INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16 - 18, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health - Pa., 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 July 21, 2008.
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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 review of the policy and procedure manual on June 16-17, 2008, the facility failed to include time frames in the written policy and procedure.
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Plan of Correction
Operations and Compliance Departments have taken this citation (failure to include time frames for training plans) under advisement and are currently in the process of revising policy to fix this citation and comply with regulation. New revisions to be rolled out by 08/15/08. Project Director to oversee. |
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 review of training records on June 17, 2008, the facility failed to document STD/TB training for employee #5. Documentation presented was a training feedback form, but there was no matching documentation to verify the training occurred.
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Plan of Correction
Clinical Supervisor will research training for TB/STD. This Associate as well as new Associates will be scheduled to attend TB/STD training by 07/31/08. Training certificate will be placed in file. Program Director to oversee. |
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
Based on review of training files, and personnel files, on June 16-17, 2008, the facility failed to present documentation of training for the project director for 2007 training year.
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Plan of Correction
Certificates of attendance will be kept on location for Project Director from each of the Leadership Universities held in Rhode Island. Clinical Supervisor will track Project Director's training in training certificate binder. Program Director will oversee. |
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 review of the training manual on June 16-17, 2008, the facility failed to document 25 hours of training for employees #9 and # 11. The facility documented 21.25 hours of training for employee #9 and 7 hours of training for employee #11 for the previous training year.
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Plan of Correction
Clinical Supervisor will review individual training plans for each associate and schedule appropriate training to comply with required training hours. Clinical Supervisor will follow up with Associate within 48 hours after training to ensure certificates are on file. Program Director to oversee. |
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 client census figures and individual counselor caseload compositions on June 17 and 18, 2008, the facility failed to ensure that caseload composition met the stipulations of the September 20, 2004 exception granted by the Department of Health for extended caseloads with clients on reduced counseling schedules. Three counselors (# 9, 12 &13) had caseloads consisting or more than 50% reduced counseling clients.
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Plan of Correction
Clinical Supervisor will review caseloads with each counselor. Arrangements of patients of counselor caseloads will be made to ensure that each counselor remains in compliance and does not have 50% reduced counseling patients. Program Director to oversee. |
705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plan inspection conducted on June 18, 2008, the facility failed to maintain carpeting and did not repair carpeting that was frayed at the seams. The carpeting was located in the upstairs hallway and the downstairs hallway, and in the office to the administrative assistant. Frayed carpets present a tripping hazard that is detrimental to the safety of staff and clients.
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Plan of Correction
Program Director has already begun the process of collecting bids to replace carpeting in Suite #4 and Suite #7. Bids will be reviewed and approved by Facilities Director. Once approved, new carpet will be installed. In the meantime, Program Director will patch tears in the carpeting to prevent safety issues. Facilities Director to oversee. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on review of the policy and procedure manual on June 16-17, 2008, the facility policy and procedure on the annual report states that the report will be completed within 90 days of the end of the reporting year. The annual report was not made available to the public until May 22, 2008, more than 140 days after the end of the reporting year.
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Plan of Correction
Project Director will approve Annual Report within 90 days of the end of the reporting year. Board of Directors to oversee. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the annual report on June 18, 2008, the financial statement of income and expenses was not documented.
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Plan of Correction
Financial Statement and expenses are now available on site for review for the public and will be presented to anyone who requests this information. Program Director to oversee to ensure this information is made available when requested. |
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
Based on review of the policy and procedure manual on June 16-17, 2008, the facility failed to provide a complete manual at the time of the inspection.
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Plan of Correction
The policy will be revised and amended by Corporate Compliance. Changes will be made to prevent confusion and conflicting information will be purged. Project Director to oversee. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on review of the policy and procedure manual on June 16-17, 2008, the facility policy and procedure on client confidentiality relating to state regulation at 4 Pa. Code subsection 255.5 was not consistent with state law at 71 P. S. Subsection 1690.108(b) which requires written client consent prior to the release of client identifying information. The facility policy and procedure currently allows for release to criminal justice entities "with or without" client consent.
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Plan of Correction
Operations and Compliance Departments have taken this citation (allowing release to criminal justice entities "with or without consent of client) under advisement and are currently in the process of revising policy to correct this citation and comply with regulation. New revisions to be rolled out by 08/15/08. Project Director to oversee. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on review of client records on June 17 -18, 2008, the facility failed to consistently document the purpose of disclosure on consent to release information forms. Based on a review of eight client records, six client records were required to document consent to release information forms. The consent to release information forms in client records #1, 3 and 4 failed to list a purpose for the release of information that was consistent with the function of the entity receiving the information.
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Plan of Correction
Training being held by Clinical Supervisor on 07/03/08 to educate Associates how to consistently document the purpose of disclosure on consents to release confidential information. Program Manager will conduct spot clinical and medical chart audits to ensure improvement and compliance. Program Director to oversee. |
709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
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Observations
Based on review of the policy and procedure manual on June 16-17, 2008, the facility failed to document a policy consistent with the regulation. The regulation specifically states that the project director may temporarily remove portions of the records prior to the inspection by the client. Facility policy allows for the "Medical Director, Nurse Practitioner, Physician Assistant or other appropriately credentialed designees as allowed by law...".
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Plan of Correction
Operations and Compliance Departments have taken this citation (policy inconsistant with regulation regarding who may temporarily remove portions of records before patient review) under advisement and are currently in the process of revising policy to correct this citation and comply with regulation. New revisions to be rolled out by 08/15/08. Project Director to oversee. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on June 17 -18, 2008, the facility failed to document complete psychosocial evaluations. Of the eight client records reviewed, psychosocial evaluations were applicable to six client records. Coping mechanisms and negative factors were incomplete in client records # 1, 2, 3, 4 and 5. Support systems were not evaluated in client records # 1, 2, 3 and 6.
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Plan of Correction
Clinical Supervisor has already held a training for clinical Associates to discuss the importance to include all areas in the evaluations of diagnostic assessments (06/25/08). These include coping mechanisms, negative factors and support systems. Another training will be held on 07/03/08 for reassurance that associates will comply. Program Manager will conduct spot clinical chart audits to ensure improvement and compliance. Program Manager will oversee. |
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 eight client records, six of which were reviewed for treatment plan content and time frames on June 17 and 18, 2008, the facility failed to document measurable criteria for the goals and objectives and failed to document goals and objectives consistent with the clinician's assessment in six of six applicable client records.
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Plan of Correction
Clinical Supervisor conducted a training with clinical Associates on 06/25/08 to ensure that future treatment plan goals and objectives are measureable and consistent with clinical assessments. Program Manager to conduct spot clinical audits to ensure improvements and compliance. Program Director to oversee. |
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 eight client records, two of which required discharge summaries, two out of two client records failed to have complete discharge summaries. Client records # 5 and 6, failed to document the reasons for treatment.
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Plan of Correction
Clinical supervisor will conduct audits of discharged patient charts within 7 days of discharge to ensure that discharge summaries have been completed and contain the reason(s) that patient had entered into treatment. Program Manager will conduct spot audits of discharged charts for quality assurance. Program Director will oversee. |