INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 6, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Bucks County Counseling 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:
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Plan of Correction
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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 a review of personnel records the facility failed to ensure that staff persons received a minimum of at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff.
The findings include:
Two personnel records requiring documentation TB/STD training were reviewed on September 6, 2012. Two out of two records, specifically records # 1 and 2, did not contain the required documentation.
Employee # 1, who holds the position of project director, facility director, and counselor, was hired on October 1, 2009. TB/STD training was due by October 1, 2010. As of the licensing inspection, there was no documentation of training that included TB.
Employee # 2, a counselor, was hired on October 1, 2009. TB/STD training was due by October 1, 2010. As of the licensing inspection, there was no documentation of TB/STD training that was at least 4 hours for employee #2.
The findings were confirmed with the project director during the exit interview.
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Plan of Correction
Add " both employee number one and employee number two have registered for, and will attend, state mandated training 4 hours STD/TB to be completed on October 23, 2012"
Project Director is responsible.
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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 personnel training records and a review of the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that each counselor receive at least 25 clock hours of training annually.
The findings include:
According to the (SRFSR), the facility training year runs from January 1, 2011 to December 31, 2011.
On September 6, 2012 one counselor's record was reviewed for training hours. One out of one counselor record did not document 25 clock hours of training for the 2011 training year, specifically employee #2.
Employee # 2 was hired as a counselor on October 1, 2009. Employee # 2 had only 16 documented clock hours of training during January 1, 2011 through December 31, 2011.
The training hours were confirmed with employee #2 and the project director during the exit interview.
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Plan of Correction
Training in Section 704.11 'Staffing requirements for drug and alcohol treatment activities" will be conducted with all counselors by 9/30/12.
Certification of training will be placed in employee file. Project Director is responsible.
Employee # 2's trainings will be monitored to insure trainings are scheduled appropriately during the year, and compliance to 704.11 is met. Project Director responsible.
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705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to clearly indicate exits by the use of signs.
The findings include:
A physical plant inspection was conducted with the facility director on September 6, 2012 at around 11:35 AM. During the inspection it was found that the second exit, from the office suite must be accessed through an office and there was no indication of that second exit when the door to said office is closed. This exit is obscured by a closed door and there were no signs to point the way to the second means of egress.
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Plan of Correction
Project Director will install exit sign above doorway blocking line of site to exit door.
To be completed by 9/30/12
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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 the review of client records, the facility failed to document a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and the counselor's conclusions and impressions or failed to document a biopsychosocial evaluation at all.
The findings include:
Six client records were reviewed for psychosocial evaluations on September 6, 2012. Four out of six client records lacked documentation of a psychosocial evaluation that included a clinical assessment, specifically client records # 2, 3, 4 and 5. Two out of six client records failed to include a psychosocial evaluation, specifically records #1 and 6.
The findings include:
Client # 1 was admitted on June 28, 2012. The facility failed to document a psychosocial evaluation in this client record as of the date of the inspection.
Client # 2 was admitted on May 10, 2012. The psychosocial assessment lacked an evaluation by the counselor of the client's assets/strengths, support systems, coping mechanisms, negative factors that may affect treatment, and attitude toward treatment.
Client # 3 was admitted on April 2, 2012. The psychosocial assessment lacked an evaluation by the counselor of the client's assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and the counselor's conclusions and impressions.
Client # 4 was admitted on April 3, 2012 and discharged on June 28, 2012. The psychosocial assessment lacked an evaluation by the counselor of the client's assets/strengths, support systems, coping mechanisms, negative factors that may affect treatment, and attitude toward treatment.
Client # 5 was admitted on December 28, 2011 and discharged on June 7, 2012. The psychosocial assessment lacked an evaluation by the counselor of the client's assets/strengths, support systems, coping mechanisms, and negative factors that may affect treatment.
Client # 6 was admitted on May 22, 2012. The facility failed to document a psychosocial evaluation in this client record as of the date of the inspection.
The findings were reviewed with the project director during the exit interview.
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Plan of Correction
Project Director will train all staff on contents and purpose of section 709.91. Certification of training will be placed in employee file.
Project director will amend the psychosocial evaluation document by adding sections titled "CONCLUSIONS : CLIENT'S APPEARANCE, BEHAVIOR AND REACTIONS DURING INTAKE" and " CONCLUSIONS: ATTITUDE TOWARD AND ABILITY TO PARTICIPATE IN THE Tx PROCESS".
project director will amend clients' 1,2,3 and 6 files to include the updated psychosocial evaluation. To be completed by 10/5/12
Project Director will add item "Completed Psychosocial Eval?" to the file checklist. Project Director will monitor compliance on all new intakes.
To be completed by 10/5/12
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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 a treatment plan update at least every 60 days as required by regulation.
Five client records requiring treatment plan updates were reviewed on September 6, 2012. The facility did not document a treatment plan update at least every sixty days in two out of five client records, specifically records # 1 and 5.
Client #1 was admitted into treatment on June 28, 2012. The treatment plan was documented on June 28, 2012. The facility failed to document a treatment plan update in this client record as of the date of inspection.
Client #5 was admitted into treatment on December 28, 2011 and discharged on June 7, 2012. The treatment plan was documented on December 28, 2011. The treatment plan was reviewed on February 28, 2012, however there was no update documented for April 30, 2012.
The findings were reviewed with the project director as of the date of inspection.
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Plan of Correction
Project Director will train all staff on the project Policy manual as it relates to section 709.92, subchapter C, General Standards for Free-standing treatment activities.
Project Director will train all staff on contents and purpose of section 709.92.
Certification of training will be placed in employee file.
Project director will add item to file checklist "Tx plan updates marked in calendar?". Office software will alert Project Director and Counselors when Treatment plan updates are due for each client. Project Director will monitor for compliance.
To be completed by 9/30/12
Client record #1 has been updated 9/7/12 to include treatment plan update. Reminder has been entered into computer tracking system |