INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 31, 2007- August 1, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A.R.S. of Lancaster, LP 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 September 5, 2007.
|
Plan of Correction
|
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
|
Observations
Based on a review of administrative training documentation it was determined that the facility failed to provide an assessment of staff training needs for the 2007 training year.
|
Plan of Correction
A.R.S. written policy and procedure requires that an assessment of staff member training needs be conducted annually by Program's Executive Director.
An assessment of staff training needs will be completed in November 2007, for the 2008 training year. To insure on-going compliance with this annual assessment responsibility, the Executive Director will address the status of training and staff needs assessment at each quarterly staff meeting. The minutes of each quarterly staff meeting will reflect this topic having been addressed; leading towards the next annual needs assessment of staff training needs in November of each calendar year.
|
704.11(a)(2) LICENSURE Overall Training 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:
(2) An overall plan for addressing these needs.
|
Observations
Based on a review of administrative training documentation it was determined that the facility failed to provide an overall plan for addressing staff training needs for the 2007 training year.
|
Plan of Correction
A.R.S. written policy and procedure requires that an assessment of staff training needs be conducted annually and an overall plan for addressing staff training needs be developed by the Program's Executive Director. An assessment of staff training needs will be completed in November 2007 and an overall training plan for addressing staff training needs will be developed by the end of December 2007 for the 2008 training year. To insure on-going compliance with producing an overall training plan annually, the Executive Director will address the status of training and staff needs assessment at each quarterly staff meeting. The minutes of each quarterly staff meeting will reflect this topic having been addressed; leading towards the development of the next annual overall plan for addressing staff training needs for the following calendar year.
|
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on a review of administrative training documentation it was determined that the facility failed to provide a mechanism to collect feedback on completed training for the 2006 training year.
|
Plan of Correction
A.R.S. written policy and procedure currently requires personnel to evaluate all training events. Effective 09/01/07, written evaluations will be completed at the conclusion of all on- and off-site training events by each participant. The Clinical Supervisor will maintain completed evaluation forms in a staff development file to be utilized as part of the annual training evaluation process. To insure on-going compliance with this regulation, completed evaluations will be reviewed quarterly, prior to the quarterly staff meeting. Completed training will be assessed for quality and quantity by the Clinical Supervisor and be reflected in the minutes of that meeting. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on the physical plant inspection it was determined that the facility failed to demonstrate that the fire alarm or smoke detector was set off during each fire drill.
|
Plan of Correction
A.R.S. written policy and procedure requires that the fire alarm or smoke detector be activated during each fire drill. The Program's Executive Director will write to the PA Department of Health by 09/15/07 requesting an exception to this requirement since the Program shares the space with another business and the operation of the alarm would be disruptive to normal commerce and counterproductive to positive community relations. |
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:
|
Observations
Based on a review of administrative documentation it was determined that the facility, which is publicly funded, failed to make available to the public by June 30, 2007 an annual report addressing the preceding fiscal year.
|
Plan of Correction
Due to the untimely death of ARS President and Board Member, our financial statement review and tax return was postponed due to the resolution of the disposition of the percentage of ARS owned by that individual. ARS is currently negotiating with the estate of this individual working under the stipulations of our partnership agreement to resolve the equity ownership issues. Once this issue has been resolved, our tax returns, financial statement review, and annual report will be completed. This will include making the annual report available to the public.
It is expected that the tax returns will be completed by September 15, 2007. The financial review should be complete by October 15, 2007 and the annual report shall be made available to the public by October 31, 2007.
|
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
|
Observations
Based on a review of administrative documentation it was determined that the project failed to obtain the services of an independent public accountant for an annual audit of all financial services associated with the project's drug and alcohol abuse services.
|
Plan of Correction
It is our understanding that Sub S corporations are not subject to this requirement. ARS of Lancaster, LP is a limited partnership that has a substantially identical legal structure and tax implications as a Sub S corporation. We will be composing a formal letter to Cheryl Williams requesting confirmation that ARS is exempt from this regulation. This letter will be sent to Cheryl Williams prior to September 15, 2007. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records it was determined that the project staff failed to document a decision to involuntarily terminate the client's treatment at the project in 1 of 1 client records reviewed, specifically client record #6.
|
Plan of Correction
A.R.S. written policy and procedure requires that written notice of termination be given to any patient being administratively discharged from the program. This is an involved process that meets all State requirements and is rarely carried out. A.R.S. is certain that the documentation was provided to the patient but is unsure how or why a copy was not placed in this patient's treatment file. However, to ensure conformance, staff training will be conducted and documented by the Program's Executive Director by 10/19/07.
The Executive Director will maintain a copy of all termination letters after they are signed by the client, counselor and medical director. When the patient chart is closed, the clinical supervisor will specifically monitor for the inclusion of the signed termination letter in the closed chart.
|
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on a review of client records it was determined that the facility failed to demonstrate the lengths and patterns associated with the client's progression of drug and/or alcohol use in 7 of 7 client records reviewed, specifically client records #2, 3, 4, 5, 8, 9 and 10.
|
Plan of Correction
A.R.S. Lancaster forms have been revised and team members have been trained to ensure improved documentation of patient drug and alcohol use histories. To ensure conformance, staff training will be conducted and documented by the Program's Executive Director by 10/19/07. To insure ongoing compliance with this regulation the clinical supervisor will make this a special interest item during the monthly chart review and will provide individual training as needed. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records it was determined that the facility failed to document a psychosocial evaluation with clinical opinions and impressions specific to the client's assets/strengths, support systems, coping mechanisms, negative factors that may effect treatment and overall recommendations in 6 of 6 client records reviewed, specifically client records #2, 3, 5, 8, 9 and 10.
|
Plan of Correction
A.R.S. Lancaster forms have been revised and team members have been trained to ensure improved documentation of psychosocial evaluation with clinical opinions and impressions specific to the client's assets/strengths support systems, coping mechanisms and negative factors that may effect treatment and overall recommendations in the interpretive summary as recommended by the reviewer. Supervision has been conducted by the acting clinical supervisor. Additional training will be completed by the Program's Executive Director on or before, 10/19/07. To insure ongoing compliance with this regulation the clinical supervisor will make this a special interest item during the monthly chart review and will provide individual training as needed.
|