INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 28-30, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Home Nursing Agency Community 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 and a plan of correction is due on May 22, 2009.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the personnel/training records and discussion with the Director, the facility failed to document the 25 hours of required training for the 2007-2008 training year for one of two counselors in their training records.
The findings include:
Eight personnel/training records were reviewed on April 28, 2009. Twenty-five training hours were required in two of the records. Personnel record #8 documented only 14.5 hours of training for the 2007-2008 training year.
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Plan of Correction
The Clinical Supervisor has met on May 4, 2009, with the treatment team and reviewed the regulation of 25 continuing education hours per year. Staff will be attending a variety of co-occuring trainings through June 30, 2009 to assure compliance for the 2008-2009 audit year.
The Clinical Supervisor will complete an ongoing quarterly staff education audit to ensure full compliance of the regulation. Audits to begin July 1, 2009.
The Clinical Supervisor will receive the individual staff needs assessment sign offs by June 15, 2009, for the 2009-2010 year. The report for the upcoming year will be completed by June 30, 2009. |
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 counselor caseloads, the facility failed to maintain caseloads of less than 35 clients for three counselors.
The findings include:
Caseloads were reviewed on April 29, 2009. Six counselors were required to have a caseload of less than 35 clients. The facility did not maintain caseloads of less than 35 clients for three counselors. The counselor identified by personnel record #3 has a caseload of 39. The counselor identified by personnel record #4 has a caseload of 49. The counselor identified by personnel record #7 has a caseload of 100.
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Plan of Correction
The Director of Adult Services and the Clinical Supervisor applied for a waiver of 1:35 caseload ratio regulation on May 20, 2009. Clients are being referred out to other providers of care for outpatient services starting May 11, 2009, staff are to continue to discharge clients as appropriate to bring caseloads into compliance by July 1, 2009.
If waiver exception is not granted, in order to adhere to the 1:35 caseload ratio three of the outpatient groups will be discontinued and services will be limited to fall within the caseload regulations. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates in two of three client records.
The findings include:
Three client records were reviewed on April 29, 2009. Treatment plan updates were required in two client records. The facility did not document treatment plan updates in client records #2 and #3. Client record #2 had no documentation of a treatment plan update which was due February 7, 2009. Client record #3 had no documentation of a treatment plan update which was due April 18, 2009.
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Plan of Correction
The Clinical Services Manager met with staff on May 4th and 11th, 2009, and reviewed required timeline for treatment plan updates. Charts that were out of compliance were brought to the meeting on May 4th and 11th and clear instructions were given for treatment plan updates as required by regulation.
The Clinical Services Manager will develop and implement a schedule for chart audits to ensure compliance with all regulations by June 1, 2009. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document treatment plans in four of seven client records.
The findings include:
Seven client records were reviewed on April 29 & 30, 2009. Treatment plans were required in seven records. One client record had no documentation of a treatment plan. Three client records documented treatment plans which were not completed until after the due date.
In client record #9, the client was admitted to treatment on 10-20-08. The treatment plan was due November 26, 2008, but it was not documented as of April 30, 2009.
In client record #4, the client was admitted on February 12, 2009, the treatment plan was due March 17, 2009, but was not completed until March 30, 2009.
In client record #6, the client was admitted on October 15, 2008, the treatment plan was due December 3, 2008, but was not completed until January 7, 2009.
In client record #7, the client was admitted on December 23, 2008, the treatment plan was due on January 26, 2009, but was not completed until March 30, 2009.
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Plan of Correction
The Clinical Service Manager met with staff on May 4 & 11, 2009, to discuss the regulation and review the charts that were in violation. Staff were instructed that Clinical Service Manager would be scheduling chart audits and would follow up with disciplinary action if necessary to assure compliance with the regualtion. Treatment team understands that goal is for all charts to be in compliance by June 1, 2009. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates in two of two client records.
The findings include:
Seven client records were reviewed on April 29 & 30, 2009. Treatment plan updates were required in two records.
One record did not have a treatment plan update documented. One record had a treatment plan update which was completed more than 60 days from the date of the treatment plan.
In client record #5, the treatment plan update was due April 17, 2009, but it was not documented as of April 30, 2009.
In client record #6, the treatment plan update was due March 7, 2009, but the treatment plan update was not completed until March 19, 2009.
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Plan of Correction
The Clinical Services Manager will develop and implement a chart audit schedule so that 10% of the client charts will be reviewed monthly with staff to determine that we are in compliance for the regulation regarding treatment plan updates. The goal would be to meet regulations as of June 1, 2009. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in one of two client records.
The findings include:
Seven client records were reviewed on April 29 & 30, 2009. Case consultations were required in two client records. Client record #7 was required to have a case consultation on file by March 23, 2009, but it was not documented as of April 30, 2009.
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Plan of Correction
Revise Agency's current policy/procedure for case consultations to include timeframes for completion, signature and filing by June 1, 2009. Educate staff to new process for completing case consultations on June 1, 2009.
Clinical Service Manager to conduct chart audits to ensure compliance with the regulation. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document discharge summaries in two of three client records.
The findings include:
Seven client records were reviewed on April 29 & 30, 2009. Discharge summaries were required in three client records. Client records #9 and #10 were required to have discharge summaries within seven days of the discharge date, but there was no documentation of the discharge summaries as of April 30, 2009, more than seven days from the discharge date in both client records.
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Plan of Correction
The Clinical Services Manager will develop a process to identify individuals who have been discharged to ensure a completed discharge summary is in the client record within seven days. Staff were reeducated on the seven day requirement on May 4th, 2009.
Clinical Services manager will assure all necessary discharge summaries are completed by June 1, 2009, or staff disciplinary action will follow. |