INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 10 and 11, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Counseling Alternatives Group, 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 November 12, 2007.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of administrative materials it was determined that the facility failed to meet the requirements of this regulation. The policy and procedure for staff training contained incomplete language regarding the agency training plan process and the time frame for completion of the annual assessment, the annual overall training plan and the evaluation of the overall staff training plan for the previous year. Time frames and responsible persons were not identified.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 a review of agency training materials and employee files it was determined that the facility failed to document an individual training plan for employee file #4 within the first month after the date of hire.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 training records and employee files it was determined that the facility failed to meet this requirement for two of seven employees. Employee # 5 did not have documentation of the required TB/STD training and employee # 6 did not have documentation of the required HIV or TB/STD training .
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 administrative materials and client census reports documented on the annual licensing staffing forms it was determined that the facility failed to meet the requirements of this regulation. Employee # 7 had a caseload of 36:1. This represents one of six counselor caseloads.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 a review of employee personnel and training records it was determined that the facility failed to provide documentation demonstrating that employees #5 and 6 had received fire extinguisher training . Each of these employees have been employed for two years. This represents two employees in the sample of seven staff reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of employee personnel and training records it was determined that the facility failed to provide documentation demonstrating that employees #5 and 6 had received emergency procedure training. Each of these employees have been employed for two years. This represents two employees in the sample of seven staff reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(b) LICENSURE Governing Body
709.22. Governing body.
(b) If a project is publicly funded, not more than one staff member of the project may sit on the governing body at a designated time.
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Observations
Based on reviews of administrative materials it was determined that the facility failed to comply with this regulation because there is more than one current staff on the governing body. All of the staff members ( five total) are also shareholders who are members of the governing body as of the dates of this inspection.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of the letters of agreement and staff interviews it was determined that the facility failed to a letter of agreement demonstrating the availability of 24 hour emergency medical services.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(a) 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:
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Observations
Based on a review of administrative materials including the policy and procedure manual it was determined that the facility failed to document governing body approval of the policies and procedures.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(a)(10) 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:
(10) Work performance evaluations.
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Observations
Based on a review of the personnel section of the policy and procedure manual , the facility did not meet the requirements of this regulation because there was no policy and procedure developed for the work performance evaluation process. The policies and procedures in place did not identify persons responsible for implementation, procedures to be followed, and the timeframe for completion and documentation requirements.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(a)(11) 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:
(11) Employe accidents and safety.
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Observations
Based on a review of the personnel section of the policy and procedure manual , the facility did not meet the requirements of this regulation because there was no policy and procedure developed for identifying how accidents and safety hazards are to be reported. The policies did not identify persons responsible for implementation or the procedures to be followed. The timeframe for completion and documentation requirements was missing.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(a)(12) 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:
(12) Employe grievances.
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Observations
Based on a review of the personnel section of the policy and procedure manual , the facility did not meet the requirements of this regulation because there was no policy and procedure developed for identifying how grievances are handled. The policies did not identify persons responsible for implementation or the procedures to be followed. The timeframe for both management and employees to follow at each step and who has the authority for final resolution of the grievance was missing. The grievance process was less than a two step process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(b) 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:
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Observations
Based on a review of administrative materials including the policy and procedure manual it was determined that the facility failed to provide documentation demonstrating that the governing body had approved the policies and procedures.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(b)(4) 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:
(4) The implementation of Federal, State and local statutes concerning fair employment practices.
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Observations
Based on a review of the personnel section of the policy and procedure manual , the facility failed to document a plan or staffing grid within the last twelve months which reported staff composition.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of employee records it was determined that 1 of 2 applicable employees did not have an annual performance rating for the past year ( employee # 6).
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of employee files the facility failed to document job descriptions in six of employee files reviewed. No job descriptions were found in employee files # 1, 2, 3, 4, 6 or 7.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 client records it was determined that the facility failed to provide for informed consents to release information in the client records reviewed. Client records # 3, 5, 6 and 8 were missing one or more of the required components for an informed consent (purpose, witness signature, and expiration dates.)
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 reviews of client records it was determined that the facility failed to document complete medical histories in 4 of 9 client records reviewed. Client records # 1, 2, 3 and 5 were missing symptoms and illnesses on the medical histories.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of a sample of client records it was determined that the facility failed document complete personal histories in five of the nine client records reviewed. The personal history in client record #2 contained a personal history that lacked detail on family dynamics and interactions. Details were lacking on sexual histories in client records # 1, 2 and 9. Educational information was brief and incomplete in client records # 1, 2, 3, 4 and 9. Client record # 5 was illegible.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 document realistic and measurable treatment goals in five of nine client records reviewed. The facility failed to identify goals which were realistic and measurable as determined by the assessed needs identified in client records # 1, 2, 4, 5, and 8.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of nine client records it was determined that the facility failed to include support services on the individual treatment and rehabilitation plan. A review of three client records, specifically client records #3, 4 and 8, revealed that support services specific to the clients' needs were not identified.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 a review of client records it was determined that the facility documented after care plans that did not address each of the required components specified. Specifically, time frames for each goal, identification of support services and reentry process were not clearly documented as part of the aftercare planning process. This was found in one of one applicable client records (#7).
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records it was determined that the facility failed to document follow up attempts in three of four client records reviewed, specifically # 1, 7 and 8.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of administrative materials the facility failed to meet the requirements of this standard because no documentation that the Medical Director was the physician of record approved for MA funding stream monies was available.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |