INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11 and 12, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Health Masters, 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 October 16, 2007.
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Plan of Correction
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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 the staff training documentation binder on 9-11-07, the facility failed to provide the 25 hours of documented counselor training for the 2006 training year for personnel records # 6 and #8.
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Plan of Correction
Of the two employees, one had actually completed the 25 hours. Proof of same will be forwarded under separate cover. The Plan of Corrections for this item is that Facility Director will be responsible for maintaining training record for all staff members. Director will review agency training plan for current year and determine staff needs on a monthly basis. Director will
also seek and enroll staff in appropriate trainings from various
providers, as well as arrange for in-house trainings on topics suggested by staff members. Monthly reviews by Director will be effective Nov.1, 2007
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on interviews with the facility director, compliance officer, and board member, the facility failed to complete an annual report for 2006. This was an issue at the last licensing visit as the annual report for 2005 was not completed.
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Plan of Correction
Board of Directors will amend the wording of the Annual Report information contained on it's web site to include the required information. The Annual Report information is then available to the public via it's website. Facility Director and Board of Directors will develop listing of annual documentation for review and renewal at the beginning of each calendar year for accurate completion and entry onto it's web site. Notification of availability of Annual Report will be effective immediately.
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709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on a review of the personnel records on 9-11-07, and interviews with the facility director, compliance officer and board member on 9-12-07, the facility failed to provide documentation in client records # 2, 3 and 4 that the employees were notified of their rights.
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Plan of Correction
Health Masters maintains a policy on employee rights. These rights have been made available to all new employees. Review of these rights will be documented during every new employee orientation. Facility Director will be responsible for including employee rights in new employee orientation package, and will include statement
and employee signature on orientation list that employee rights have been reviewed with employee. This will be effective immediately
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the policy and procedure manual on 9-11-07, the facility failed to provide an accurate policy for the disclosure of information. The policy identified as "The Release of Confidential Patient Information to Others", item #2 states, "to those duly authorized probation or parole officers or both who have assigned responsibility to patients in treatment, with or without approval,..........". This policy is not in compliance with the requirement to obtain an informed and voluntary consent to release information from the client.
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Plan of Correction
Board of Directors will be responsible for amending policy to reflect regulation correctly concerning patient confidentiality and release of information with patient's consent. Policy will be changed to read that "information will be released to authorized parole/probation officers with patient approval only" (without
patient approval will be stricken). This will be effective by Oct. 31,
2007.
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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 the client records on 9-11-07 and 9-12-07, the facility failed to provide a completed, informed consent to release information for the clients in five of eight client records reviewed. The specific information section was blank in client records # 2, 6, 7 and 8. Client record #3 did not document the witness signature or the date. Client record #7 did not identify the person/agency to whom the information was to be disclosed, or identify the specific information that was to be disclosed. Client record #8 did not provide the person/agency to whom the information was to be disclosed, identify the specific information that was to be disclosed, or identify the purpose of the disclosure. Parent/guardian signature lines are included on the consent to treatment form found in eight of eight client records reviewed, in spite of the fact that only the minor can consent to the release of information.
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Plan of Correction
Facility Director will be responsible for instructing physician regarding proper completion of patient consent forms. Facility Director will also instruct counseling staff to monitor release forms from the medical staff for completion during initial meeting with patient. Any incomplete form will be reviewed with physician and patient for appropriate completion. This will be effective Oct.31, 2007. The Parent/guardian signature line will be stricken.
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709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of the policy and procedure manual on 9-11-07, and a review of the inspection log and an interview with the nurse on 9-12-07, the facility failed to provide documentation of the inspections of the drug storage area per the agency policy. The policy states monthly inspections will be completed, but inspections were not completed for six of the eight months. Missing inspections were noted for January, February, March, May, July, August 2007.
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Plan of Correction
Nursing supervisor will be responsible for conducting monthly inspections of drug storage areas for compliance with policy. Documentation of inspection in the form of a monthly checklist will be submitted to CRNP, who will be responsible for overseeing policy compliance. This will be effective Oct. 31, 2007.
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709.32(c)(5) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(5) Security of drugs.
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Observations
Based on a review of the facility policy and procedure regarding medications it was determined that the facility practice for dealing with the potential for loss, theft and/or misuse of drugs was not consistent with the written policy and procedure in effect at the time of the inspection.
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Plan of Correction
Board of Directors will change policy to omit contacting local law enforcement in the event of loss, theft, or misuse of medication. Policy will continue to read that " Program Director, Medical Director, Nurse Supervisor, Compliance Officer, and the Department will be notified. The Facility Director and Compliance Officer will initiate and
investigation within 24 hours of the incident. The results of the
investigation will be forwarded to the Department and DEA.
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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.
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Observations
Based on a review of the clinical records on 9-11-07 and 9-12-07, the facility failed to provide detailed progression of substance use/abuse relating to the patterns of use in the drug and alcohol history. This progression is missing in client records # 1, 2, 7 and 8. Client record # 5 does not have an updated history for this client's most recent admission.
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Plan of Correction
Facility Director will be responsible for implementing an updated psychosocial history form for use by counselors. Training will be provided to counselors by Facility Director as to the use of new form and the necessity of addressing drug use progression in completing a history. This will be effective by Oct. 31, 2007
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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 a review of client records it was determined that the facility failed to include short term goals with measurable criteria in the client records reviewed.
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Plan of Correction
Facility Director will be responsible for ongoing in-services and search for training materials to assist counselors in the
development of short term goals with measurable criteria into acceptable and realistic treatment plans. This will be effective immediately, and remain a clinical priority for Director.
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709.93(a) 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:
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Observations
Based on a review of client records it was determined that the facility failed to document the nursing notes in the client records reviewed.
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Plan of Correction
Nursing notes will now be printed on paper after each entry, and will be forwarded to appropriate counselor before the nursing shift has ended. These notes will become part of the permanent chart record for each patient. Nursing Supervisor will be
responsible for instructing staff on the proper and timely use of recording nursing notes. This will be effective immediately.
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