INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 6, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Project Transition, 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:
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Reports, the facility failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Reports for the 6 facilities contained within the project were reviewed on August 6, 2015. The equivalent of 17 full-time counselors are employed within the project. This would require at least 2 full-time clinical supervisors. The project currently employs 1 full-time clinical supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Project Director. Based on the review of these findings and a review of our staffing model against DDAP Regulations, we have designated 2 additional full-time Clinical Supervisor positions. These will be full time positions, will not carry any direct case loads and will provide the direct supervision over the counselors. The Project Director filled both positions by 9/1/15 with two individuals who are Certified Addictions Counselors with extensive clinical and supervisory experience. To prevent this issue from occurring in the future, the project director will monitor the formula for calculating how many FTE counselors are in the project and the project director will ensure that the project employs the required number of clinical supervisors based on the results of these calculations. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on the review of client records, the facility failed to ensure that a copy of the signed client consent was offered to the client in four of eight client records reviewed.
The findings included:
Eight client records requiring informed and voluntary consent to release information forms were reviewed on August 6, 2015. The facility failed to document that the signed consent forms were offered to the client in client records, #1, 2, 3, and 8.
Client #1 was admitted into treatment on February 4, 2014 and was still an active client at the time of the inspection. There were a total of 6 consent to release information forms - 2 to family members, 1 to an outside agency, 1 to a government agency, 1 to a pharmacy, and 1 to the funding source - signed and dated on 04/03/15 that did not include documentation that the client was offered a copy of each form.
Client #2 was admitted into treatment on June 23, 2015 and was still an active client at the time of the inspection. There were a total of 5 consent to release information forms - 1 to a family member, 1 to an outside agency, 2 to 2 separate government agencies, and 1 to the funding source - signed and dated on 06/23/15 that did not include documentation that the client was offered a copy of each form.
Client #3 was admitted into treatment on March 19, 2014 and was still an active client at the time of the inspection. There were a total of 4 consent to release information forms - 1 to a pharmacy, 1 to the funding source, 1 to a government agency, and 1 to another treatment provider - signed and dated on 03/18/15 that did not include documentation that the client was offered a copy of each form.
Client #8 was admitted into treatment on June 24, 2014 and was discharged on June 30, 2015. There were a total of 3 consent to release information forms - 1 to a pharmacy, 1 to a government agency, and 1 to the funding source - signed and dated on 01/29/15 that did not include documentation that the client was offered a copy of each form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed with the Project Director. All Admissions Team Members were re-trained on the process for completing Consents for Release of Information, including ensuring that Members receive a signed copy if they choose. This re-training of the process is to ensure all future consents are completed fully and accurately in the future. A full audit of existing member consents is being conducted and updated consents have been completed as required to meet all regulatory requirements. The Project Director is responsible for oversight of the audit process and will work with the Facility Director to ensure all consents are completed as required. |