INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29, 2008 through July 31, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Self Help Movement 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 September 1, 2008.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of 22 personnel records on July 29, 2008, the facility failed to document supervision notes in one of the counselor assistant's record for the week of July 21 through 25, 2008 and July 28 through 30, 2008, specifically employee record #5. Employee #5 started employment as a counselor assistant on July 14, 2008.
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Plan of Correction
Effective 8/4/08, counselor assistant will be directly supervised by the director of treatment services or lead counselor and they will document observations, training provided, and progress. Documentation will be in daily clinical supervision notes. Superviison will be based on state guidleines involving time lines and assistant counselor's educational status. All documentation and superviison notes will be contained in the assistant counselor's supervision file kept in the director of treatment services office. |
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 training records on July 29, 2008, the facility failed to document HIV/AIDS and TB/STD training in nine of twenty-two employee records reviewed, #3, 15, 16, 17, 18, 19, 20, 21 and 22. Records # 3, 19, 21 and 22 did not document HIV/AIDS and TB/STD training. Records #15, 16, 17, 18 and 20 did not document HIV/AIDS training.
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Plan of Correction
The Director of Administration is responsible for staff training and will ensure that all staff receive all necessary training yearly. HIV/Aids training was held at Self Help Movement for the staff in question on 8/20/08. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's fire drill record on July 29, 2008, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. The last overnight fire drill was conducted on January 5, 2008.
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Plan of Correction
The fire drill log has been revised by the director of maintenance so that time cannot be mistaknely checked off as just a.m. or p.m. The new log calls for the exact times to be noted in addition to this it is further stated on the sheets that the log must be filled out in its entirety and times must vary between all 3 shifts. This will be monitored by the director of maintenance. |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on the physical plant inspection on July 30, 2008, the facility failed to ensure that fire drills were conducted on different times and different shifts. From October 2007 through July 2008 fire drills were not conducted between the hours of 4 PM to 8 AM except for the overnight drill that was conducted on January 5, 2008. During these times clients and staff are still in the building and engaged in individual or group counseling sessions.
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Plan of Correction
The fire drill log has been revised by the director of maintenance so that time cannot be mistaknely checked off as just a.m. or p.m. The new log calls for the exact times to be noted in addition to this it is further stated on the sheets that the log must be filled out in its entirety and times must vary between all 3 shifts. This will be monitored by the director of maintenance |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of 17 client records on July 30 and 31, 2008, the facility failed to obtain an informed consent to release information form in eleven of eleven records reviewed where required, specifically client records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11. Information released to CBH exceeded the limitations imposed at 4 PA. Code 255.5(b) in eight of eight client records reviewed where that documentation was required. Information was sent out to the Philadelphia "FIR" program, (a City program that coordinates activities with probation/parole), that exceeded the limitations imposed at 4 PA. Code 255.5(b) in client record #7. In client record #8 a consent to release information form did not state the name of the person, agency or organization to whom disclosure was made.
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Plan of Correction
Effective immediately the director of intake will be responsible to ensure that all clients sign a disclosure of information with the name of the person, agency or organization to whom the disclosure is being made at the time of intake. The responsibility for completion and containment in the client's intake package will be the assigned intake worker during the intake interview. Client #8's case has been closed and is unable to be re-adjusted. The remaining records will be readjusted and resigned by the client in the presence of the intake worker and assigned counselor on each case. The consent to release information will be specific and limited to shared information as per 4 PA Code 255.5(b) confidentiality mandates. No information will be sent to FIR aside from mandatory state restrictions. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of the medication policies and procedures and medication administration records on July 29 and 30, 2008, the facility failed to document complete medication administration records. The medication administration records were blank on numerous days in July 2008. Documentation was missing and/or failed to indicate whether or not a client received his/her medication, whether or not a client refused his/her medication or whether the medication was discontinued.
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Plan of Correction
It will be the responsibility of the director of house supervision to ensure that the medication control policy and procedure is reviewed with the supervision staff as well as the job description related to this matter. This is to ensure that the supervision staff will document complete medication administration records. Daily review of such records will be performed by the house coordinator to ensure that there are no blank records and it is indicated whether or not the client received medication, refused medication or medication was discontinued. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of 17 client records on July 30 and 31, 2008, the facility failed to completely document physical examinations in eight of eight records reviewed where the physical examination documentation was required, specifically client records # 1, 2, 3, 4, 5, 6, 7 and 8. The physician failed to document the date of the exams, the clients' general appearance and the physician's impressions of the client.
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Plan of Correction
The director of intake will speak with the physician by 9/30/08 to insure that the client's general appearance and the physician's impression of the client as well as the date of the physical will be reported on the physical form. The director of intake/and or intake coordinators will read the physical to make sure that the physician has completed all information required on the physical form. The form already has a section for the general appearance and physician's impression of the client as well as a place for the date which will be clearly marked for the physician to fill out. If the paperwork is not completed the physician will be contacted by the intake department to insure that the paperwork is completed. |
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 a review of 17 client records, the facility failed to document complete psychosocial evaluations in eight of eight records reviewed where psychosocial evaluations were required, specifically client records #1, 2, 3, 4, 5, 6, 7 and 8. The counselor did not evaluate the client from the counselors' point of view when it came to documenting the client's support systems, coping mechanisms, negative factors that my inhibit treatment, client's attitude towards treatment and the counselors' conclusions/impressions of the client.
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Plan of Correction
The director of treatment services will have a staff meeting to reinforce the following plans of action; The counselors, on a separate document in the bio-psychosocial, will be required to document their own point of view regarding the client's support systems, coping mechanisms,negative factors that may inhibit treatment and the client's attitude towards treatment as well as the counselor's impression of the client. The counselors will be required to submit this information to the director of treatment services for review within 72 hours of the client's admittance to the program. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of 17 client records on July 30 and 31, 2008, the facility failed to consistently document records of service in eight of eleven records reviewed where records of service were required, specifically client records #1, 2, 3, 4, 6, 8, 10 and 11.
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Plan of Correction
All counselors must complete and inital a record of service for each of their clients on a daily basis and palced in the client's file. The director of treatment services will insure that an audit of the clinical file will contain the record of services. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of 17 client records on July 30 and 31, 2008, the facility failed to document complete progress notes in eight of eight records reviewed where required, #1, 2, 3, 4, 5, 6, 7 and 8. Progress notes for group counseling failed to include the clinician's assessment and data for each client in all records reviewed. Records #1, 2 and 3 failed to document individual notes in records reviewed.
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Plan of Correction
A counselor's meeting will be held by the director of treatment services on 9/8/08 to insure that the counselors will be responsible for documenting progress notes and individual notes including the counselor's assessment and data for each client. The director of treatment services will insure that this is being done when auditing the client files. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of 17 client records on July 30 and 31, 2008, the facility failed to document case consultation notes in two of four records where case consultations were required and due, #1 and 8.
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Plan of Correction
The director of treatment will advise all counselors that consultation notes must be completed by documenting client's progress, change in status, infractions and sanctions imposed after conferences between client, counselor and director of treatment services. The director of treatment services will reveiw the files weekly to insure that consultation notes are completed and in the client's file. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of 17 client records on July 30 and 31, 2008, the facility failed to document follow-up information in four of five discharge records reviewed where follow up documentation was due, specifically client records #7, 8, 10 and 11.
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Plan of Correction
The director of treatment services will meet with the counselors on 9/8/08 to insure that counselors are documenting the follow-up information on each client within 30 days of completion of the program. The director of treatment services will not sign off on file until the 30 day follow-up has been placed in the file. |