INITIAL COMMENTS
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This is a report of the on-site licensure renewal inspection conducted on March 20 through 21, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on April 20, 2007.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Feedback forms were not completed for any outside training.
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Plan of Correction
HR Assistant sent notice via email to all Program Directors and Supervisors in early March 2007, informing of the regulation/policy requiring the
collection of feedback on all completed trainings. The HR Department is ensuring compliance with this standard by monitoring all submitted training certificates, and not issuing credit for the training until the evaluation is completed and submitted to Human Resources. HR Director is responsible for the overall organizational compliance with this standard. Target date for completion was March 15, 2007.
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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
Employees #13 and 14 are missing TB/STD training.
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Plan of Correction
Counselors will attend the next
STD/TB training available, tentatively scheduled for May 3, 2007. On an ongoing basis, Program Director will ensure that all department supervisors monitor compliance with regard to meeting staff training requirements through individual and group supervision monthly with the clinical staff, and quarterly reviews of training records with the Human Resources staff.
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704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Employees # 14, 15 and 16 did not have over 50% of training provided by trainers not employed by Pyramid Healthcare, Inc.
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Plan of Correction
HR Assistant will provide an updated list, completed quarterly of all regional trainings available to employees. Program Director will ensure that at least 51% of employee's training hours are done by outside trainers that are not employed by Pyramid Healthcare. Target date for final completion of this project is April 13, 2007. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The fire drill log did not include the exit routes used, number of persons in the facility, problems encountered or whether the fire alarm or smoke detector was operative from August 2006 to present.
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Plan of Correction
Program Director revised the fire drill log. This log indicates which exit routes were used, number of persons in the facility, problems encountered, and whether the smoke detector or fire alarm was operative. Program Director will conduct a training for all staff on the correct completion of the new fire drill log. The maintenance department will monitor accurate completion of the fire drill log on a biweekly basis. Target date for completion is 4/13/07. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
The manual at the main administrative office and the manuals at the various locations reviewed were not consistent with regard to policies and procedures. The general organization of the manual made the review difficult and increased the potential for misunderstanding the intent of various procedures.
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Plan of Correction
The Master Policy Manual will be reviewed by the Policy Coordinator and the Chief Operating Officers from each division (Adult Residential, Adolescent Residential and Outpatient). The purpose of this review is to 1) ensure consistency of policies across the organization, and 2) to re-organize the Master manual, separating out Drug and Alcohol Program policies from DPW-licensed Program policies, ensuring ease of access to the policies, and diminishing the potential for misunderstanding of the intent of the policies/procedures. The Policy Coordinator will be responsible for ensuring that the Table of Contents accurately reflect the content of the manual. CEO/Project Director will be responsible for ensuring timely completion of this project. Target date for final completion of this project is June 1, 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
The HIPAA Notice of Privacy Practices contained incorrect information in sections III L.and O.; IV. F; V. A and C.; VI E and H and VII.
Information was released to parents without client consent in two records reviewed, #1 and 4.
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Plan of Correction
The Notices of Privacy Practices document was revised on April 4, 2007 by our Medical Records Corporate Coordinator, as per recommendations by Department of Health staff during the licensing visit. The COO of Adult Residential Services will submit the revised document to the Department of Health for review and approval by April 13, 2007. Once approved by the State, targeted implementation is April 20, 2007. Clinical Supervisor will provide training and supervision to counselors reguarding release of information, target date April 13, 2007. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
The record of services were incomplete or missing in five of seven client records reviewed, # 1, 2, 3, 5 and 6.
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Plan of Correction
Clinical Supervisor will be responsible
for ensuring that a record of service is completed for every client record. Clinical Supervisor will review with each staff during clinical supervision the proper procedure for completing the record of service. Clinical Supervisor will ensure compliance by doing monthly chart audits, as well as following up with the counselor in regularly scheduled supervision sessions. Target date for final completion of this target is 4/13/07.
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709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
The assessment portion of the group notes did not evaluate the treatment that was occurring. Progress notes did not address the treatment plan goal in individual or group notes.
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Plan of Correction
Clinical Supervisor will conduct
individual clinical supervision with current and new counselors regarding appropriate documentation of client progress in the record. Supervision will focus on the quality of the documentation of the data, assessment, and plans relative to treatment. New counselors will receive orientation and training regarding the same. Program Director and Clinical Supervisor will ensure compliance with this standard through ongoing clinical supervision and monthly chart monitors. Target date for final completion of this project is April 13, 2007.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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.
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Observations
Follow up information was not documented in seven of seven closed records, # 7, 8, 9, 10, 11, 12 and 14.
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Plan of Correction
The current policy and procedure addresses follow-up contact on all clients discharged from each level of
care, regardless of discharge status, and requires documentation of the follow-up attempt which is to be made within seven days of the appointment date. Clinical Supervisor will review the policy and procedure with the Counselors and Administrative assistant. The counselors will continue to complete follow up contact. In addition the Administrative assistant will be responsible, when necessary, for completion of follow-up procedures in lieu of the counselors. Program Director will be responsible for ensuring compliance with this standard through monthly chart monitors. Target date for final completion of this project is April 13, 2007.
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