INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 5 - 7, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Deerfield Center For Addictions Treatment 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 4, 2010. .
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Plan of Correction
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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records and an interview with the Clinical Supervisor, the facility failed to document that a staff member, who is a counselor assistant, is working toward meeting the qualifications for the position of counselor.
The findings include:
Five personnel records were reviewed on April 6, 2010. One personnel record pertained to the position of counselor assistant. Per regulation, a counselor assistant shall document to the facility director that she is working toward counselor status. This information shall be documented upon completion of each calendar year. The facility failed to provide documentation that the counselor assistant is working toward meeting the qualifications for the position of counselor in staff record # 4.
Employee # 4 was hired on September 18, 2006. Employee # 4 did not provide documentation by December 31, 2009 that she is working toward counselor status.
The Clinical Supervisor was interviewed on April 6, 2010. The Clinical Supervisor reported that employee # 4 has been on medical leave several times in the past year and has been unable to attend any college courses.
This is a repeat citation.
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Plan of Correction
The Facility Director and Clinical Supervisor will continue to work with the employee to assist her in her pursuit of the necessary credentials to be able to apply for her CAC. The Clinical Supervisor has updated the training plan and will review the Counselor Assistant's progress towards meeting her requirements in their monthly meetings. If the Counselor Assistant is unable to meet the requirements to apply for here CAC she will be relieved of her counseling responsibilities. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs and an interview with the Clinical Supervisor, the facility failed to document the fire alarm/smoke detector system was operational.
The findings include:
The fire drill logs were reviewed on April 6, 2010. Per regulation, the nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The facility has an exception to this regulation. This exception requires documentation of an annual test of the fire alarm/smoke detector system and documentation that the system is operational. The facility could not provide documentation of an annual inspection of the fire alarm/smoke detector system or documentation that the system was operational.
The Clinical Supervisor was interviewed on April 6 and April 7, 2010. The Clinical Supervisor reported that she did not have documentation of an annual test of the fire alarm/smoke detector system.
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Plan of Correction
The Program Director or Clinical Supervisor will send a letter to the office manager within one week requesting documentation regarding the date the fire alarm/smoke detector system was tested. In addition the Program Director will request that a copy of the annual testing report be sent to him so that it can be added to the Policy and Procedure manual. |
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 clinical supervisor, the facility failed to provide written documentation of the proposed type of support service, in the individual treatment and rehabilitation plans, in three of eight client records.
The findings include:
Eight client records were reviewed on April 6 - 7, 2010. Per regulation, an individual treatment and rehabilitation plan shall be developed with a client to include the proposed type of support service. The individual treatment and rehabilitation plans were required to include documentation of the proposed type of support services in eight client records. The facility did not document the proposed type of support services in the treatment plan in client records # 5, 6 and 7.
Client # 5 was admitted on June 24, 2009. The individual treatment and rehabilitation plan was completed on July 1, 2009. There was no documentation of support services in the treatment plan.
Client # 6 was admitted on April 22, 2009. The individual treatment and rehabilitation plan was completed on May 29, 2009. There was no documentation of support services in the treatment plan.
Client # 7 was admitted on July 22, 2009. The individual treatment and rehabilitation plan was completed on August 6, 2009. There was no documentation of support services in the treatment plan.
On April 7, 2010, the Clinical Supervisor was interviewed and confirmed that support services were not listed on the individual treatment and rehabilitation plans in client records
# 5, 6 and 7. The Clinical Supervisor reported that this information will be reviewed with the clinical staff.
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Plan of Correction
The Clinical Supervisor with conduct a staff meeting within the next 30 days to inform the clinical staff of the importance of documenting the recommendation and use of support services in the patient treatment plans. As part of the random chart review process, the Clinical Supervisor will look for the above information in the treatment plans for the next four months to insure counselor compliance. |