INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 7, 2011 through July 8, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Women's Institute for Family Health 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.
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Plan of Correction
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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.
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Observations
Based on a review of personnel records, a review of the Staffing Requirements Facility Summary Report, and a conversation with the project director, the facility failed to ensure that staff persons and volunteers received 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.
The findings include:
On July 7, 2011 four personnel records were reviewed.
Employee # 2 was required to have documentation of HIV/AIDS and TB/STD training.
The facility failed to provide documentation of the required 4 hours of TB/STD training.
Employee # 2 was hired 4/1/09.
Employee # 2 is a clinical supervisor.
4 hours of TB/STD training is to be completed within the first year of employment.
At the time of review on 7/7/11, the facility documented 3 hours of TB/STD training for employee # 2.
The project director confirmed the findings.
This is a repeat citation.
The facility was previously cited on 6/10/10.
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Plan of Correction
The Project Director will assure that the Clinical Director will receive the additional 1 hour of training needed to meet the 4 hour requirement within 30 days of this plan of correction. To avoid any future reoccurrence the facility will develop and obtain certification and approval for a agency sponsored 4 hour training on TB and STD's within 60 days of this plan of correction. The training will offered on a reqular basis and will be included in staff orientation. The Board of Directors have approved ammendments to the facility's personnel policies to state that newly hired staff must complete the TB, STD and HIV/AIDS training requirements before being placed on the work schedule. The Project Director will assure that staff are not scheduled to work until after they have completed this requirement and that documentation is stored in personnel files. |
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 conversation with the project director, the facility failed to document an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
During the onsite licensing inspection, the administrative materials were reviewed and no documentation of an annual audit was provided.
The facilities fiscal year runs from January 1 through December 31.
The project director was interviewed about the documentation of the annual audit; she confirmed that an annual audit of financial activities was not complete at the time of review for the year ending 2010.
This is a repeat citation.
The facility was previously cited on 9/1/09, 8/8/08, 4/17/08, and 9/6/07.
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Plan of Correction
The agency has been granted an Exception to the audit requirement from the Department of Drug and Alcohol program licensure. A copy of the Exception is on file at the facility.
In addition, Women's Institute for Family Health will maintain on site for review all financial records relating to the project's operations including payroll and staffing records, tax returns and related documents. The project will continue to utilize bookkeeping and accounting principles and standards that are generally accepted. The above will be presented during future on site inspections. |
709.28(c) 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:
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Observations
Based on a review of client records, and a conversation with the project director, the facility failed to adhere to the requirements specified at 4 Pa. Code 255.5 (b) and 42 CFR relating to specific information disclosed.
The findings include:
On July 8, 2011 six client records were reviewed to ensure compliance with 4 Pa. Code 255.5. The facility failed to adhere to the requirements in four out of six records, specifically client records # 2, 3, 5, and 6.
Client # 2 was admitted to the program on 4/19/11.
A signed Disclosure of Client Information documents allowing the release of treatment plans and discharge plans to a government agency, this exceeds the limits imposed by 4 Pa. Code 255.5.
Client # 3 was admitted to the program on 11/18/10 and discharged on 6/7/11.
A signed Disclosure of Client Information documents allowing the release of treatment plans and discharge plans to a government agency, this exceeds the limits imposed by 4 Pa. Code 255.5. In addition, the facility sent the government agency forms on 3/8/11, 4/7/11, and 7/6/11 titled "Monthly Treatment Report" which were actually a detailed progress report of the client's treatment that included intimate details about drug of choice, behavior patterns, and treatment sessions, thus failing to further comply with 4 Pa. Code 255.5 (b) and 42 CFR.
Client # 5 was admitted to the program on 10/20/10 and discharged on 1/6/11.
A signed Disclosure of Client Information documents allowing the release of treatment plans and discharge plans to a government agency, this release exceeds the limits imposed by 4 Pa. Code 255.5. In addition, the facility sent the government agency forms on 11/4/10, 12/7/10, and 1/6/11 titled "Monthly Treatment Report" which were actually a detailed progress report of the client's treatment that included intimate details about drug of choice, behavior patterns, and treatment sessions, thus failing to further comply with 4 Pa. Code 255.5 (b) and 42 CFR.
Client # 6 was admitted to the program on 2/1/11 and discharged on 5/26/11.
A signed Disclosure of Client Information documents allowing the release of treatment plans and discharge plans to a government agency, this exceeds the limits imposed by 4 Pa. Code 255.5.
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Plan of Correction
The Project Director revised the format of the Monthly Treatment Report to limit entries to only include information allowable by 4 Pa. Code 255.5 (b) on 7/11/2011. The Project Director developed and conducted a training with staff on the revised format that includes detailed instruction on the completion and confidentiality requirements of 4 Pa. Code 255.5 (b) and 42 CFR. The training was conducted on 7/21/11. The agency has added an amendment to its standard operating procedures that have been approved by the board of directors that state that all staff receive training on confidentiality and reporting during their orientation and that staff shall not be placed on the work schedule until after receiving this training. The Project Director shall assure that all staff receive this training before being scheduled to work and that documentation of this training is stored in personnel files.
Treatment reports will be approved and signed by the Project Director and the Clnical Director before being released to the requesting official. The Project Director has the ultimate responsibility for assuring that treatment reports are in compliance with 4 Pa. Cose 255.5 (b) and 42 CFR. |
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 client records, a review of the facilities policy and procedures manual, and a conversation with the project director, the facility failed to document a psychosocial evaluation according to policy in five of five records.
The findings include:
The facilities policy titled "Psychosocial evaluation" states:
The evaluation shall provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's situation:
Also: A clear description of the client's presenting and underlying problems.
Client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment.
Client assets, strengths or other factors that can contribute to the resolution of identified problems.
The potential or available client support systems.
Negative factors that might affect treatment.
The client's preferred coping mechanisms.
Conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Five client records were reviewed on July 8, 2011 for documentation of a psychosocial evaluation.
The facility failed to document a psychosocial evaluation according to policy in client records # 1, 2, 3, 5, and 6.
Client # 1 was admitted to the program on 2/21/11.
The psychosocial evaluation was documented on 3/14/11.
However, the facility failed to document an evaluation that included a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's situation.
In addition, the evaluation failed to include a clear description of the client's presenting and underlying problems; and the client ' s needs or problems that can or cannot be resolved through treatment or that might inhibit treatment.
Furthermore, the evaluation failed to include negative factors that might affect treatment; and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 2 was admitted to the program on 4/19/11.
The psychosocial evaluation was documented on 5/18/11.
However, the facility failed to document an evaluation that included a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's situation.
In addition, the evaluation failed to include a clear description of the client's presenting and underlying problems; and the client ' s needs or problems that can or cannot be resolved through treatment or that might inhibit treatment.
Furthermore, the evaluation failed to include negative factors that might affect treatment; and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 3 was admitted to the program on 11/18/10.
The psychosocial evaluation was documented on 12/15/10.
However, the facility failed to document an evaluation that included a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's situation.
In addition, the evaluation failed to include a clear description of the client's presenting and underlying problems; and the client ' s needs or problems that can or cannot be resolved through treatment or that might inhibit treatment.
Furthermore, the evaluation failed to include negative factors that might affect treatment; and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 5 was admitted to the program on 10/20/10.
The psychosocial evaluation was documented on 11/10/10.
However, the facility failed to document an evaluation that included a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's situation.
In addition, the evaluation failed to include a clear description of the client's presenting and underlying problems; and the client ' s needs or problems that can or cannot be resolved through treatment or that might inhibit treatment.
Furthermore, the evaluation failed to include negative factors that might affect treatment; and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 6 was admitted to the program on 2/1/11.
The psychosocial evaluation was documented on 2/28/11.
However, the facility failed to document an evaluation that included a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's situation.
In addition, the evaluation failed to include a clear description of the client's presenting and underlying problems; and the client ' s needs or problems that can or cannot be resolved through treatment or that might inhibit treatment.
Furthermore, the evaluation failed to include negative factors that might affect treatment; and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The project director did not dispute the findings.
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Plan of Correction
To assure that the project meets all requirements of Pa Code 709.91 and that there is no reoccurrence,the Clinical Director will assure that the Counselors develop a Clinical Assessment based on information gathered and/or reported by the client through medical, social, psychological and personal histories. This will occur through Clinical Supervision and review and approval of clinical assessments.
The Project Director developed a training on conducting the Clinical Assesssment and the Clinical Director will be responsible for conducting the training during staff orientation.
A training was conducted on 7/21/11 for current staff and Standard operating procedures have been revised to include the provision that all staff receive training on composing the Clinical Assessment prior to being placed on the agency work schedule.
The Clinical Director will provide training to staff on conduting the Clinical Assessment, the Project Director will verify that the training has occurred before approving staff to begin work.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On July 7, 2011 the facility was again found to be out of compliance with the following standards:
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.
This area of noncompliance was also identified during the licensing inspections conducted on:
9/1/09 (plan of correction submitted on 10/8/09 and approved on 10/19/09)
8/8/08 (plan of correction submitted on 9/5/08 and approved on 9/8/08)
4/17/08 (plan of correction submitted on 6/9/08 and approved on 6/10/08)
9/6/07 (plan of correction submitted on 11/8/07 and approved on 11/16/07)
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Plan of Correction
The agency has been granted an Exception to the audit requirement. A copy of the Exception is on file at the facility.
In addition, Women's Institute for Family Health will maintain on site for review all financial records relating to the project's operations including payroll and staffing records, tax returns and related documents. The project will continue to utilize bookkeeping and accounting principles and standards that are generally accepted. The above will be presented during future on site inspections. |