INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on December 13 - 14, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Parkside Recovery 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.
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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 the Staffing Requirements Facility Summary Report, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other related topics 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.
The findings include:
On December 13, 2012, the Staffing Requirements Facility Summary Report was reviewed.
The facility failed to provide documentation of the required HIV/AIDS and TB/S training for two out of two support staff, employee # 15 and 16.
Employee # 15 was hired 4/1/2004. Employee # 15 is a support staff member, security guard. HIV/AIDS and STD/TB training was to be completed within the first 2 years of employment, by 4/1/06. At the time of review on December 13, 2012, employee # 15 had not received the HIV/AIDS and STD/TB training.
Employee # 16 was hired 10/29/06. Employee # 16 is a support staff member, security guard. HIV/AIDS training was to be completed within the first 2 years of employment, by 10/29/08. At the time of review on December 13, 2012, employee # 16 had not received the HIV/AIDS training.
The Project Director confirmed the findings.
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Plan of Correction
The two staff members referred to will be in a HIV/AIV/TB/STD training scheduled to be held at Parkside Recovery on February 22nd. Trainings will for all staff will be tracked on an internal grid and tracked by a clinical supervisor who will be responsible to ensure this deficiency does not re-occur. The clinical supervisor will meet with the Program Director weekly to discuss the staff's training needs.
Training: February 22nd, 2013
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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 a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that each counselor completed the minimum 25 hours of training for the training year.
The findings include:
The facility's training year is from July through June.
On December 13, 2012, the Staffing Requirements Facility Summary Report which was complete by the facility on December 13, 2012 was reviewed.
The Staffing Requirements Facility Summary Report documented 23 training hours for employee # 12, 20 training hours for employee # 13, and 14 training hours for employee # 14.
The Project Director did not dispute the findings.
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Plan of Correction
Trainings for all staff will be tracked on an internal database and tracked by a clinical supervisor who will be responsible to ensure this deficiency does not re-occur. The clinical supervisor will meet weekly with the Program Director to discuss the scheduling and completion of required trainings for all staff.
Completed: Immediately
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709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of administrative policies and Board meeting minutes the project failed to demonstrate that the project director assisted the governing body in formulating project goals and objectives for the 2012/2013 fiscal year.
The findings were:
A review of administrative documentation and conversation with the project director on December 10, 2012 confirmed that the project director did not assist nor present to the governing body the project goals and objectives for the fiscal year of July 1, 2012 to June 30, 2013.
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Plan of Correction
Effective December 11, 2012 the Project Director assisted the governing body in formulating project goals and objectives for the 2012/2013 fiscal year. This will be maintained with an annual review in the 3rd Quarter Board Meeting of each fiscal year.
Completed: Immediately
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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 a review of personnel records, the facility failed to provide salary information in eight of eleven records reviewed.
The findings include:
On December 10 - 11, 2012, eleven personnel records requiring documentation of salary information were reviewed. The facility failed to provide documentation of salary information in eight of eleven records reviewed, personnel records # 1, 2, 3, 4, 6, 7, 8, and 11.
The Project Director confirmed the findings.
This is a repeat citation. The facility was previously cited on 11/8/11.
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Plan of Correction
Effective January 9th, 2013, the salary history information has been added to the Employee Record audit checklist. The Human Resources Manager and Program Director will be responsible to monitor the Parkside Recovery employee files to ensure this deficiency does not re-occur.
Completed: Immediately
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one record required.
The findings include:
On December 14, 2012, one record requiring documentation of notification of termination was reviewed. The facility failed to document notification of termination in client record # 22.
Client # 22 was admitted to the program on 7/26/12, the client's last session was 9/12/12, and the client was administratively discharged for attendance non-compliance on 10/10/12. The facility did not inform the client, in writing, of a decision to involuntarily terminate treatment.
The clinical supervisor reviewed the record on 12/14/12 and confirmed the findings.
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Plan of Correction
Clinical supervisors will bring all involuntary termination notices with the notification letter attached to the to the Program Director for signature. Clinical Supervisors will be responsible to make a copy of the notification letter to put in the client's file and give the original to the client. Clinical Supervisors will responsible to ensure this deficiency does not re-occur.
Completion: Immediately
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to document a psychosocial evaluation according to policy.
The findings include:
On December 13 - 14, 2012, twenty client records requiring documentation of a psychosocial evaluation were reviewed. The facility failed to document a psychosocial evaluation according to facility policy in eleven of twenty records reviewed, client records # 1, 2, 3, 4, 5, 6, 8, 9,13, 14, and 19.
The facility policy states "within the first thirty days, the counselor completes the psychosocial evaluation. This provides a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. The history should include a clear description of presenting and underlying problems, client needs or problems, client assets, strengths, support systems, negative factors, client's preferred coping mechanisms, appearance, behavior and reactions during the process, and conclusions regarding attitude and ability to participate in treatment. The counselor complete the psychosocial history by summarizing and evaluating the information into a composite picture of the client."
Client # 1 was admitted to the program on 8/15/12. The psychosocial was documented on 9/4/12. However, the facility failed to evaluate the information into a composite picture. In addition, the psychosocial did not include the client's assets/strengths or the counselor's conclusions/impressions of the client.
Client # 2 was admitted to the program on 9/4/12. The psychosocial was documented on 9/20/12. However, the facility failed to evaluate the information into a composite picture. In addition, the psychosocial did not include the client's assets/strengths, coping mechanisms, negative factors, and the counselor's conclusions/impressions of the client.
Client # 3 was admitted to the program on 7/30/12. The psychosocial was documented on 8/8/12. However, the facility failed to evaluate the information into a composite picture. In addition, the psychosocial did not include the client's assets/strengths, negative factors, and the counselor's conclusions/impressions of the client.
Client # 4 was admitted to the program on 7/2/12. The psychosocial was documented on 7/13/12. However, the facility failed to evaluate the information into a composite picture. In addition, the psychosocial did not include the client's assets/strengths, negative factors, and the counselor's conclusions/impressions of the client.
Client # 5 was admitted to the program on 7/10/12. The psychosocial was documented on 7/25/12. However, the facility failed to evaluate the information into a composite picture. In addition, the psychosocial did not include the client's assets/strengths, support systems, coping mechanisms, negative factors, and the counselor's conclusions/impressions of the client.
Client # 6 was admitted to the program on 9/13/12. The psychosocial was documented on 9/20/12. However, the facility failed to evaluate the information into a composite picture. In addition, the psychosocial did not include the client's assets/strengths, support systems, coping mechanisms, negative factors, and the counselor's conclusions/impressions of the client.
Client # 8 was admitted to the program on 8/9/12. The psychosocial was documented on 8/30/12. However, the facility failed to evaluate the information into a composite picture. In addition, the psychosocial did not include the client's assets/strengths, support systems, coping mechanisms, negative factors, and the counselor's conclusions/impressions of the client.
Client # 9 was admitted to the program on 7/9/12. The psychosocial was documented on 7/25/12. However, the facility failed to evaluate the information into a composite picture. In addition, the psychosocial did not include the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, the client's attitude toward treatment, and the counselor's conclusions/impressions of the client.
Client # 13 was admitted to the program on 7/25/12. The psychosocial was documented on 8/10/12; however, it was not legible; therefore it could not be determined if the psychosocial was evaluative and included the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, and the counselor's conclusions/impressions of the client.
Client # 14 was admitted to the program on 9/24/12. The psychosocial was documented on 10/2/12. However, the facility failed to evaluate the information into a composite picture. In addition, the psychosocial did not include the client's assets/strengths or the counselor's conclusions/impressions of the client.
Client # 19 was admitted to the program on 4/5/12. The psychosocial evaluation is due within 30 days or by 5/5/12. The facility failed to document a psychosocial evaluation at the time of review on 12/14/12.
The Project Director did not dispute the findings.
This is a repeat citation. The facility was previously cited on 11/8/11.
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Plan of Correction
Clinical Supervisors will conduct two trainings with the counselors on how to document a clinical evaluation gleaned from the information developed on a psychosocial to ensure that it provides a picture composite picture, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and client's attitude toward treatment. The initial training session will occur on February 11 with a follow up training in April. The second training will assess the clinician's progress in successfully developing a psychosocial evaluation. The Program Director will conduct five random chart reviews per month to monitor the psychosocial evaluations.
Clinical supervisors will be responsible to monitor the counselors completed evaluations and they will meet weekly with the Program Director to discuss the progress counselors are making towards developing appropriate clinical evaluations to ensure this deficiency does not re-occur.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in seven of seventeen records reviewed.
The findings include:
On December 13 - 14, 2012, seventeen client records were reviewed to ensure that the facility was providing counseling services according to the individual treatment plan. The facility failed to assure that counseling services were provided per plan in seven of seventeen records reviewed, client records # 1, 4, 10, 12, 13, 14, and 15.
Client # 1 was admitted to the program on 8/15/12 and was still an active client at the time of review on 12/14/12. The individual treatment plan documented on 8/30/12 prescribed individual sessions twice a month and group sessions three times a week. However, the facility failed to follow the prescribed treatment plan as the facility documented the last session on 11/23/12.
Client # 4 was admitted to the program on 7/2/12 and was still an active client at the time of review on 12/14/12. The individual treatment plan documented on 7/13/12 prescribed individual sessions twice a month and group sessions three times a week. However, the facility failed to follow the prescribed treatment plan as the facility documented the last session on 11/28/12. In addition, there were only two individual sessions documented on 11/21/12 and 9/28/12.
Client # 10 was admitted to the program on 8/6/12 and was still an active client at the time of review on 12/14/12. The individual treatment plan documented on 8/24/12 prescribed individual sessions twice a month and group sessions three times a week. However, the facility failed to follow the prescribed treatment plan as the facility documented the last session on 11/27/12.
Client # 12 was admitted to the program on 8/10/12 and was still an active client at the time of review on 12/14/12. The individual treatment plan documented on 9/6/12 prescribed individual sessions twice a month and group sessions three times a week. However, the facility failed to follow the prescribed treatment plan as the facility documented the last session on 11/30/12.
Client # 13 was admitted to the program on 7/25/12 and was still an active client at the time of review on 12/14/12. The individual treatment plan documented on 8/10/12 prescribed individual sessions twice a month and group sessions three times a week. However, the facility failed to follow the prescribed treatment plan as the facility documented the last session on 11/29/12.
Client # 14 was admitted to the program on 9/24/12 and was still an active client at the time of review on 12/14/12. The individual treatment plan documented on 10/10/12 prescribed individual sessions twice a month and group sessions three times a week. However, the facility failed to follow the prescribed treatment plan as the facility documented the last session on 11/28/12.
Client # 15 was admitted to the program on 10/17/12 and was still an active client at the time of review on 12/14/12. The individual treatment plan documented on 11/7/12 prescribed individual sessions twice a month and group sessions three times a week. However, the facility failed to follow the prescribed treatment plan as the facility documented the last session on 11/28/12.
The clinical supervisor did not dispute the findings.
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Plan of Correction
Clinical Supervisors will conduct a training with the counselors which will directly address the fact that all clients must receive the treatment services which are documented on the client's treatment plan. The Clinical Supervisors will monitor the counseling sessions with the client's treatment plan through weekly supervision with counselors to ensure this deficiency does not re-occur.
Completion: Training January 28th.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to document follow-up in two of five records required.
The findings include:
On December 13, 2012, six client records requiring documentation of follow-up information were reviewed. The facility failed to document follow-up information according to policy in two of six records, specifically # 18 and 19.
The facility policy states a follow-up letter will be mailed to the client within 30 days of discharge.
Client # 18 was admitted to the program on 9/26/12 and discharged on 11/2/12. Follow-up information was to be documented within 30 days, by 12/2/12. Client record # 18 did not contain follow-up information at the time of review on 12/13/12.
Client # 19 was admitted to the program on 4/5/12 and discharged on 7/6/12. Follow-up information was to be documented within 30 days, by 8/6/12. Client record # 19 did not contain follow-up information at the time of review on 12/13/12.
The clinical supervisor confirmed the findings.
This is a repeat citation. The facility was previously cited on 11/8/11.
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Plan of Correction
Clinical Supervisors will be responsible to complete all 30 day follow up letters which are sent to clients who are discharged and note the completion of this requirement on a newly developed discharge grid. The Program Director will monitor the discharge census weekly and through the weekly supervisors meeting to ensure this deficiency does not re-occur.
Completion: Immediately
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