INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 12-13, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Summit Academy 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 September 15, 2008.
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Plan of Correction
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704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
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Observations
Based on the review of the agency's policy manual on August 12, 2008, the facility failed to document a written policy that addressed the relapse of recovering clinical personnel and the discipline of non recovering employees who abuse alcohol or drugs.
Findings-
The policy manual did not include a policy addressing the relapse of recovering clinical personnel and the discipline of non recovering employees who abuse alcohol or drugs.
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Plan of Correction
Academy Policy Number 509
addresses a Drug/Alcohol
Workplace. Policies addressing the
issues of relapse of recovering
clinical personnel and discipline of
non-recovering employees who
abuse drugs or alcohol will be
presented to the Board of Directors
at the next regularly scheduled
meeting September 15, 2008. That
additional wording is expected to
read as follows:
To the extent that any employee is
receiving treatment in a
drug/alcohol program, said
employee will be treated like other
employees with an illness. To the
extent drugs or alcohol are being
used by employees in violation of
the drug and alcohol policy, said
employees will be subject to
discipline.
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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 the review of twelve personnel records, nine were required to have the minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training. The facility failed to document the training was completed in two of nine employee records where required.
Findings-
In employee record # 2, the staff was missing the required STD/TB training. In employee record #12 the staff was missing the required HIV/AIDS and STD/TB training.
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Plan of Correction
Staff will complete six hour HIV/AIDS and four hour Tuberculosis and STD training designs, providing certificates of attendance and Training Feedback Forms to the Personnel Department. The Clinical Supervisor will review the training calendars with drug/alcohol staff in September, 2008 and January, 2009. Memos will be sent to drug/alcohol staff 10 days before each scheduled training, as a reminder for attendance.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the review of twelve personnel records, one was reviewed as the project director and one was reviewed as the facility director. The facility failed to document that the required number of training hours had been completed in one record.
Findings-
In record #1, there were only 6 training hours documented of the required 12 training hours.
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Plan of Correction
An updated Training Calendar is in effect for this employee. Training designs include: Fire Safety and Emergency Planning, Risk Management, Strategic Planning, Field Trends, Quality Assurance, Corporate Compliance and Cognitive Therapy. A Training Log documenting attendance is kept by the Human Resources Department.
The Human Resources Training Coordinator will ensure compliance through the use of a spreadsheet which records scheduled trainings and employee attendance at trainings. The Clinical Supervisor will review individual training calendars with each therapist in September and again in January. Memos will be distributed to each therapist 10 days prior to each scheduled training to remind therapists of the need to attend.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on the review of twelve personnel records, seven were reviewed as counselors. Of the seven records, two were required to have the 25 hours of annual training. The facility failed to document the required number of training hours in one record.
Findings-
In record #6, there were only 10.5 training hours documented of the required 25 training hours.
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Plan of Correction
The Counselors shall attend the required 25 hours of training as outlined on individual training calendars, filed in the Personnel File. Counselors are also required to complete a Training Feedback Form which is to be placed in the Personnel File. The Clinical Supervisor will review the training calendars with drug/alcohol staff in September, 2008 and January, 2009. Memos will be sent to drug/alcohol staff 10 days before each scheduled training, as a reminder for attendance.
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705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
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Observations
Based on the review of the facility's policy and procedures manual on August 12, 2008, the facility failed to provide a written procedure for the evacuation and transfer of residents impaired by alcohol or other drugs.
Findings-
The policy and procedures manual was missing a policy that informed staff and residents of the procedure to follow in case of an emergency that included the evacuation and transfer of residents impaired by alcohol or other drugs.
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Plan of Correction
The policy and procedure for evacuation and transfer of residents will be amended to include those impaired by alcohol and/or other drugs and will be completed by the Facility Director and Clinical Supervisor, presented for approval to the Board of Directors at their meeting in December, 2008 and will be established at the December Health & Safety Committee annual meeting
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on the review of administrative documents on August 12, 2008, the facility failed to make available to the public an annual report within six months of the end of the fiscal year.
Findings-
The facility completed an annual report for the 2006/2007 fiscal year, but failed to make it available to the public until August 22, 2008.
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Plan of Correction
L0135
The Annual Report will be made available as advertised in the newspaper within the required time frame, upon completion of the annual audit. The Annual Report is to be advertised by the Executive Administrative Assistant, at the direction of the Facility Director.
Annual Report for Fiscal Year 2006-2007 is completed. Notification for Fiscal Year ending June, 2008 will be published by 12/15/08. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on the review of administrative documents on August 12, 2008, the facility failed to make available to the public an annual report which included financial statement of income and expenses.
Findings-
The annual report did not include a statement of income and expenses.
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Plan of Correction
The annual audit includes a statement of income and expense, which will be included in the Annual Report. The Annual Report is compiled by the Executive Administrative Assistant and will be completed by 12/08/08.
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709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based on the review of twelve personnel records on August 12, 2008, the facility failed to document salary information in ten records.
Findings-
The salary information was unavailable for review in personnel records #2, 4, 5, 6, 7, 8, 9, 10, 11 and 12. This information is kept separate from the main file. The individual responsible for the salary records was not available at the time of the inspection.
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Plan of Correction
Salary information will be made available by our Accounting Department upon request at the time of our next inspection. Salary history is kept on a CD; if the Business Manager is off campus, that request may be made directly to the Chief Financial Officer.
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709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based on the review of twelve personnel records on August 12, 2008, the facility failed to document that the employee had a right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records in eight of twelve records.
Findings-
There was no documentation that the employees were informed of this right in personnel records # 4, 5, 6, 7, 8, 9 and 10. In revising the personnel manual, these rights were missed.
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Plan of Correction
The Addendum to Personnel Procedure Number 107, dated 07/15/94 has been in place but not consistently reviewed with employees. Therefore, review of this addendum, by the Clinical Supervisor, has been added to the Employee Orientation Packet for drug/alcohol counselors to ensure future compliance.
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709.26(e)(3) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(3) The employe's right to submit rebuttal data or memoranda to his own records.
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Observations
Based on the review of twelve personnel records on August 12, 2008, the facility failed to document that the employee had a right to submit rebuttal data or memoranda to his own records in eight of 12 personnel records.
Findings-
There was no documentation that the employees were informed of this right in personnel records # 4, 5, 6, 7, 8, 9 and 10. In revising the personnel manual, these rights were missed.
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Plan of Correction
The Addendum to Personnel Procedure Number 107, dated 07/15/94 has been in place but not consistently reviewed with employees. Therefore, review of this addendum, by the Clinical Supervisor, has been added to the Employee Orientation Packet for drug/alcohol counselors to ensure future compliance
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709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of eight client records on August 13, 2008, five client records were reviewed for the medical history. The facility failed to document that a complete medical history was completed according to the facility's policy in four of five client records where required.
Findings-
According to the facility's policy, the medical history is to be completed within five days of admission. The facility did not include the date the history was completed in client records # 1, 3, 4 and 5. It was not possible to determine if the histories were completed in a timely manner without the date.
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Plan of Correction
The medical history will be dated and signed by the counselor upon completion according to our policies' timeframes. The Clinical Supervisor will conduct training with counselors.
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709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of eight client records on August 13, 2008, five were reviewed for the drug and alcohol history. The facility failed to document that a complete drug and alcohol history was completed according to the facility's policy in four of five client records where required.
Findings-
According to the facility's policy, the drug and alcohol history is to be completed within five days of admission. The date the history was completed was not documented in client records # 1, 3, 4 and 5. It was not possible to determine if the histories were completed in a timely manner without the dates.
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Plan of Correction
The drug and alcohol history will be dated and signed by the counselor upon completion according to our policies' timeframes. The Clinical Supervisor will conduct training with counselors.
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709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of eight client records, five client records were reviewed for the personal history. The facility failed to document that a complete personal history was completed according to the facility's policy in four of five client records where required.
Findings-
According to the facility's policy, the personal history is to be completed within five days of admission. The facility did not document the date the history was completed in client records # 1, 3, 4 and 5. It was not possible to determine if the personnel histories were completed in a timely manner without the dates.
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Plan of Correction
The personal history will be dated and signed by the counselor upon completion according to our policies' timeframes. The Clinical Supervisor will conduct training with counselors.
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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 the review of eight client records, five of which were reviewed for psychosocial evaluations, the facility failed to document a psychosocial evaluation which was completed according to the facility's policy in four of five client records where required.
Findings-
According to the facility's policy, the psychosocial evaluation is to be completed within five days of admission. The facility did not document the date the evaluation was completed in client records # 1, 3, 4 and 5. It was not possible to determine if the evaluations were completed in a timely fashion.
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Plan of Correction
The Psychosocial Evaluation will be dated and signed by the counselor upon completion according to our policies' timeframes. The Clinical Supervisor will conduct training with counselors.
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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 eight client records, four were required to have an aftercare plan. The facility failed to document a complete aftercare plan in two of four client records where required.
Findings-
The contact person and the reentry process were missing from the aftercare plans in client records # 5 and 8.
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Plan of Correction
The Clinical Supervisor retrained current counselors 09/10/08 in the area of proper documentation in regards to the completion of the Aftercare Plan, specifically the importance of providing the name of a contact person and the re-entry process.
In order to ensure that this does not recur, the Clinical Supervisor will review Aftercare Plans for all clients prior to discharge.
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