INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 20, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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 February 18, 2010.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy and procedure manual and an interview with the facility director, the facility failed to document an assessment of staff training needs, as required by regulation.
The findings include:
On January 20, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, the assessment forms will be distributed to each employee on May 1, and the forms will be returned to the clinical supervisor on May 31. The regulation requires an assessment of staff training needs to be completed as a component of a staff development program. The facility failed to document the completion of a staff training needs assessment for the July 1, 2009- June 30, 2010 training year.
The facility director/clinical supervisor was interviewed on January 21, 2010. The facility director/clinical supervisor confirmed that an assessment of staff training needs was not completed for the July 1, 2009- June 30, 2010 training year.
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Plan of Correction
Due to the transition of our QA/Compliance Co-ordinator over the last year, the training plan, including the needs assessment was overlooked.Since the Compliance Co-ordinator is responsible for for assuring that we are up to date and in compliance with regulations, he will be responsible for notifying the Facility Director that the training plan is due. This will prompt the Facility Director to distribute to the Drug and Alcohol Staff and collect from them the needs assessment forms in accordance with our policy and procedure.
This will begin May 1, 2010. |
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 policy and procedure manual and an interview with the facility director/clinical supervisor, the facility failed to document an overall plan for addressing training needs, as required by regulation.
The findings include:
On January 20, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, a training plan will be completed by June 30. The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. The facility failed to document an overall training plan for the July 1, 2009 - June 30, 2010.
The facility director/clinical supervisor was interviewed on January 21, 2010. The facility director/clinical supervisor confirmed that a plan for addressing training needs of staff was not completed for the July 1, 2009- June 30, 2010 training year.
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Plan of Correction
Due to the transition of our QA/Compliance Co-ordinator over the last year, the training plan was overlooked.For this reason, no agency wide training plan was completed. The Facility Director will receive the needs assessment forms from all Drug and Alcohol staff by May 31,2010. He will then review the assessments and develop a program training plan to meet those needs for the next fiscal year. The plan will be completed by June 30,2010.
Due to the brief time left in this fiscal year, this will begin May 31,2010. |
704.11(a)(4) LICENSURE Evaluation of Overall 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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the policy and procedure manual and an interview with the facility director/clinical supervisor and the Quality Assurance/Compliance Coordinator, the facility failed to document an annual evaluation of the overall training plan, as required by regulation.
The findings include:
On January 20, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, an annual review of the training plan will be completed by July 31. The regulation requires an annual evaluation of the overall training plan to be completed as a component of a staff development program. The facility failed to document the completion of an annual evaluation of the overall training plan for the July 1, 2008 - June 30, 2009 training year.
The facility director/clinical supervisor and the Quality Assurance/Compliance Coordinator was interviewed on January 21, 2010. The facility director/clinical supervisor and the Quality Assurance/Compliance Coordinator confirmed that an annual evaluation of the overall training plan was not completed for the July 1, 2008 - June 30, 2009 training year.
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Plan of Correction
Due to the transition of our QA/Compliance Co-ordinator over the last year, the evaluation of the 2008-2009 training plan was overlooked.For this reason, no agency wide review was documented. According to the policy, this evaluation must be completed by July 31.
As it is the responsibility of the QA/Compliance Co-ordinator to assure that tasks are completed in a timely to meet regulations,he will notify the Facility Director of the need to complete an evaluation of the training plan for the prior fiscal year. This summary will be completed by July31.
This process will recommence July 1,2010. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of individual training plans in five of five personnel records reviewed.
The findings include:
Five personnel records were reviewed on January 21, 2010. Individual training plans were required in five personnel records. The facility did not document individual training plans for the July 1, 2009 - June 30, 2010 training year in personnel records # 1, 2, 3, 4, and 5.
The employee represented by personal record #1 was hired November 9, 1998. An individual training plan was not completed for the July 1, 2009 - June 30, 2010 training year.
The employee represented by personal record #2 was hired November 2, 2009. An individual training plan was not completed for the July 1, 2009 - June 30, 2010 training year.
The employee represented by personal record #3 was hired June 23, 2008. An individual training plan was not completed for the July 1, 2009 - June 30, 2010 training year.
The employee represented by personal record #4 was hired June 23, 2008. An individual training plan was not completed for the July 1, 2009 - June 30, 2010 training year.
The employee represented by personal record #5 was hired June 14, 2004. An individual training plan was not completed for the July 1, 2009 - June 30, 2010 training year.
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Plan of Correction
As noted previously, the needs assessment and training plan were not completed for this year. However, training was provided based on the indivual therapists needs although not documented in the appropriate manner.
The individual training plan will be developed in conjunction with the needs assessment procured for the overall program training plan. It is the responsibility of the Supervisor to develop a training plan for each therapist based on inout from both parties involved. Training plans will be completed byMay31, to allow input to the program plan and budget submission for the next fiscal year.
This will begin in May, 2010. |
704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the staffing requirements facility summary report form completed by the facility on January 20, 2010 and a discussion with the facility director/clinical supervisor on January 21, 2010, the facility failed to ensure that staff to client caseloads remained at or under 35:1.
The findings included:
Four counselor caseloads were reviewed on January 21, 2010. Based on the number of hours the employee worked at this facility, and the number of clients on the counselors' caseload, one counselor exceeded the caseload of 35:1. The counselors represented by personnel records # 2, 3 and 4 had caseloads under 35:1. The counselor represented by personnel record #5 had a caseload of 38:1, which exceeds the maximum of 35:1.
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Plan of Correction
This ratio was the result of an overlap of assigning new clients before client discharge paperwork was completed on closed clients. This continues to be a delicate balance, as requirements of productivity and maximum use of time are also priorities.
The electronic medical record within the agency has a variety of triggers and notifications built into the system.At this time we are exploring the possibility of setting a trigger to notify the therapist when he is at capacity.
The goal is to have a system in place by May1,2010. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher 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 document the instruction of staff in the use of the fire extinguisher within seven days of staff employment, in one of one personnel records.
The findings include:
Five personnel records were reviewed. One personnel record required fire extinguisher training. The facility failed to document the completion of fire extinguisher training within seven days of staff employment in personnel record # 2.
Employee # 2 was hired on November 2, 2009. The training was due within seven days, by November 11, 2009. The training was documented on November 16, 2009, which is later than the seven days required.
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Plan of Correction
Due to the number of programs housed under CCC, a monthly training is scheduled for all new hires. Since it is scheduled monthly, the HR Director and the program supervisor will make every effort to co-ordinate the first date of hire with the training week, so that the training will fall within the required timeframe. In the event that it is not possible to do this, an individual training will be held on the first day of hire to comply with regulations. This is effective immediately, February 23, 2010 |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 ensure that all personnel on all shifts are trained upon employment to perform assigned tasks during emergencies, in one of one personnel records.
The findings include:
Five personnel records were reviewed. One personnel record required the emergency training. The facility failed to document the completion of emergency training within seven days of staff employment in personnel record # 2.
Employee # 2 was hired on November 2, 2009. The training was due within seven days, by November 11, 2009. The training was documented on November 16, 2009, which is later than the seven days required.
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Plan of Correction
Due to the number of programs housed under CCC, a monthly training is scheduled for all new hires.This training includes crisis and emergency management protocols. Since it is scheduled monthly, the HR Director and the program supervisor will make every effort to co-ordinate the first date of hire with the training week, so that the training will fall within the required timeframe. In the event that it is not possible to do this, an individual training will be held on the first day of hire to comply with regulations. This is effective immediately, February 23, 2010
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative polices and procedures and an interview with the Quality Assurance/Compliance Coordinator, the facility failed to document that the project director affixed his/her signature to document that an annual update of the written manual delineating project polices and procedures had been conducted.
The findings include:
The administrative policies and procedures were reviewed on January 20, 2010. The project director failed to document the annual update of the written project policies and procedures, as required by regulation.
The Quality Assurance/Compliance Coordinator was interviewed on January 20, 2010. The Quality Assurance/Compliance Coordinator reports the policy and procedure manual was prepared and annually updated, but could not find documentation that this had occurred.
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Plan of Correction
Updates to the Policy and Procedure manual occur throughout the year. These are reviewed by the project director prior to being initiated as policy and are signed by the Clinical Director in accordance with agency policy.However, review of the entire policy and procedure manual is not documented.
Therefore, in the future, the Compliance Co-ordinator will prompt the project director that the manual needs to be reviewed and to document the review with a signature and date. This will occur at the beginning of the new fiscal year and will be completed by July 31.
This procedure will begin July 1,2010.Interum review will be done by March 31, 2010. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document treatment plan updates in one of four client records, and failed to document the treatment plan updates within the facility policy and procedure time frame in one of four client records.
The findings include:
Four client records were reviewed on January 20, 2010. The findings were reviewed with the facility director on January 21, 2010. Four of the client records were required to have treatment plan updates. Per the facility policy, treatment plan review and updates are required to be completed every sixty days. The facility failed to document treatment plan review and updates within sixty days, in client records # 1 and 3.
In client record # 1, the client was admitted on February 25, 2009, and was discharged on October 23, 2009. The comprehensive treatment plan was completed on March 25, 2009. The first treatment plan update was due no later than May 25, 2009 and was completed late on June 23, 2009. The facility failed to document the completion of the treatment plan update within the sixty day time frame.
In client record # 3, the client was admitted on July 28, 2009. The comprehensive treatment plan was completed on September 1, 2009. The first treatment plan update was due no later than November 1, 2009. The facility failed to document the completion of the first treatment plan update.
The director confirmed the treatment plan updates were not completed within the 60 day timeframe.
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Plan of Correction
CCC uses an electronic medical record for all documentation. One of the features of the software is to be able to notify a clinician when an update is due in time to complete it in a timely manner. In this case, the notification for updating treatment plans was set inappropriately ,notifing the clinician too late. We have since changed the prompting date to an earlier time frame ad the staff has been informed of the change. Additionally,a chart audit will be initiated in the next quarter by the Compliance Co-ordinator. This will provide an ongoing review of charts for documentation in compliance with regulations.
The change in the EMR occurred immediately following the site visit. The audits will begin in April 2010 |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document a case consultation within the 60 day time frame in two of four client records.
The findings include:
Four outpatient client records were reviewed on January 20, 2010. The findings were reviewed with the facility director on January 21, 2010. Per agency policy, case consultations shall be completed every 60 days. Case consultations were required in four client records. The facility did not document a case consultation within the 60 day time frame in client records #1 and #3.
The findings include:
In client record # 1, the client was admitted on February 25, 2009, and was discharged on October 23, 2009. The case consultations were due by May 25, 2009, July 25, 2009, and September 25, 2009. The facility failed to document the case consultations.
In client record # 3, the client was admitted on July 28, 2009. The case consultations were due by November 1, 2009 and January 10, 2010. The facility failed to document the case consultations.
The director confirmed the case consultations were not completed.
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Plan of Correction
CCC uses an electronic medical record for all documentation. One of the features of the software is to be able to notify a clinician when an update is due in time to complete it in a timely manner. Case consultations are done at the time of the treatment plan update as well. In this case, the notification for updating treatment plans was set inappropriately ,notifing the clinician too late.
We have since changed the prompting date to an earlier time frame ad the staff has been informed of the change. Additionally,a chart audit will be initiated in the next quarter by the Compliance Co-ordinator. This will provide an ongoing review of charts for documentation in compliance with regulations.
The change in the EMR occurred immediately following the site visit. The audits will begin in April 2010
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