INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 11, 2010 through January 13, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation, 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 February 13, 2010.
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Plan of Correction
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a facility tour and staff interviews conducted on January 12, 2010 and January 13, 2010, the facility failed to ensure that client records were stored within locked storage containers.
The findings include:
On January 12, 2010 at 2:35 p.m. a facility tour was conducted with the Treatment Coordinator/ Clinical Supervisor and it was determined that the open files were being stored in unlocked file cabinets in the staff break room. On January 13, 2010 at 3:15 p.m. licensing specialists were able to gain access to the unlocked staff break room. The door was ajar, no staff was present in the break room. The facility failed to lock the door and additionally, 26 file drawers were found unlocked. A staff interview was conducted with the Treatment Coordinator/ Clinical Supervisor on January 13, 2010 and it was confirmed that this has been an issue in the past and the facility is aware of the problem that exists.
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Plan of Correction
Training has been provided to all staff on 709.28 Confidentiality of client records. In addition, signage has been posted on the door to the staff break room where client record file cabinets are located which advises and reminds all staff that all cabinets and the door must remain locked at all times. The office manager will make daily rounds to ensure that this is maintained. |
709.29(a) & (b) LICENSURE Retention of Client Records
709.29. Retention of client records.
(a) Client records, whether original, reproductions or microfilm, shall be kept on file for a minimum of 4 years following the discharge of a client.
(b) If the project discontinues operation, it shall make known to the Department where its records are stored.
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Observations
Based on review of the policy and procedure manual the facility failed to have in place a policy that informed the Department where the records would be stored if the project discontinued operations.
The findings include:
The policy and procedure manual was reviewed on January 11 and 12, 2010. The facility failed to have a policy in place to inform the Department where they would store their records if the project discontinued its operations.
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Plan of Correction
Aldie's Quality Assurance Officer was made aware at the time of the licensing visit that the retention of client records policy failed to identify how the agency would inform the Department where the records would be stored if the prject discontinued operations. The Quality Assurance Officer wrote this item into policy at the time of the inspection at which time it was approved. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a tour of the physical plant and an interview with the Treatment Coordinator/ Clinical Supervisor, the facility failed to have a telephone number displayed conspicuously to the general public for emergency purposes.
The findings include:
On January 12, 2010 at 2:35 p.m. a physical plant tour was conducted. The facility failed to have a telephone number displayed conspicuously to the general public for emergency purposes. An interview with the Treatment Coordinator/ Clinical Supervisor at 2:40 p.m. confirmed that there was no emergency phone number posted.
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Plan of Correction
Aldie Quality Assurance and Compliance Officer and Site Director were made aware at the time of licensing that the site failed to have the phone number conspicuously displayed to the general public for emergency purposes. A new sign for the outside of the building has been approved and is being ordered on March 15, 2010 which will include the agency phone number. In the interim the phone number has been displayed conspicuously on a window at the entrance to the building. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a tour of the physical plant and an interview with the Treatment Coordinator/ Clinical Supervisor, the facility failed to have a telephone number displayed conspicuously to the general public for emergency purposes.
The findings include:
On January 12, 2010 at 2:35 p.m. a physical plant tour was conducted. The facility failed to have a telephone number displayed conspicuously to the general public for emergency purposes. An interview with the Treatment Coordinator/ Clinical Supervisor at 2:40 p.m. confirmed that there was no emergency phone number posted.
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Plan of Correction
Aldie Quality Assurance and Compliance Officer and Site Director were made aware at the time of licensing that the site failed to have the phone number conspicuously displayed to the general public for emergency purposes. A new sign for the outside of the building has been approved and is being ordered on March 15, 2010 which will include the agency phone number. In the interim the phone number has been displayed conspicuously on a window at the entrance to the building. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records on January 11 and 12, 2010, and a conversation with the Quality Assurance/Compliance Officer on January 11, 2010, the clinical supervisor failed to complete a core curriculum training in clinical supervision.
The findings include:
Employee #3 was hired by the facility on May 18, 2005 and promoted to clinical supervisor on February 24, 2009. As of the date of the personnel record review and interview with the Quality Assurance/ Compliance Officer on January 11, 2010, employee #3 failed to complete a core curriculum training in clinical supervision.
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Plan of Correction
The current Pharmacotherapy Coordinator was promoted to this position on 2/24/09. She has completed 188 hours of Magellan Behavioral health Clinical Supervisor training, however this was neither identified at the time of the licensing visit to the specialists nor was prior approval for this sought from the Department. She is now registered to complete the Department approved core curriculum training at the soonest scheduled opportunity available which is June 7th to the 11th, 2010 in Philadelphia. Site Director and Quality Assurance and Compliance Officer will monitor this for succesful completion at which time a copy of the training certificate and training appraisal form will be documented and placed in her personnel file. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the staffing self report form completed by the agency and employee records during the annual onsite licensing inspection, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings included:
During the annual onsite licensing inspection the employee records of eight clinical staff were reviewed. One employee, specifically, employee #6, was determined to be unqualified for their position based on the documentation included in their personnel records and , as a result , their clinical hours could not be counted. This resulted in the client to staff ratio that exceeded the required 35:1 ratio.
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Plan of Correction
At the time of the licnsing visit, the specialist identified that staff #6 did not meet the staffing requirements to be included within the staff/client ratio calculations. As of the licensing visit, staff # 6 has completed her requirement for her Masters in Clinical Psychology and is awaiting the awarding of her degree. On February 12,2010, she will also have completed her 6 months of observed supervision as a counselor assistant and will be eligible for assignment of a full caseload based on her supervisor's positive assessment of skill level. A letter attesting to this will be placed in her personnel file. The Quality Assurance and Compliance Officer will oversee that these items are adhered to and documented in this instance as well as review all qualifications of all future employees prior to hire to ensure that standards for staff/clinet ratio are met. |