INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 28, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc, Erie Outpatient 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in two of five personnel records.
The findings include:
Ten personnel records were reviewed on October 4-5, 2012. Five personnel records were required to include documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel records # 4 and 5.
Employee # 4 was hired as a counselor May 21, 2012. The employee met the educational requirement with Bachelor of Arts in Sociology. The employee's resume did not document that the employee had completed the required 1 year of clinical experience.
Employee # 5 was hired as a counselor May 21, 2012. The employee met the educational requirement with Bachelor of Arts in Sociology. The employee's resume did not document that the employee had completed the required 1 year of clinical experience.
Human resources personnel were interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
Beginning October 22, 2012 The Vice President of Human Resources, Program Director, and Clinical Supervisor will ensure that all persons hired for or promoted to the position of counselor meet the qualifications for the position of counselor. Specifically, employee #4 & #5 were transferred to the position of counselor assistant and will remain there until they have completed the appropriate requirements to return to the position of counselor. Program Director and Clinical Supervisor will monitor compliance with the close supervision needs of employee #4 & #5 through weekly supervision which will include one hour of direct observation per week. Vice Present of Human Resources, Program Director, and Clinical Supervisor will monitor hiring or promoting people to meet criteria for their portion by reviewing the staffing regulations prior to making offers or promoting chosen candidates for the position of counselor. Human Resources Department will also review employee files quarterly to ensure compliance. Compliance will be by 11/29/2012. |
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 a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project director and the facility director in one of two personnel records.
The findings include:
Ten personnel records were reviewed on October 4-5, 2012. One personnel record pertained to the project director. The facility's training year is January- December. The facility's 2011 training year was reviewed. Two personnel records required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the project director since July 1999. There were no training hours documented for the 2011 training year.
Human resources personnel were interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
Beginning October 22, 2012, Human resource coordinators will ensure that training evaluations for all trainings are placed in each individual's employee file. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance. The Human Resource Coordinators will also ensure that emplyees will have the correct number of training hours each year.
Project Manager will complete 12 hours of training by November 30, 2012. Human Resource Coordinator will ensure completion of these 12 training hours this year and each year after. |
705.26 (1) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(1) Shall have a heating and cooling ventilation system that is adequate to maintain an indoor temperature of at least 65F in the winter. When indoor temperatures exceed 90F, mechanical ventilation such as fans or air conditioning shall be used.
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Observations
Based on the physical plant inspection, the facility failed to maintain an indoor temperature of at least 65 degrees.
The findings include:
A physical plant inspection was conducted on November 28, 2012 at approximately 3:15 P.M. Group room A was at 60 degrees as per a thermometer in the room.
The facility director was present during the physical plant inspection and did not dispute the findings.
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Plan of Correction
Program Director contacted the landlord and informed her that the indoor temperature was not appropriate and that a citation was given during a DOH Licensing visit. The Landlord had the heating system replaced on 12/11/2012 which fixed the problem with the indoor temperature within the facility. This will be monitored monthly by facilities department and the Program Director. |
709.83(a)(11) LICENSURE Client records
709.83. 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:
(11) Follow-up information.
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Observations
Based on a review of the client records, the facility failed to document follow-up information in two of three partial hospitalization client records.
The findings include:
Sixteen client records were reviewed on November 28, 2012. Five client records pertained to the partial hospitalization activity. Three of the partial hospitalization client records were closed. Three of the closed client records required documentation of a follow-up attempt. Per agency policy, a follow-up will be conducted within 7 days of discharge. The facility failed to document a follow-up attempt within 7 days of discharge in client records # 1 and 3.
Client # 1 was admitted into treatment on September 17, 2012 and discharged on September 27, 2012. A follow-up attempt was due to be completed no later than October 4, 2012. The client was last seen for counseling on his date of discharge, September 27, 2012. There was no documentation that a follow-up had been completed within seven days of discharge.
Client # 3 was admitted into treatment on August 29, 2012 and discharged on October 3, 2012. A follow-up attempt was due to be completed no later than October 10, 2012. There was no documentation of a follow-up attempt.
The facility director was interviewed on November 28, 2012 and confirmed the findings.
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Plan of Correction
Program Director and Clinical Supervisor will re-train all of the clinical staff on completing follow ups by 12/10/2012. The Program Director and Clinical Supervisor will monitor the clinical staff's compliance with this through the monthly chart monitor reviews. Compliance will be by 2/2/2013. |
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 at least every 60 days in four of five client records.
The findings include:
Sixteen client records were reviewed on November 28, 2012. Eleven client records were reviewed as outpatient client records. Five client records required documentation of treatment and rehabilitation plan updates. Treatment and rehabilitation plans were not updated at least every 60 days in client records # 7, 10, 11 and 12.
Client # 7 was admitted on August 31, 2012. The individualized treatment and rehabilitation plan was completed with the client on September 12, 2012. The treatment and rehabilitation plan update was to be completed by November 12, 2012. There was no documentation of a treatment and rehabilitation plan update.
Client # 10 was admitted on September 13, 2012. The individualized treatment and rehabilitation plan was completed with the client on September 20, 2012. The treatment and rehabilitation plan update was to be completed by November 20, 2012. There was no documentation of a treatment and rehabilitation plan update.
Client # 11 was admitted on September 11, 2012. The individualized treatment and rehabilitation plan was completed with the client on September 25, 2012. The treatment and rehabilitation plan update was to be completed by November 25, 2012. There was no documentation of a treatment and rehabilitation plan update.
Client # 12 was admitted on June 4, 2012. The individualized treatment and rehabilitation plan was completed with the client on June 4, 2012. The treatment and rehabilitation plan updates were to be completed by August 4 and October 4, 2012. There was no documentation that the October 4, 2012 treatment and rehabilitation plan update had been completed.
The facility director was interviewed on November 28, 2012 and confirmed the findings.
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Plan of Correction
The ProgramDirector and Clinical Supervisor will re-train staff to completetreatment plan updates at least every 60 days, which include the client's progress as it relates to the goals identified in the individualized
treatment plan, and addition of any
new goals. This will be monitored
by monthly chart monitors by the Clinical Supervisor. Compliance will be by 2/2/2013
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