INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 27-28, 2013 by staff from the Program Licensure Division. Based on the findings of the on-site inspection, RHD/New Start II was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 one of four record reviewed.
Findings:
Seven personnel records were reviewed on June 27, 2013. In personnel record #4, the counselor did not meet the qualifications for the position of counselor based on not having at least one year clinical experience. An interview with the facility director on June 27, 2013 confirmed the findings.
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Plan of Correction
By 7/19/13 Director will ensure each counselor meets the qualififcations for their position. Employee #4 will become a Counselor Assistant on 7/19/13. Director will monitor for on- going compliance. |
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 and training records, the facility failed to provide documentation of a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in one of seven personnel records.
The findings include:
Seven personnel records were reviewed on June 27, 2013. Seven personnel records required documentation of HIV/AIDS and/or tuberculosis, sexually transmitted diseases and other health related topics training. Employee record # 7 did not include documentation of the completion of the required training.
Employee # 7 was hired on October 27, 2009. HIV/AIDS and Tuberculosis and sexually transmitted diseases and other health related topics training was due to be completed by October 27, 2011. There was no documentation that the employee had completed the HIV/AIDS and TB/STD training as of June 27, 2013.
An interview with the facility director on June 28, 2013 confirmed the findings.
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Plan of Correction
Director will meet with empolyee and identify TB/STD and HIV/AIDS trainings for employee to attend. Employee will attend trainings by 8/30/13. Director will monitor for on-going compliance. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility director on June 25, 2013, and a discussion with the facility director, the facility failed to ensure that the staff to client ratios remained at or below 8:1.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on June 27, 2013. The form listed the project director, facility director and four counselors for the clinical staff. However, one of the four counselors did not meet for the position of counselor and their hours could not be included into the ratio equation.
The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40), and the total number of current clients as of June 27, 2013 exceeded the allowable maximum of 8:1.
The actual client ratio is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients treatment by the facility's standard work week.
The number of hours per week for the three counselors was 65 hours. 65 divided by the facility work week of 35 hours equals 1.857142857 FTE. The number of current clients is 16 divided by the 1.857142857 FTE is 8.615384616. This results in a ratio of 9:1 which exceeds the maximum of 8:1.
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Plan of Correction
By 7/15/13 Director will insure that staff meet the qualifications for counselor and the staff to client ratio is at or below 8:1. Director will monitor for compliance. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in two of seven personnel record, as required by regulation.
The findings include:
Seven personnel records were reviewed on June 27, 2013. Five employees were hired since the last inspection. Per regulation, the residential facility shall instruct all staff in the use of the fire extinguishers upon staff employment. The facility failed to document that fire extinguisher training was completed upon employment in employee record # 3 and 6.
Employee #3 was hired April 21, 2013. Fire extinguisher training was due to be completed no later than April 28, 2012. Employee #3's fire extinguisher training was completed on June 6, 2013.
Employee # 6 was hired on January 19, 2013. Fire extinguisher training was due to be completed no later than January 26, 2013, . The facility did not document the completion of fire extinguisher training.
An interview with the facility director on June 27, 2013 confirmed the findings.
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Plan of Correction
By 7/15/13 Assistant Director will instruct all staff in the use of fire extinguishers. Upon hire Assistant Director will train staff in the use of fire extinguishers. Director will monitor for on-going compliance. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to train staff to perform assigned tasks during emergencies upon staff employment in two of seven personnel record, as required by regulation.
The findings include:
Seven personnel records were reviewed on June 27, 2013. Five employees were hired since the last inspection. Per regulation, the residential facility shall train staff to perform assigned tasks during emergencies upon staff employment. The facility failed to document that this training was completed upon employment in employee records # 3 and 6.
Employee # 3 was hired on April 21, 2013. Emergency training was due to be completed no later than April 28, 2013. The facility did not document the completion of the emergency training until June 6, 2013.
Employee # 6 was hired on January 19, 2013. Emergency training was due to be completed no later than January 26, 2013. The facility did not document the completion of the emergency training.
An interview with the facility director on June 27, 2013 confirmed the findings.
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Plan of Correction
By 7/15/13 employees will be trained by Director to perform assinged tasks during emergencies. Anyone who is hired will be trained by Director or Assistant Director on how to perform assigned tasks in an emergency within 7 days of hire. |
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.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of eight client records.
The findings include:
Eight client records were reviewed on June 28, 2013. Four of the eight were discharge records, #5, 6, 7 and 8. One of the discharged clients was administratively terminated from treatment at the program. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 5.
Client # 5 was admitted into treatment on October 24, 2012 and was administratively terminated from the program on February 1, 2013.
An interview with the facility director on June 28, 2013 confirmed the findings.
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Plan of Correction
By 7/10/13 Director will teach staff how to complete administrative discharge documetation that will notify the client in writitng, of a decision to involuntarily terminate the client's treatment at the project.
Director will monitor for on-going compliance. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to completely document the results of the client's physical exams in four of eight client records.
The findings include:
Eight client records were reviewed on June 28, 2013. The physical exams are to include the date, vital signs, review of organ systems, general appearance and the physician's impressions. Also, physical exams are to be completed within 7 days of the client ' s admission date.
Client #2 was admitted on April 11, 2013. The physical exam was to be completed by April 18, 2013. Client #2's physical exam was completed on June 14, 2013. Also, the physical exam was missing the physician's general appearance of the client.
Client #3 was admitted on November 30, 2012. The physical exam was to be completed by December 7, 2012. Client #3's physical exam was completed on June 14, 2013. Also, the physical exam was missing the physician's general appearance of the client.
Client #4 was admitted on February 14, 2013. The physical exam was completed on February 20, 2013. The physical exam was missing the client's vital signs.
Client #5 was admitted on October 24, 2012. The physical exam was completed on October 26, 2012. The physical exam was missing the client's vital signs.
Client #6 was admitted on November 9, 2012. The physical exam was to be completed by November 16, 2012. Client #6's record failed to have documentation of the client ' s physical exam.
An interview with the facility director on June 28, 2013 and confirmed the findings.
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Plan of Correction
Director will meet with staff by 7/15/13 to identify resources to ensure physical exams are documented completely with the date, vital signs, review of organs systems, general appearance and the physician's impression within 7 days of the client's admission. Director will monitor for on-going compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to documented psychosocial evaluation in four of eight client records.
The findings include:
Eight client records were reviewed on June 28, 2013. Psychosocial evaluations were reviewed in six client records. The policy states, that the psychosocial evaluations will be completed within 20 days of the clients admission date. An interview with the facility director on June 28, 2013 confirmed the findings.
Client #1 was admitted on March 20, 2013. The psychosocial evaluations were to be completed by April 9, 2013. Client #1's record failed to have documentation of the psychosocial evaluation.
Client #2 was admitted on April 11, 2013. The psychosocial evaluations were to be completed by May 1, 2013. Client #2's record failed to have documentation of the psychosocial evaluation.
Client #5 was admitted on October 24, 2012 and discharged on February 1, 2013. The psychosocial evaluations were to be completed by November 13, 2012. Client #5's record failed to have documentation of the psychosocial evaluation.
Client #6 was admitted on November 9, 2012 and discharged on May 22, 2013. The psychosocial evaluations were to be completed by November 29, 2012. Client #6's record failed to have documentation of the psychosocial evaluation.
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Plan of Correction
Director will meet with therapist by 8/1/13 to insure psychosocial evaluations are completed within 20 days of admission. Director will monitor for on-going compliance. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 client record review, the facility failed to document case consultations in four of eight client records.
The findings include:
Eight client records were reviewed on June 28, 2013. Case consultations were required in six client records. Per facility policy, case consultations will be completed within 90 days of the client's admission date. An interview with the facility director on June 28, 2013 confirmed the findings.
Client # 1 was admitted on March 20, 2013. The case consultation was due by June 20, 2013. Client #1's case consultation was completed on June 26, 2013.
Client # 3 was admitted on November 30, 2012. The first case consultation was documented on December 30, 2012. The next case consultation was due by March 30, 2013. The second case consultation was documented on May 2, 2013.
Client # 5 was admitted on October 24, 2012 and discharged on February 1, 2013. No documentation of a case consultation was found.
Client # 6 was admitted on November 9, 2012 and discharged on May 22, 2013. No documentation of a case consultation was found.
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Plan of Correction
By 7/30/13 Director will meet with Assistant Director and therapist to insure case consultations are completed with the client within 90 days of adimssion and every 90 days there after. Director will monitor for on-going compliance. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document aftercare plans in one of four discharge records reviewed.
The findings include:
Eight client records were reviewed on June 28, 2013. Four of the eight were discharge records, #5, 6, 7 and 8. Of the four discharge records, one was required to have documented an aftercare plan, #6. Per the facility ' s policy, aftercare plans will be complete 7 days prior to discharge. Also, aftercare plans are to include on the form the clients goal with time frames, support services, contact person and reentry process.
An interview with the facility director on June 28, 2013 confirmed the findings.
Client #6 was admitted on November 9, 2012 and discharged on May 22, 2013. Client #6's aftercare plan was completed on May 22, 2013 and failed to include the client ' s goals with time frames.
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Plan of Correction
By 7/30/13 Director will review after-care plans with Therapist and Assistant Director to ensure after-care plans are completed within 7 days prior to discharge. After-care plans will include the clients goal with time frames, support services, contact person and reentry process. Director will monitor for on-going compliance. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document discharge summaries in two of four discharge records.
The findings include:
Eight client records were reviewed on June 28, 2013. Of the eight, four were required to show documentation of a discharge summary, #5, 6, 7 and 8. Per the facility policy, discharge summaries will be completed within 7 days after the clients discharge date. An interview with the facility director on June 28, 2013 confirmed the findings.
Client #5 was admitted on October 24, 2012 and discharged on February 1, 2013. The discharge summary was required to be documented by February 8, 2013. Client #5's discharge summary was completed but failed to have a date when it was completed. Couldn't determine if the discharge summary was completed by February 8, 2013, 7 days after client #5 ' s discharge date.
Client #6 was admitted on November 9, 2012 and discharged on May 22, 2013. The discharge summary was required to be documented by May 29, 2013. Client #6's discharge summary was completed but failed to have a date when it was completed. Couldn't determine if the discharge summary was completed by May 29, 2013, 7 days after client #6 ' s discharge date.
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Plan of Correction
By 7/15/13 Director will meet with Therapist to ensure discharge summaries are completed within 7 days after a client discharge. All discharge summaries will have a date when it was completed. Director will monitor for on-going compliance. |