INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 21 & 22, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Perry Human Services, 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 and a plan of correction is due on March 21, 2008.
|
Plan of Correction
|
704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
|
Observations
Based upon a review of the staffing information and personnel files on February 21, 2008, the facility failed to ensure that the project director met the qualifications for the position. Applying the criteria set forth in the standards and outlined in the Licensing Alert 05-05, the Executive Director is responsible for performing the functions of project director, but does not meet the specific educational qualifications for this position.
|
Plan of Correction
Due to a misunderstanding by the agency's Executive Director and Project Director, the facility believed that it was taking all the necessary steps to comply with the standards for the position of project director. However, after a meeting at Licensure on 11/14/07 and with additional clarification by Licensure, an initial plan of action was developed to work towards compliance (letter 11/17/07 to Licensure). As per that meeting the Executive Director contacted colleges to evaluate her college transcripts of current degree and qualify credits towards an approved major. The Executive Director has begun the enrollment process in the event that additional courses may need to be taken. Prior to the site visit of Feb. 21-22, 2008, the Executive Director had already sent Licensure an updated plan of action (letter 2/14/08) detailing the next steps to be taken to acquire the needed major.
|
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.
|
Observations
Based upon a review of personnel records on February 21, 2008, the facility failed to ensure that all staff had completed the mandatory HIV/AIDS training within two years of the date of hire using a Department approved curriculum. Two of five personnel records reviewed, #4 & 5, lacked documentation to show that at least 6 hours of HIV/AIDS training had been completed,as per the 1996 Department of Health Curriculum, within one year of date of hire for employee #4 and within two years for employee #5.
|
Plan of Correction
The facility did not know it was not in compliance with this standard until this site visit. Employee #4 was hired after the last previous site visit (July 10-11, 2006) and had certificates for 12 hours of HIV training. However, at this site visit it was determined those training hours were prior to 1996 and therefore were not acceptable. Employee #5 is a consultant for the agency and has been for 7 years. Since this position was never cited in previous site visits, it was not known this person needed documentation of HIV training within 2 years of consultation letter of agreement. The Executive Director has already researched when and where HIV trainings are available within the next three months and a driving distance under 2 hours. Employee #4 will complete the required HIV training by attending HIV training at Roxbury on May 28. Employee #5 is checking his training and medical education records for documentation that he received required hours of HIV training. If documentation is not found then employee #5 will also complete HIV training. After staff have attended HIV training, the Executive Director will file certificates of attendance in the HIV training certification folder. |
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 upon a review of client records during the licensing inspection on February 22, 2008, the facility failed to provide a complete drug and alcohol history in two of six client records reviewed, specifically client records #2 and 6. The records did not document the patterns or progression of use.
|
Plan of Correction
There is already a drug/alcohol history section in the psychosocial history form. However the information asked did not provide sufficient information regarding patterns and progression of use. Clinical supervisor is contacting other d/a facilities regarding questions used on their forms. D/A history section will be revised to include a more complete d/a history including patterns and progression of use. This section will be revised and ready for use by April 30. Clinical supervisor will discuss with counselors the revisions during the monthly treatment meeting and will also review this section for completion during the initial client file review.
|
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based upon a review of client records on February 22, 2008, the facility failed to provide a complete personal history in six of six client records reviewed. Client records #1 through 6 did not provide for a sexual history of the clients.
|
Plan of Correction
There is already a sexual history section in the psychosocial history form. However the information asked did not provide sufficient information regarding sexual history information. Clinical supervisor is contacting other d/a facilities regarding questions used on their forms. Sexual history section will be revised to include a more complete history including the age of first sexual encounter, sexual orientation and other appropriate questions. This section will be revised and ready for use by April 30. Clinical supervisor will discuss with counselors the revisions during the monthly treatment meeting and will also review this section for completion during the initial client file review. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based upon a review of client records during the licensing inspection on February 22, 2008, the facility failed to develop treatment plans that identified support services and/or provided short and long term goals to address all of the problems identified on the treatment plan and/or in the psychosocial histories and assessment. Four of six client records reviewed, #1, 4, 5 & 6 had identified multiple problem areas for the client, however; the treatment plans lacked goals and action steps to address some of the identified problem areas. One of six client records reviewed, #1, identified issues regarding childhood abuse, depression, and a history of self mutilation, however; the treatment plan failed to identify if any support services were being recommended or were in place.
|
Plan of Correction
Treatment plans will be developed that are individualized and specific for each client and reflect action steps that refer back to identified problem areas in the psychosocial evaluation. Action steps will include documentation of recommendations for support services or support services that are in place. Clinical supervisor will monitor more closely when completing initial client file review and treatment updates how the treatment plan is developed and documented. Clinical supervisor will also review treatment plans and updates with counselors during the monthly treatment meeting. |
709.93(a)(2) 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:
(2) Medication records.
|
Observations
Based upon a review of client records during the licensing inspection on February 22, 2008, the facility failed to provide complete documentation of medications in four of five client records reviewed, specifically client records #1, 3, 4 & 6. Client record # 1 was left blank, client records #3 & 6 failed to clearly identify the frequency for taking the medication; and client record #4 had an entry stating "just starting, no info", however; the information had not been updated since the initial entry.
|
Plan of Correction
In the medication section of the health questionnaire counselors were not providing complete documentation of client medications. If client is not taking any medications counselor will document this section as None or NA. Clinical supervisor will review with counselors the health questionnaire's medication section and discuss process for complete documentation of medications. Clinical supervisor will review this section during the initial client file review for complete documentation. Clinical supervisor will also review this section during treatment updates for any documentation of changes in client's medication. |