INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 2-3, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Project Transition 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 April 22, 2011.
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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 and an interview with the Director of Quality Improvement, the facility failed to document the qualifications for the position of counselor in one of one personnel records.
The findings include:
On February 3, 2011 one personnel record was reviewed for documentation of the qualifications for the position of counselor. The facility did not document the qualifications for the position of counselor in personnel record #3.
Personnel record #3 did not contain documentation of one of the groups of qualifications listed under (b). Personnel record #3 only contained documentation of an Associate Addictions Counselor II certificate.
An interview with the Director of Quality Improvement confirmed that personnel #3 did not meet the qualifications for the position of counselor.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
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Observations
Based on a review of the facility ' s training records and an interview with the Director of Quality Improvement, the facility failed to document an overall training plan to address staff training needs.
The findings include:
On February 3, 2011 the facility ' s training records were reviewed for documentation of an overall training plan. The facility did not document an overall training plan for the 2011 training year.
An interview with the Director of Quality Improvement on February 3, 2011 confirmed that the facility did not document an overall training plan to address staff training needs.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on the review of the facility's policy manual and an interview with the Director of Quality Improvement, the facility failed to develop written procedures for the management of treatment services.
The findings include:
On February 3, 2011 the facility's policy manual was reviewed for written procedures for the management of treatment services. The facility's policy manual did not document admission procedures into their drug and alcohol program for clients already receiving services under the project's mental health license. The facility's policy manual only addresses admission procedures for clients who are new to the project.
An interview with the Director of Quality Improvement on February 3, 2011 confirmed that the policy manual did not address admission procedures for clients already receiving services in their mental health program.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records and an interview with the Director of Quality Improvement, the facility failed to comply with 4 Pa. Code relating to projects and coordinating bodies: disclosure of client-oriented information in four of four records.
The findings include:
On February 3, 2011 four client records were reviewed for documentation of informed and voluntary consent. The facility documented the release of client information which exceeded the limitations imposed at 4 Pa. Code (b) in client records #1, 2, 3 and 4.
Client records # 1, 2, 3 and 4 contained signed consent to release information forms that documented the release of " Treatment Planning " to a funding source. The release of treatment plans and treatment planning information to third party payers exceeds the limitations imposed at 4 Pa. Code 255.5 (b).
In client record #1, a signed consent form dated 1/11/10 documented the release of "Treatment Planning" information to a funding source. The release of treatment planning information to third party payers exceeds the limitations imposed at 4 Pa. Code 255.5 (b).
In client record #2, a signed consent form dated 7/9/09 documented the release of "Treatment Planning" information to a funding source. The release of treatment planning information to third party payers exceeds the limitations imposed at 4 Pa. Code 255.5 (b).
In client record #3, a signed consent form dated 11/24/09 documented the release of "Treatment Planning" information to a funding source. The release of treatment planning information to third party payers exceeds the limitations imposed at 4 Pa. Code 255.5 (b).
In client record #4, a signed consent form dated 10/25/08 documented the release of "Treatment Planning" information to a funding source. The release of treatment planning information to third party payers exceeds the limitations imposed at 4 Pa. Code 255.5 (b).
Additionally, client records # 1, 2, 3 and 4 contained a signed general consent to release information form that stated:
"Although the medical records of your treatment with this facility are confidential, there are specific conditions under which information contained in your files may be released. The conditions are as follows:
To the Mental Health Administration pursuant to his duties under applicable statutes and regulations.
To the Court or Mental health Review Officer in the course of legal proceedings.
To an attorney who may be assigned to conduct a defense at a commitment hearing.
To appropriate personnel pursuant to regulations governing drug and alcohol abuse or dependence.
To Parents or guardians and others when necessary to obtain consent to medical treatment."
The regulation at 55 Pa. Code 5100.37 " Records relating to drug and alcohol abuse or dependence. - provides for the following:
" Whenever information in a patient ' s records (mental health) relates to drug or alcohol abuse or dependency, as defined in 71 P. S. 1690.102, those specific portions of the patient ' s records are subject to the confidentiality provisions of section 8 (c) of the Pennsylvania Drug and Alcohol Abuse Control Act (71 P. S. 1690.108 (c)), and the regulations promulgated there under,, 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client oriented information). "
The releases of information described above are not permitted at 71 P. S. 1690.108 (b) and 4 Pa. Code 255.5 (b). In addition, the use of general consents to release information are prohibited by the federal regulations at 42 C.F.R Part 2, Subpart C, 2.32.
In client record #1, this general consent to release information form was signed on 1/11/10.
In client record #2, this general consent to release information form was signed on 7/9/09.
In client record #3, this general consent to release information form was signed on 11/24/09.
In client record #4, this general consent to release information form was signed on 10/25/08.
An interview with the Director of Quality Assurance on February 3, 2011 confirmed the facility documented the release of information which exceeded the limitations imposed at 4 Pa. Code in client records # 1, 2, 3 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |