INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 1 - 3, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health - Pa, 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 December 29, 2009.
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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 and an interview with the facility director, the facility failed to provide documentation of HIV/AIDS and TB/STD training in two of eight personnel records.
The findings include:
Ten personnel records were reviewed on December 1, 2009. Eight personnel records were due to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training in personnel records # 9 and 10.
Employee # 9 is a PRN nurse and was hired April 28, 2007. HIV/AIDS and TB/STD training was due to be completed no later than April 28, 2009. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee #9 as of December 5, 2009.
Employee # 10 is a PRN nurse and was hired August 24, 2004. HIV/AIDS and TB/STD training was due to be completed no later than August 24, 2006. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee #10 as of December 5, 2009.
The facility director confirmed that there was no documentation of HIV/AIDS and TB/STD training in the personnel records of employees # 9 and 10. The facility director did attempt to contact these employees to obtain documentation of the required training. The facility director was unable to reach either employee.
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Plan of Correction
Associates #9 and #10 are scheduled to work during the weeks of 12/20 and 12/27 for holiday coverage. A TB training following PA Department of Health course curriculum will be presented and completed for each Associate during these weeks.
Associate #9 and #10 will be enrolled in Laban's Addiction Specific Trainings in home study to fulfill the criteria for 6 hours HIV/AIDs training. These Associates will complete this training by 01/15/2010.
Clinical Supervisor will schedule trainings and Program Director will monitor to ensure training has been completed to obtain compliance with regulation. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of fiscal documents presented at the time of the inspection and an interview with the facility director, the facility failed to document an annual audit of financial activities for the year ended 12/31/08.
The findings included:
During the onsite licensing inspection conducted from December 1 - 3, 2009, the fiscal documents were reviewed. The certified public accountant's dated and signed comments at the beginning of the fiscal document indicated that the document was not an audit. The facility director was interviewed about the documentation of the annual audit which included the opinion of the accountant and confirmed that this was the only fiscal document available for review.
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Plan of Correction
Discovery House will conduct an audit for fiscal year 2010. We will submit a 2009 compellation review and an engagement letter for 2010. Program Director will be charged to ensure this task is completed. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, and an interview with the facility director, the facility failed to provide written documentation of the proposed type of support service, in the individual treatment and rehabilitation plans, in thirteen of twenty-one client records.
The findings include:
Twenty-six client records were reviewed on December 1 - 3, 2009. The individual treatment and rehabilitation plans were required to include documentation of the proposed type of support services in twenty-one client records. The facility did not document the proposed type of support services in client records # 1, 2, 5, 8, 13, 14, 15, 19, 20, 21, 23, 25 and 26.
Client # 1 was admitted on June 24, 2009. The individual treatment and rehabilitation plan was completed on July 24, 2009. There was no documentation of support services in the treatment plan.
Client # 2 was admitted on July 21, 2009. The individual treatment and rehabilitation plan was completed on August 21, 2009. There was no documentation of support services in the treatment plan.
Client # 5 was admitted on August 12, 2009. The individual treatment and rehabilitation plan was completed on September 9, 2009. There was no documentation of support services in the treatment plan.
Client # 8 was admitted on August 11, 2009. The individual treatment and rehabilitation plan was completed on September 14, 2009. There was no documentation of support services in the treatment plan.
Client # 13 was admitted on July 29, 2009. The individual treatment and rehabilitation plan was completed on August 28, 2009. There was no documentation of support services in the treatment plan.
Client # 14 was admitted on August 25, 2009. The individual treatment and rehabilitation plan was completed on September 29, 2009. There was no documentation of support services in the treatment plan.
Client # 15 was admitted on August 19, 2009. The individual treatment and rehabilitation plan was completed on September 18, 2009. There was no documentation of support services in the treatment plan.
Client # 19 was admitted on August 18, 2009. The individual treatment and rehabilitation plan was completed on September 21, 2009. There was no documentation of support services in the treatment plan.
Client # 20 was admitted on July 7, 2009. The individual treatment and rehabilitation plan was completed on August 10, 2009. There was no documentation of support services in the treatment plan.
Client # 21 was admitted on July 7, 2009. The individual treatment and rehabilitation plan was completed on August 18, 2009. There was no documentation of support services in the treatment plan.
Client # 23 was admitted on August 19, 2009. The individual treatment and rehabilitation plan was completed on September 21, 2009. There was no documentation of support services in the treatment plan.
Client # 25 was admitted on July 21, 2009. The individual treatment and rehabilitation plan was completed on August 25, 2009. There was no documentation of support services in the treatment plan.
Client # 26 was admitted on July 20, 2009. The individual treatment and rehabilitation plan was completed on August 21, 2009. There was no documentation of support services in the treatment plan.
The facility director confirmed that some of the counselors were not documenting support services on the treatment plans, as required.
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Plan of Correction
Clinical Supervisors have reviewed the charts that did not meet compliance and have addressed this citation with counselors who are not including support services in the first comprehensive treatment plan. For quality control, the clinical supervisors are reviewing patient psychosocial and will not approve treatment plans that do not include support services. Counselors have been trained and are required to review support service goals with patients to align with psychosocial information presented upon intake.
Clinical Supervisors are charged to ensure support services are included in first comprehensive treatment plan. Program Director will complete chart audits to ensure that Center for Behavioral Health - PA obtains and maintains compliance to this regulation.
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