/10, but follow-up was not documented at the time of review on October 26, 2010.
Client #11 was admitted to the program 4/22/10 and discharged on 5/29/10, but follow-up was not documented at the time of review on October 26, 2010.
Client #12 was admitted to the program 6/11/10 and discharged on 8/11/10, but follow-up was not documented at the time of review on October 26, 2010.
Client #13 was admitted to the program 12/17/09 and discharged on 5/14/10, but follow-up was not documented at the time of review on October 26, 2010.
Client #14 was admitted to the program 1/29/10 and discharged on 5/19/10, but follow-up was not documented at the time of review on October 26, 2010.
Client #15 was admitted to the program 3/10/10 and discharged on 6/18/10, but follow-up was time of review on October 26, 2010.
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Plan of Correction
Medical records will be re-trained on the follow-up procedures and policies and a tracking system will be devised and implemented. The tracking system will include a shared file of completed discharges for medical records and supervior to access to ensure both parites are complying with policy. A follow up letter will be attached to the discharge packet to ensure the counselor is completing the letter. Medical records will then mail out the letter once they are given the packet and chart for closure and place a copy of the letter in the closed chart. Superviosr will monitor progress in this area. |