INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 18-20, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Addiction Medicine And Health Advocates, 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 September 19, 2009.
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
Based on the review of personnel records, the facility failed to document a core curriculum in clinical supervision in two of two personnel records.
The findings include:
Fourteen personnel records were reviewed on August 18-20, 2009. Of those fourteen, two were supervisors, requiring a core curriculum in clinical supervision. The facility did not document a core curriculum in clinical supervision in personnel records # 2 and 3.
Personnel records # 2 and 3 had not functioned for two years as a supervisor prior to being placed in a supervisory role.
|
Plan of Correction
Both employees identified as supervisors have been registered and accepted for the December 7-11, 2009 core curriculum training in Wilkes Barre, Pa. This is the earliest this training can be scheduled according to BDAP. The Executive Director will be responsible for monitoring compliance and completion.
In the future, all individuals identified to be supervisors who do not have the two years of supervisory experience, must complete the required training prior to taking on the role of supervisor. The Executive Director will monitor this for compliance. |
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.
|
Observations
Based on the review of personnel records, the facility failed to document the qualifications for the position of counselor in one of eleven personnel records.
The findings include:
Fourteen personnel records were reviewed on August 18-20, 2009. Of those fourteen, eleven were required to document the qualifications for the position of counselor. Personnel record #12 did not meet the qualification for the position of counselor.
Personnel record #12 documented a bachelor ' s degree in a related field but only three months of clinical/counseling experience. Record # 13 was required to document at least one year of clinical/counseling experience.
|
Plan of Correction
Counselor #12 has been made a counselor assistant and will be under the direct clinical supervison of the Clinical Coordinator for a minimum of 9 months as per 704.9. In the future, all individuals with questionable experience will be reviewed more closely to assure they meet the experiential standard. Through reference verification, we will determine whether the experience is applicable and valid. If necessary, we will review the candidate's background with a licensing specialist for further clarification. The Executive Director will be responsible for compliance with this standard. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel records, the facility failed to document a minimum of 6 hours of HIV/AIDS training in three of seven personnel records.
The findings include:
Fourteen personnel records were reviewed on August 18-20, 2009. Of those fourteen, seven were required to have documentation of 6 hours of HIV/AIDS training. The facility did not document 6 hours of HIV/AIDS training in personnel records # 7, 8 and 14.
|
Plan of Correction
Employee # 7 & 8 have been scheduled for HIV/AIDS training on 10/8/09. #14 is tentatively scheduled for 11/4/09 pending BDAP approval of the trainer. AMHA has newly appointed a Training Coordinator to schedule, monitor and evaluate all trainings for each staff member. A spreadsheet has been developed to track all required trainings and completion dates in order to meet licening and other credentialing entities' requirements. The Training Coordinator and Clinical Coordinator will be responsible for implementation and continued compliance. |
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.
|
Observations
Based on a review of personnel records, the facility failed to document a minimum of 25 hours of training in one of two personnel record.
The findings include:
Fourteen personnel records were reviewed on August 18-20, 2009. Of those fourteen, two required documentation of 25 clock hours of training for the 2008 training year. The facility only documented 23 hours of the required 25 hours for the 2008 training year in personnel record # 7.
|
Plan of Correction
AMHA has appointed a new Staff Development Coordinator to monitor compliance with required training for all staff. Each individual will be monitored to assure compliance with required training hours as per their indivdualized training plan. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a tour of the facility's physical plant, the facility failed to prohibit the use of heaters that are not permanently mounted or installed.
The findings include:
A physical plant inspection was conducted on August 19, 2009 at approximately 14:00. Two portable space heaters were observed in the facility.
|
Plan of Correction
AMHA has removed all portable space heaters from the facility. Supervisory staff will monitor each office for continued compliance and report monthly to the Health and Safety Committee. |
709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on the review of client records, the facility failed to document the specific client information to be disclosed on a release of information form in six of eight client records.
The findings include:
Eight client records were reviewed on August 18-20, 2009. The specific client information to be disclosed was required to be documented in eight client records. The facility did not document the specific information to be disclosed on a release of information form in client records # 1, 2, 3, 4, 5 and 6.
Client record 1, 2, 3, 4, 5 and 6 documented signed consents to release information to a transportation provider and to a managed care organization, but the consents did not include the specific information that was disclosed.
|
Plan of Correction
In a staff meeting on 8/27/09, administration reviewed the appropriate completion of all release forms to comply with Federal and State confidentiality regulations (42CFR and PA 255.5) As part of AMHA's Performance Improvement Program, we will randomly review patient records, specifically looking at appropriate completion of release forms. Additionally, the Clinical Supervisor will montior this during his/her review of patient records during supervision sessions. |
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.
|
Observations
Based on the review of client records, the facility failed to document a drug and alcohol history in seven of eight client records.
The findings include:
Eight client records were reviewed on August 18-20, 2009. Drug and alcohol histories were required in eight records. The facility did not document a drug and alcohol history within ten days after admission, as stated in the project ' s policy manual, in client records # 1, 2, 3, 4, 6, 7 and 8.
Client record #1 admission date 4/10/09, but the drug and alcohol history was dated 5/1/09.
Client record #2 admission date 4/7/09, but the drug and alcohol history was dated 4/23/09.
Client record #3 admission date 4/3/09, but the drug and alcohol history was dated 4/17/09.
Client record #4 admission date 4/27/09, but the drug and alcohol history was dated 5/11/09.
Client record #6 admission date 2/27/09, but the drug and alcohol history was dated 3/17/09.
Client record #7 admission date 1/28/09, but the drug and alcohol history was dated 2/10/09.
Client record #8 admission date 1/28/09, but the drug and alcohol history was dated 2/12/09.
|
Plan of Correction
AMHA has changed it's policy regarding the timeframe for completing the biopsychosocial history which includes the drug and alcohol history. The policy now requires the biopsychosocial history to be completed within 21 days of intake. This timeframe appears to be more realistic for our patient population. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on the review of client records, the facility failed to document a personal history in seven of eight client records.
The findings include:
Eight client records were reviewed on August 18-20, 2009. Personal histories were required in eight records. The facility did not document a personal history within ten days after admission, as stated in the project ' s policy manual, in client records # 1, 2, 3, 4, 6, 7 and 8.
Client record #1 admission date 4/10/09, but the personal history was dated 5/1/09.
Client record #2 admission date 4/7/09, but the personal history was dated 4/23/09.
Client record #3 admission date 4/3/09, but the personal history was dated 4/17/09.
Client record #4 admission date 4/27/09, but the personal history was dated 5/11/09.
Client record #6 admission date 2/27/09, but the personal history was dated 3/17/09.
Client record #7 admission date 1/28/09, but the personal history was dated 2/10/09.
Client record #8 admission date 1/28/09, but the personal history was dated 2/12/09.
|
Plan of Correction
AMHA has changed its policy and procedure regarding personal histories for patients. While we will still complete a biopsychosocial on each patient within 21 days of admission, we have added a personal history section to our initial screening form which is completed at intake. All staff have been trained on this new procedure and will be monitored during clinical supervision. As part of our Quality Improvemnt Committee's internal chart review, we will monitor compliance to this time frame. The Clinical Coordinator will be responsible for implementation and ongoing monitoring. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in seven of eight client records.
The findings include:
Eight client records were reviewed on August 18-20, 2009. Psychosocial evaluations were required in eight records. The facility did not document a psychosocial evaluation within ten days after admission, as stated in the project ' s policy manual, in client records # 1, 2, 3, 4, 6, 7 and 8.
Client record #1 admission date 4/10/09, but the psychosocial evaluation was dated 5/1/09.
Client record #2 admission date 4/7/09, but the psychosocial evaluation was dated 4/23/09.
Client record #3 admission date 4/3/09, but the psychosocial evaluation was dated 4/17/09.
Client record #4 admission date 4/27/09, but the psychosocial evaluation was dated 5/11/09.
Client record #6 admission date 2/27/09, but the psychosocial evaluation was dated 3/17/09.
Client record #7 admission date 1/28/09, but the psychosocial evaluation was dated 2/10/09.
Client record #8 admission date 1/28/09, but the psychosocial evaluation was dated 2/12/09.
|
Plan of Correction
AMHA has changed it's policy and procedure regarding the timeframe for completing the biopsychosocial history which includes the psychosocial evaluation. The policy now requires the biopsychosocial history to be completed within 21 days of intake. This timeframe appears to be more realistic for our patient population. All staff have been trained on this new procedure and will be monitored during clinical supervision. As part of our Quality Improvement Committee's internal chart review, we will monitor compliance to this time frame. The Clinical Coordinator will be responsible for implementation and ongoing monitoring. |
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.
|
Observations
Based on a review of client records, the facility failed to document follow-up in two of three client records.
The findings include:
Eight client records were reviewed on August 18-20, 2009. Of those eight, follow-up was required in three records. The facility did not document follow-up within 30 days after discharge, as stated in the projects policy manual, in client records # 8 and 9.
Client record #8 discharge date 6/15/09, but follow-up was dated 7/20/09.
Client record #9 discharge date 6/15/09, but follow-up was dated 7/20/09.
|
Plan of Correction
AMHA has changed its procedure for post-discharge follow-up. The person responsible for completing a post-discharge follow-up evaulation with patients will be given a list of discharged patients every two weeks to ensure they are contacted within the required 30 days. The Clinical Coordinator will be responsible for overseeing this procedure. |