INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Riverside Care, 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 January 13, 2010.
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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 staff development records, staff interviews and organizational procedures, the facility failed to meet the general training requirements for two of two staff who are required to meet the general training requirements within one the first year of employment.
Findings:
Two staff development records reviewed on December 2, 2009 failed to include documentation of six hours of HIV/AIDS training within the first year of employment.
Employee record # 2. Employed October 20, 2008. Documentation of six hours of HIV/AIDS was not in the staff development record on December 2, 2009.
Employee record # 6. Employed August 1, 2008. Documentation of six hours of HIV/AIDS was not in the staff development record on December 2, 2009.
A request made to facility staff on December 2, 2009 and December 17, 2009 to provide verification of the general training requirements for employee # 2 and 6 was not met. The facility did not provide the necessary documentation.
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Plan of Correction
POC 0067
In addition to quarterly report of staff training needs by the Human Resource Department, the Program Director will utilize spreadsheet to monitor staff training needs monthly inclusive of mandatory trainings. Employee # 2 completed the HIV/AIDS training and the certificate will be submitted to Human Resources. Employee # 6 has been scheduled for HIV /AIDS training on 4/8/10.
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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
Based on a review of staff development records and staff interviews the organization failed to meet the annual training requirements for counselors in two of three employee records reviewed.
Findings:
Employee record #3. The employee was hired as a counselor on March 31 2005. The counselor was required to obtain 25 hours of training for the organizational training year of July 1, 2008 through June 30, 2009. A review of the staff development record on December 2, 2009 revealed that the facility documented only 16 hours of training for the staff development year July 1, 2008 through June 30, 2009.
Employee record #4. The employee was hired as a counselor on January 4. 2007. The counselor was required to obtain 25 hours of training for the organizational training year of July 1, 2008 through June 30, 2009. A review of the staff development record on December 2, 2009 revealed that the facility documented only 4 hours of training for the staff development year July 1, 2008 through June 30, 2009.
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Plan of Correction
POC 0083
In addition to quarterly report of staff training needs by the Human Resource Department, the Program Director will utilize spreadsheet to monitor staff training needs monthly. A co-occurring training series was implemented throughout this year for all clinicians which entailed at least a half day of training per month which should close fulfill the majority of training hours required as well.
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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.
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Observations
Based on a review of client records, a review of agency procedures and an interview with agency staff, the facility failed to obtain an informed consent to release information which listed the specific information to be disclosed to third party payers in 9 of 12 client records.
Findings:
Nine of twelve client records reviewed on December 17, 2009 contained consent to release information forms that failed to include the specific information to be disclosed. Nine of the twelve client records included documentation of consents to release of information to third party payors.
Clients records # 1, 2, 3, 4, 5, 6, 7 8, and 9 included documentation of a release of information forms to third party payors where the forms did not include the specific information to be disclosed. A review of organizational procedures provided verification that the organization would follow the requirements at 28 Pa. Code subsection 709.28 (c) (2) - Specific information disclosed. An interview with the facility clinical supervisor on December 17, 2009 provided verification of the lack of documentation of the specific information to be disclosed in the nine client records reviewed on December 17, 2009.
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Plan of Correction
POC 0279
Clinical staff will be trained on release of information form, policies and regulations by Program Director. Clinical Supervisor will audit and review charts monthly.
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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 a review of client records, organizational procedures and staff interviews, the facility failed to complete case consultations notes in five of nine client records that required case consultations.
Findings:
Four of nine client records reviewed on December 17, 2009 did not have documentation of case consultation notes.
Client record # 4. Admitted on June 23, 2009. A review of the record on December 17, 2009 revealed that the facility failed to document a case consultation. Organization procedures required case consultation notes every 90 days from date of admission.
Client record # 7. Admitted on March 24, 2009 . A review of the record on December 17, 2009 revealed that the facility failed to document case consultation notes. Organization procedures required case consultation notes every 90 days from admission.
Client record # 9. Admitted on April 17, 2009 . A review of the record on December 17, 2009 revealed that the facility failed to document case consultation notes. Organization procedures required case consultation notes every 90 days from admission.
Client record # 12. Admitted on January 27, 2009 . A review of the record on December 17, 2009 revealed that the facility failed to document case consultation notes. Organization procedures required case consultation notes every 90 days from admission.
One of nine client records reviewed on December 17, 2009 revealed that the facility failed to document case consultation notes every 90 days.
Client record #11 Admitted on January 22, 2009. Case consultation notes were due on April 22, 2009. A review of the client record on December 17, 2009 revealed that the facility documented a case consultation on May 13, 2009. Case consultation notes were documented 21 days late.
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Plan of Correction
The Program Director (PD) will instruct the Clinical Supervisor (CS) to create a list consisting of the client's name and case consult due date at the beginning of each month. The CS will give notice to each staff member during bi-weekly supervision the client's name and due date of each case consult. The CS will instruct each staff member to notify the CS when case consults are completed. The PD to follow-up during staff meetings with each staff member to ensure client case consults are completed. The CS will conduct a random chart audit to ensure compliance.
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