INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6-8, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Healthmasters, 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 17, 2008.
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Plan of Correction
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on the review of administrative and personnel records during the February 6-8, 2008 onsite licensing inspection, the facility failed to demonstrate that the person assigned the duties of the Project Director position (#1), fulfilled the responsibilities outlined in the Licensing Alert issued in May, 2005.
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Plan of Correction
Although 704.5(a) authorizes the Project Director to carry out the responsibilities and duties, the Board of Directors has assumed and carried out the subject responsibilities and duties, however the Project Director is aware of the Board's actions. In light of the responsibilities of the Project Director outlined in Licensing Alert in May, 2005 being made aware to the Board, Michael Palladini, Facility Director, will assume the position of Project Director as well. This assigment will be in compliance with the standards and Licensing Alert. Effective date 4/1/2008. |
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 administrative training and personnel records during the February 6-8, 2008 onsite licensing inspection, the facility failed to document individual training plans as required for all staff. No training plan was documented for one counselor (#6) hired 10/22/07 or for support staff (records # 7, 8, 9, 10, 11, 12, 13). The employee sample reviewed consisted of 13 records.
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Plan of Correction
Counselor #6 had completed a training plan with Director for the year 2008, but failed to return to Director for placement in proper folder. Facility Director will be responsible for completing individual training plans with all personnel, including support staff, for the year 2008. These plans will identify subject areas appropriate for each employee's position, and will also include mandatory communicable disease training, ethics, and confidentiality training. Compliance with standard on or before 4/30/2008. |
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 the review of administrative training and personnel records during the February 6-8, 2008 onsite licensing inspection, the facility failed to document the required mandatory communicable disease training for all staff as required. Personnel records #2 and 5 had incomplete documentation and could not substantiate the required 4 hours of training.
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Plan of Correction
The two counselor training records were listed as incomplete due to the fact that the required training was obtained in calender year 2005 and documentation was not included in training hours record that was reviewed. Facility Director will be responsible for monitoring that all employess receive mandatory communicable disease training in appropriate timeframe, and that a record of trainings will be included in personnel file as well as training record. Compliance to receive full training for all applicable employees in year 2008 by 12/31/2008. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of staff training records during the February 6-8, 2008 onsite licensing inspection, the facility failed to document that staff had received training in fire extinguisher use in six of six applicable records reviewed. (# 1, 2, 3, 4, 5, 6).
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Plan of Correction
Health Masters trains all staff in the fire extinguisher use, which is documented by checking the fire safety training box on the new employee orientation manual. Training includes the use of the fire extinguisher. Board of Directors will be responsible for including the language of fire extinguisher use with fire safety training. Compliance on or before 4/30/2008.
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709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on the review of administrative procedures during the February 6-8, 2008 onsite licensing inspection, the facility failed to document policies and procedures reflective of actual practice at the facility.
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Plan of Correction
Facility Director and Board of Directors will be responsible for amending policy to reflect who is responsible for the development, approval, monitoring, and evaluation of client services from intake through discharge. A policy and procedure will be in place by 4/30/2008. |
709.26(a)(2) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(2) Utilization of volunteers.
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Observations
Based on the review of administrative procedures during the February 6-8, 2008 onsite licensing inspection the facility failed to document a policy and procedure which addressed utilization of volunteers.
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Plan of Correction
Health Masters has a statement addressing the fact that the program will not use volunteers in an employee manual, but failed to include such statement in the policy and procedures manual. A policy will be adopted, written and placed in policy and procedures manual stating that Health Masters does not utilize volunteers. Board of Directors will be responsible for the implementation of policy on or before 4/30/2008. |
709.26(b)(1) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(1) Confidential maintenance of personnel records.
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Observations
Based on the review of administrative policies during the February 6-8, 2008 onsite licensing inspection, the facility failed to document a complete policy which addressed the confidential maintenance of personnel records. Components missed included: security of records, release of records and access to records.
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Plan of Correction
Health Masters has maintained the security of personnel records, but has not developed a complete written policy regarding the security, release, and access to records. Facility Director and Board of Directors will be responsible for developing a written policy addressing all aspects of the confidential maintenance of employee records. This will include the method of security, the release of records, who has access to records. Compliance on or before 4/30/2008. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records during the February 6-8, 2008 onsite licensing inspection, the facility failed to consistently document a symptoms and illnesses checklist in twelve of twelve client records in the sample. (client records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12).
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Plan of Correction
Health Masters' physical exam documentation has not included a checklist regarding symptoms and illnesses. Medical Director will be responsible for incorporating a checklist that addresses symptoms and illnesses into the initial physical exam documentation. Facility Director will be responsible for monitoring the inclusion of this checklist in all patient documentation following intake and admission into program. Compliance on or before 4/30/2008. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of client records during the February 6-8, 2008 onsite licensing inspection the facility failed to consistently formulate goals and objectives which addressed the assessed needs of each client. This issue was noted in six of twelve client records reviewed. (#2, 4, 7, 8, 9, 10).
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Plan of Correction
Health Masters will provide ongoing trainings as necessary for clinical staff in formation of treatment plan goals and objectives. Referral to initial assessment and personal history, as well as utilizing resource materials such as treatment planning guides written by various authors. Facility Director will be responsible for providing clinical staff with training and resource material, as well as monitoring and supervision regarding treatment plan formation and assessed needs of patients identified during intake, admission, and ongoing counseling sessions.
Compliance on or before April 30.
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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 during the February 6-8, 2008 onsite licensing inspection the facility failed to consistently provide an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan and/or appropriately modify treatment goals at the time of the update. This was observed in four of twelve records reviewed. (client records # 3, 5, 9, 10).
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Plan of Correction
Health Masters will provide ongoing training to staff to educate on the skills and processes involved in assessing client progress in relationship to the stated goals of treatment plan. Facility Director will be responsible for obtaining materials and resources regarding treatment planning and documentation and providing to staff. Ongoing compliance will be monitored by Facility Director with staff supervision and review of treatment plans for individual clients. Compliance on or before 4/30/2008.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records during the February 6-8, 2008 onsite licensing inspection, the facility failed to document aftercare plans which addressed all required issues. One of one applicable record did not address timeframes for stated goals and did not specify a re-entry process on the plan. (client record # 13).
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Plan of Correction
Health Masters has utilized an aftercare plan form that fails to address the required issues regarding complete aftercare. Facility Director and Project Director, with the assistance of the Board of Directors will develop a new Aftercare Plan form. This form will include required areas of (1) future goals and time frames (2) services provided by program staff (3) method and frequency of continuing contact for client support (4) re-entry criteria. Staff will be instructed on use of new form during aftercare planning by Facility Director. Compliance with standards on or before 4/30/08. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on the review of agency policy during the February 6-8, 2008 onsite licensing inspection the facility failed to document a follow up policy which was consistent with actual practice.
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Plan of Correction
Health Masters' policy and procedures manual had stated that follow-up documentation would be sent to clients at 10 and 30 days after discharge from program, when practice is actually 30 and 90 days after discharge. Policy will be corrected by Facility Director and Board of Directors to state that follow-up will take place at 30 and 90 days after client discharge to be consistent with practice. Staff will be informed by Facility Director to continue with current practice. Policy change will reflect compliance with standards by 4/30/08. |