INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 1, 2010 through November 5, 2010 licensure renewal inspection. The follow-up inspection was conducted on March 30, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Parkside Recovery 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 May 5, 2011.
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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, staffing requirements facility summary report on November 1, 2010 through November 5, 2010, and based on an interview with Human Resources staff on March 30, 2011, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Seventeen personnel records were reviewed on November 1, 2010 through November 5, 2010 and the staffing requirements facility summary report was reviewed on November 1, 2010 through November 5, 2010. There was no documentation of HIV/AIDS or TB/STD training in five employee records. Of the five records, four were required to have HIV/AIDS and TB/STD training within the first year of employment and the remaining staff person was required to have HIV/AIDS and TB/STD training within the first two years of employment. Personnel records for employees # 13, 14, 15, 16 and 17 were requested on March 30, 2011 during the unannounced follow-up inspection. A staff person from human resources spoke with the licensing specialists on March 30, 2011 and stated that employees #13, 14, 15, 16 and 17 were scheduled for an HIV/AIDS and TB/STD training on 11/8/10, but employees #13, 14, 15, 16 and 17 either failed to show up for the training or failed to sign the sign-in sheet for the training, so there were no certificates of completion in their employee files.
Employee #13 was hired April 14, 2009 and was required to have HIV/AIDS & TB/STD training by April 14, 2010. There was no documentation of TB/STD training in the employee's record as of March 30, 2011.
Employee #14 was hired September 24, 2009 and was required to have HIV/AIDS & TB/STD training by September 24, 2010. There was no documentation of TB/STD training in the employee's record as of March 30, 2011.
Employee #15 was hired September 28, 2009 and was required to have HIV/AIDS & TB/STD training by September 28, 2010. There was no documentation of TB/STD training in the employee's record as of March 30, 2011.
Employee #16 was hired March 30, 2009 and was required to have HIV/AIDS & TB/STD training by March 30, 2010. There was no documentation of TB/STD training in the employee's record as of March 30, 2011.
Employee #17 was hired October 9, 2008 and was required to have HIV/AIDS & TB/STD training by October 9, 2010. There was no documentation of HIV/AIDS training in the employee's record as of March 30, 2011.
This is a repeat citation from the November 1, 2010 through November 5, 2010 annual licensing inspection. The facility's plan of correction from the November 1, 2010 through November 5, 2010 inspection stated, "The training department will conduct mandatory trainings which include HIV/AIDS and TB/STD to insure that all new hires meet the DOH mandatory training requirements. Trainings are scheduled to complete all mandatory trainings for all employees before December 31, 2010 The clinical supervisors will monitor all new counselors trainings to ensure compliance with regulations the to ensure this deficiency does not re-occur. Completion date: December 31, 2010."
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Plan of Correction
Employees 13,14,15,16 and 17 all completed HIV/AIDS training on April 14, 2011. The program director will monitor all employee training hours and will require mandatory attendance by way of the sign in sheet and evaluation form to ensure this deficiency does not re-occur.
Completion date: Immediately for employees out of compliance and ongoing for all staff. |
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 records and an interview with the facility director, the facility failed to ensure and document that counselors completed at least 25 hours of training for the 2009/2010 training year in one of five personnel records.
The findings include:
Seventeen personnel records were reviewed on November 1, 2010 through November 5, 2010. Five employee records represented the counselors who were required to have obtained 25 hours of training for the 2009/2010 training year based on the hire dates, #8, 9, 10, 11 and 12.
Employee #12 was hired September 28, 1989 and was required to have obtained 25 training hours for the 2009/2010 training year. Employee #12 only had 24 hours of training for training year 2009/2010.
This could not be re-evaluated until the next licensing inspection. Please resubmit the original plan of correction that had been approved by the Department previously.
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Plan of Correction
Counselors will be instructed that it is their responsibility to complete 25 hours of training per year. The training department will schedule the trainings and clinical supervisors will monitor all trainings to ensure compliance. The training department along with the clinical supervisors will conduct quarterly reviews to assure compliance with DOH requirements. The clinical supervisors will report to the Program Director the results of the quarterly reviews.
The employee noted has completed her 25 hours.
Completed: Immediately for employee lacking the 25 hours
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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 the review of the facility's annual report for fiscal year July 1, 2009 through June 30, 2010, the facility failed to ensure that the annual report included a financial statement of income and expenses.
The findings include:
An interview was conducted with the Project Director on November 1, 2010. The Project Director confirmed that the financial statement of income and expenses was not documented on the annual report for July 1, 2009 to June 30, 2010.
This could not be re-evaluated until the next licensing inspection. Please resubmit the original plan of correction that had been approved by the Department previously.
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Plan of Correction
"The Project Director will introduce the standard to the NHS Parkside Board of Directors and ask them to acknowledge that from this time forward the Department of Treasury Internal Revenue Service Form 990 will be available to the public as a financial statement of income and expenses. This Form 990 will be made available to the public upon request in the same manner as the annual report. The Project Director will ensure all components of the standard are fulfilled."
This is effective as of December 14, 2010
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document counseling services provided according to the individual treatment plan in six of thirteen client records.
The findings include:
On March 30, 2011, thirteen records were reviewed for documentation of counseling services provided according to the treatment plan. The facility did not document counseling services according to the treatment plan in client records #3, 5, 6, 7, 9 and 22.
In client record #3 the treatment plan, dated 1/28/11, stated that the individual counseling sessions would occur biweekly and group sessions 3 times a week, but at the time of review, individual counseling sessions were only documented on 2/28/11 and 3/10/11.
In client record #5 the treatment plan, dated 1/13/11, stated individual counseling sessions would occur 2 times per month and group sessions 3 times a week, but at the time of review, individual counseling sessions were only documented on 3/8/11 and 3/22/11.
In client record #6, the treatment plan, dated 2/9/11, stated individual counseling sessions would occur 2 times a month and group sessions 3 times a week, but at the time of review, individual sessions were only documented on 1/26/11, 2/7/11, 2/9/11, 2/18/11 and 3/16/11.
In client record #7, the treatment plan, dated 2/3/11, stated individual counseling sessions would occur 2 times a month and group sessions 3 times a week, but at the time of review, individual counseling sessions were only documented on 1/6/11, 2/1/11. 2/18/11 and 3/11/11.
In client record #9, the treatment plan, dated 1/19/11, stated individual counseling sessions would occur 2 times per month and group counseling sessions 3 times per week, but at the time of review, individual counseling sessions were only documented on 1/7/11, 1/19/11, 2/2/11, 2/9/11 and 2/23/11.
In client record #22, the treatment plan, dated 1/21/11, stated that individual counseling sessions would occur 2 times per month and group sessions 3 times a week, but at the time of review, individual counseling sessions were only documented on 1/20/11, 3/11/11 and 3/21/11.
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Plan of Correction
A training will be held to ensure all counselors are aware and accountable for giving clients the services required under the treatment plan. The lead clinical supervisors will receive copies of all progress notes denoting at least two individual sessions per month for an IOP client. This information will be given to the Program Director each month in order to assure this deficiency does not re-occur
Training: May 2nd.
Completed by May 2nd. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations within the ninety day time frame in three of seven client records reviewed.
The findings include:
On March 30, 2011, seven client records requiring documentation of case consultations were reviewed. Per agency policy, case consultations shall be completed every ninety days. Case consultations were required in seven client records, specifically client records #1, 2, 4, 8, 10, 16 and 19. The facility did not document a case consultation within the ninety day time frame in client records # 1, 8 and 10.
Client #1 was admitted on 12/1/10. The case consultation was due by 3/1/11. Client #1's case consultation was done on 3/21/11.
Client # 8 was admitted on 12/2/10. The case consultation was due by 3/2/11. Client #8's case consultation was done on 3/10/11.
Client #10 was admitted on 12/17/10. The case consultation was due by 3/17/10. As of the date of the inspection, a case consultation had not been documented in client record #10.
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Plan of Correction
The lead clinical supervisor will provide another training on time frames regarding case consultations. A new monitoring and accountability grid has been developed to ensure that all case conferences are completed three days before due date. The lead clinical supervisor will monitor all grids to ensure this deficiency does not re-occur. The lead clinical supervisor reports directly to the program director.
Training: May 2nd
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