INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 14, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Counseling Services 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the facility's administrative documentation, the facility failed to provide verification of a written agreement with a licensed hospital or physician, for 24 hour emergency medical coverage.
The findings include:
The administrative documents were reviewed on December 5-8, 2011. The facility was unable to provide a written agreement with a licensed hospital or physician for 24 hour emergency medical coverage, as required.
An interview with the Quality Assurance Specialist confirmed the facility did not secure a contract for emergency medical coverage.
|
Plan of Correction
A written agreement with a licensed hospital or physician, for 24 hour emergency medical coverage was in place but had expired. A new agreement was signed and is now in place. The effective date of the new agreement is Jan. 5, 2012.
The Coordinator of Medical Services will ensure compliance as part of her annual review of agreements.
|
709.26(b)(2) 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:
(2) The dissemination of employment information to project staff.
|
Observations
Based on the review of the project's Policy and Procedure Manuals and Human Resource Manual, the project failed to adopt a written policy regarding the dissemination of information to staff members.
The findings include:
The project's Policy & Procedure Manuals and the Human Resource Manual were reviewed from December 5 - 8, 2011. The Licensing Specialist was unable to locate a policy that identified the specific methods that the project used to disseminate information to its staff members. The Corporate Director, Quality Specialist, and Human Resource Generalist were asked to assist in finding the policy but were unable to do so.
The findings were confirmed during the exit interview attended by the Facility Director, Quality Specialist, Human Resource Generalist, and Quality Director.
|
Plan of Correction
A written policy regarding the dissemination of information to staff members has been written and will be added to our HR policies. The policy will be approved at our next Leadership meeting in March. The policy will be reviewed with current staff and will be added to our new employee orientation program.
The Director of Human Resources is responsible for implementation and compliance and will make sure the policy is maintained in order to comply with this standard.
Re-occurrence will be prevented by annual review at the end of each fiscal year by our Corporate Director of Performance and Standards.
|
709.26(f)(3) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
(3) The requisite skills, knowledge and experience.
|
Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to ensure that all staff met the qualifications of their positions.
The findings include:
On December 23, 2011 the job description and transcripts for employee #5 were reviewed. Employee #5 was hired on April 28, 1997. A job description for Director of Outpatient Services was signed by employee #5 on July 1, 2010. The job description specifies that the employee in this position is required to have a Bachelor's degree in related field. After a review of employee #5's college transcripts, it was found that only an Associate's degree had been conferred on May 15, 2010.
|
Plan of Correction
There was a typographical error in the Job Description that stated Bachelor's Degree in related field or study preferred. It should have stated Bachelors Degree in related field of study preferred not required. The job description was revised on January 5 to state Associates Degree or Bachelor's Degree preferred in Drug and Alcohol.
The Director of HR will ensure compliance and review job descriptions for accuracy so this does not re-occur. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of partial hospitalization client records, the facility failed to document treatment plans to include the type and frequency of treatment and rehabilitation services.
The findings include:
On December 14, 2011, five partial hospitalization client records requiring treatment plans were reviewed. Five out of five partial hospitalization client records lacked documentation of a treatment plan that included the type and frequency of treatment and rehabilitation services, specifically client records #8, 9, 10, 11, and 12.
Client # 8 was admitted on September 28, 2011. The treatment plan was completed on September 28, 2011 and did not include the type and frequency of treatment and rehabilitation services.
Client # 9 was admitted on October 11, 2011. The treatment plan was completed on October 11, 2011 and did not include the type and frequency of treatment and rehabilitation services.
Client #10 was admitted on August 8, 2011 and discharged on October 10, 2011. The treatment plan was completed on August 8, 2011 and did not include the type and frequency of treatment and rehabilitation services.
Client # 11 was admitted on March 29, 2011 and discharged on May 26, 2011. The treatment plan was completed on March 31, 2011 and did not include the type and frequency of treatment and rehabilitation services.
Client # 12 was admitted on May 13, 2011 and discharged on July 12, 2011. The treatment plan was completed on May 25, 2011 and did not include the type and frequency of treatment and rehabilitation services.
|
Plan of Correction
Effective immediately (1/4/12) all current patient files will be reviewed and the type and frequency of treatment will be added to the developed treatment plans by the Addiction Counselor.
The Team Leader will do monthly chart reviews to ensure that the type and frequency of treatment is incorporated into the patient's treatment plan.
|
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of outpatient client records, the facility failed to document treatment plans to include the type and frequency of treatment and rehabilitation services.
The findings include:
On December 14, 2011, seven outpatient client records requiring treatment plans were reviewed. Seven out of seven outpatient client records lacked documentation of a treatment plan that included the type and frequency of treatment and rehabilitation services, specifically client records # 1, 2, 3, 4, 5, 6, and 7.
Client # 1 was admitted on October 17, 2011. The treatment plan was completed on October 26, 2011 and did not include the type and frequency of treatment and rehabilitation services.
Client # 2 was admitted on October 10, 2011. The treatment plan was completed on October 21, 2011 and did not include the type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on October 13, 2011. The treatment plan was completed on October 26, 2011 and did not include the type and frequency of treatment and rehabilitation services.
Client # 4 was admitted on October 27, 2011. The treatment plan was completed on November 8, 2011 and did not include the type and frequency of treatment and rehabilitation services.
Client # 5 was admitted on February 24, 2011 and discharged on April 12, 2011. The treatment plan was completed on March 9, 2011 and did not include the type and frequency of treatment and rehabilitation services.
Client # 6 was admitted on April 7, 2011 and discharged on May 27, 2011. The treatment plan was completed on April 7, 2011 and did not include the type and frequency of treatment and rehabilitation services.
Client # 7 was admitted on June 1, 2011 and discharged on August 2, 2011. The treatment plan was completed on June 16, 2011 and did not include the type and frequency of treatment and rehabilitation services.
|
Plan of Correction
Effective immediately (1/4/12) all current patient files will be reviewed and the type and frequency of treatment will be added to the developed treatment plans by the Addiction Counselor.
The Team Leader will do monthly chart reviews to ensure that the type and frequency of treatment is incorporated into the patient's treatment plan.
|