INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on May 30, 2007 through May 31, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on June 29, 2007.
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Plan of Correction
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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 facility failed to provide documentation that the project director updated the policy and procedure manual.
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Plan of Correction
The cover page indicating annual updates to the policy manual has been signed by the CEO, the Program Director and the Board on 6/28/07.
The Program Director will now include the Board as well as the CEO as part of the annual updating process. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
The facility failed to post a service fee schedule in a prominent place.
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Plan of Correction
The previous service fee schedule was ripped down off the bulletin board by a client. The new fee schedule has been replaced and posted in a silicon cover in order to indicate permanency. This was posted 06/19/07. The Program Director will make checking the bulletin board part of the annual updating process. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
The specific information to be released was missing on the consent form in one of four client records reviewed, #3.
Specific information disclosed to Dauphin County Prison exceeded that allowed by 4 Pa. Code 255.5 in one of four client records reviewed, #6.
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Plan of Correction
The Director was at fault for releasing too much information to probation. To better understand the restrictions as it relates to judicial systems, the Director is scheduled to attend a Confidentiality Training again September 21, 2007 through White Deer Run. |
709.32(c)(4) 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:
(4) Methods for control and accountability of drugs.
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Observations
The facility failed to document that medications were administered to clients as prescribed in four of seven client records reviewed, #2, 3, 5 and 7. Specifically, the medication administration record was incomplete and left blank for several days when medications were not administered to clients. The facility failed to document why clients did not receive their medication as prescribed.
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Plan of Correction
All staff will be retrained on July 11, 2007 during a 2 hour Medication Training, 6pm-8pm. The training will cover how to document missed meds and how to keep compliance when utilizing the med log. Also, stiffer disciplinary actions will be enforced when med errors are made such as 3 med errors will earn a Disciplinary Action Notice. The Program Director will hold the training and catching med errors has been assigned to two staff people who give out meds at the end of the day. They will look for errors that were missed throughout the day. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to provide documentation that all staff were instructed in the use of fire extinguishers within seven days from the date of employment in one of nine personnel records reviewed, #3.
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Plan of Correction
A fire extinguisher training will be held for all employees during a July 11 staff meeting at 2:00pm. The local fire department will conduct the training which was coordinated by the Director. The Director will make Fire Extinguisher Training part of Orientation when an employee first starts and document this through a checklist. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
The facility failed to provide counseling to clients on a regular and scheduled basis in two of four client records reviewed, #1 and 6.
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Plan of Correction
Due to not being fully staffed and having no counselors, counseling was unable to be conducted on a regular basis except through the Director. As of 7/6/07, the Director will assume the title of Counselor and the Associate Executive Director will assume the title of Program Director. therefore, the direct care of clients will be addressed on a regular basis and the facility will be fully staffed with two clinicians. |
709.52(e)(3) LICENSURE Legal support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
The facility failed to provide documentation of available supportive legal services to clients.
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Plan of Correction
A Letter of Agreement was sent last year to Mid Penn Legal and they would not to sign. No other legal services would comply. Another attempt was made on 06/27/07. A Letter of Agremenet was mailed 06/27/07 to Mid Penn Legal and another will be mail 7/2/07 to Dickinson Family Law Clinic.On 7/6/07 a follow up call will got to Mid Penn Legal as well as Dickinson Family Law. Letters should be secured by 7/13/07. The Program Director will update letters of Agreements in January and will follow up when specific ones are not returned. |
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
The facility failed to provide documentation of follow-up information in three of three client records reviewed, #4, 5 and 7.
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Plan of Correction
Efforts are made to contact clients by phone at least one month after discharge for all clients. There is a form that captures follow up information and that form, once completed, is placed in their file. If a client cannot be contacted by phone the form is mailed to last known address. No copies of the mailed forms were being placed in the clients' charts as proof contact was attempted before they were mailed. This was a glitch in the system. Effective 6/13/07 and reflected by staff meeting minutes, a copy of the form being mailed to the client as follow-up will be placed in the client's chart as proof that contact was attempted. The Director will make copies of mailed forms before they go out and make sure they are filed in charts. |
704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
The facility failed to present the completed plan documenting the qualification and training of staff to the Department licensing representatives at the time of the site visit.
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Plan of Correction
There was missing information regarding specific qualifications on the form when it was handed in to the representatives. The Director does not have all personnel materials at the program site, such as resumes, etc. to complete all the needed information. Therefore, there were unknown pieces of information left blank on the form. On 6/19/07, the Director now has resumes and other supportive materials for staff as part of the program's personnel files. It will be complete at the next visit in advance. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
The facility failed to ensure that the counselor hired met the qualifications for the position of counselor. The counselor hired had a bachelor's degree in an unrelated field and does not meet the qualifications for the position of counselor.
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Plan of Correction
The facility will seek the critique of the dept of licensure in order to better select an appropriate and qualified candidate for a counselor position. In the meantime, as of 7/6/07 the Program Director will assume the title of Counselor and the Associate Executive Director will assume the title of Program Director. The credentials of the Program Director is a Master's in Counseling, seven years of human serve experience, and a CCDP certification from the PA Certification Board. The Associate Executive Director has a Master's in Human Services and over 15 years human service experience. |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
The counselor assistant was supervised by the program director, who is not a full-time clinical supervisor or counselor. The counselor assistant was employed with the project until May 18, 2007.
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Plan of Correction
As of 7/6/07 the Program Director will assume the title of Counselor and the Associate Executive Director will assume the title of Program Director. The Counselor Assistant will be supervised by a full time qualified Counselor. The Program Director will assure that the Counselor Assistant is being supervised by a clinical supervisor. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
The facility failed to produce documentation that the counselor assistant, who was employed by the project until May 18, 2007, was working towards a degree to meet counselor status.
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Plan of Correction
A supervision log has been started and is ongoing documenting diret supevision hours and a training log is maintained. The Counselor Assistant does not have the appropriate degree, but is earning her way to meet the Counselor criteria by accumulating supervision hours and PCB trainings. Once she completes her training hours for PCB she will then be eligible to apply for her CAC. The Counselor will ensure that documentation is happening. The Program Director will supervise that documetation is happening. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
The facility failed to provide an annual evaluation of the overall training plan.
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Plan of Correction
Although an added component of the annual evaluation was designed to meet this regulation previosuly, there were certain parts of the old method which were still needed. The Director added back the old piece which was needed to the new design so that the overall annual evaluation was comprehensive and would comply. This piece will also be addressed each year in January. |
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
The facility failed to develop an individual training plan in one of nine personnel records reviewed, #1.
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Plan of Correction
The Director of Administration will assure that the project director's individual training plan is updated each year. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
The facility failed to provide documentation of training for the project director.
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Plan of Correction
The Director of Administration will assure that each year documentation of trainings is kept in the project director's personnel file. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
The client/staff ratio was 18/1.
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Plan of Correction
The Director will assume the position of Counselor and supervise the Counselor Assistant. The ratio will be corrected. Currently there are 6 clients. The ratio is 3/1. When a Counselor position is open, the Director will assume the COunselor role and the Associate Eexcutive Director will assume the Director role while in pursuit of a Counselor hire. The Director will automatically assume this role. |