INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 1, 2008 through April 3, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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 and a plan of correction is due on April 30, 2008.
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Plan of Correction
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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
Based on the amount of time it took the facility to pull 20 closed client records, the facility failed to insure enough support staff were in place to efficiently operate the facility. The licensing specialists requested the names of 20 closed records at 10:30 a.m. and only 9 records had been received for review by 12:00 p.m.
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Plan of Correction
Parkside will ensure that there is enough support staff to operate the medical records department in order to retrieve records in a timely fashion. |
704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of administrative documentation and personnel records, the facility failed to identify the a project director responsible for the overall management of the project. Employee #1 was identified as the project director but does not report directly to the Board of Directors.
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Plan of Correction
The facility will name a new Project
Director who will be responsible for the overall management of the project and will report directly to the Board of Directors. The Parkside Recovery Policy will be updated to reflect this change. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel and training records, the facility failed to document the core curriculum training in clinical supervision in three of five records reviewed, #5, 7 and 23.
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Plan of Correction
We plan to get supervisors who need this training registered for the next clincial supervision training as soon we learn of the date. |
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 and training records, the facility failed to document complete individual training plans in 25 of 34 records reviewed, #4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25, 26, 27, 30, 31 and 32. Individual training plans did not include individual training needs/subject areas.
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Plan of Correction
The individual training plan will be revised to include individual training needs/subject area section and this and all required information will be fully completed. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted April 3, 2008 from 13:30 p.m. to 14:30 p.m., the facility failed to ventilate all bathrooms by an exhaust fan or window. Five bathrooms did not have operational exhaust fans.
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Plan of Correction
The Facility Mangager will check the bathrooms daily to ensure all exhaust fans are in working order. This will be corrected immediately. |
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 the Board meeting minutes and the goals and objectives for the 2007 - 2008 fiscal year, the facility failed to document that the project director assisted the in the formulation and presentation of the goals and objectives to the governing body.
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Plan of Correction
The Project Director will be involved in the formulation and presentation of the program's goals and objectives moving forward. This involvemnet will be demonstrated by signed acknowledgement and approval of the Governing Body on the goals and objectives document. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of policy and procedure and personnel records, the facility failed to document work performance evaluations according to the facility's policy and procedure in ten of twenty-four records reviewed, #4, 6, 8, 15, 18, 24, 25, 26, 27 and 30. The facility's policy and procedure requires performance evaluations to be completed either within the 180 days from the date of hire for new employees or on the anniversary date of hire for all other employees. Performance evaluations were not documented according to the policy in ten records.
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Plan of Correction
The faciltiy will ensure through on going internal auditing and monitoring of HR charts that performance evaluations are completed according to the program's policies and procedures which is within the 180 days from the date of hire for the new employee and/or annually for all other employees. |
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, the facility failed to document complete psychosocial evaluations in 15 of 32 client records reviewed, #1, 3, 6, 13, 14, 15, 21, 22, 23, 26, 27, 28, 29, 30 and 32.
Psychosocial evaluations were missing in five records #3, 6, 22, 26 and 30.
Psychosocial evaluations did not include an assessment of the client's problems and needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and attitude towards treatment in ten records, #1, 13, 14, 15, 21, 23, 27, 28, 29 and 32.
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Plan of Correction
The facility training department will re-train all clinical supervisors and counselors on how to complete psychosoical evaluations. Comments from this inspection will be incorporated in the training. On going training will be done in supervision sessions for those counselors who continue to need support. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document complete comprehensive treatment plans in 17 of 28 client records reviewed, #2, 3, 4, 6, 11, 12, 13, 14, 15, 16, 18, 21, 23, 24, 27, 31 and 32. The comprehensive treatment plans did not include goals stated in terms of measurable criteria.
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Plan of Correction
The training department will re-train all clinical staff on how to complete a comprehensive treatment plan and the time frame in which this document should be done. This training will address the criteria for determining a measureable goal. Supervisors will review the comprehensive treatment plan and will be responsible for seeing that on going training occurs in supervision for counselors who need more support. |
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, the facility failed to document complete treatment plan updates in 15 of 18 records reviewed, #2, 3, 4, 6, 9, 10, 11, 12, 13, 15, 16, 18, 27 and 32. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the prior treatment plans.
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Plan of Correction
Supervisors will be responsible for making sure treatment plans updates are done every 60 days. The training department will re-train all supervisors and counselors on how to document and write assessments based on the client's progress in relationship to his or her goals from the previous treatment plan. |
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 provide counseling services in accordance with the individual treatment plans in six of 32 records reviewed, #10, 11, 13, 14, 16 and 32.
Client #10 was to attend weekly individual sessions, but no sessions were documented from 12/13/07 to 2/4/08. Client #11 was to attend individual sessions twice per month, but no sessions were documented from 1/2/08 to 3/3/08. Client #13 was to attend weekly individual sessions, but no sessions were documented from 11/27/07 to 12/18/07 and from 12/20/07 to 1/14/08. Client #14 was to attend weekly individual session, but no sessions were documented from 7/18/07 to 7/31/07 and from 8/2/07 to 8/28/07. Client #16 was to attend bi-weekly individual sessions, but no sessions were documented from 11/14/07 to 12/5/07. Client #32 was to attend biweekly individual sessions, but no sessions were documented from 12/6/07 to 3/6/08.
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Plan of Correction
During the auditing process and on going monitoring of file documentation, supervisors will review the charts to see if the treatment plan is in accordance with sessions stated by the counselor. If not they will review this with the counselor and have the counselor document the reason for missed sessions.
This will also be reviewed in an up coming training on correct documentation of treatment plans, psychosocials/evaulations and progress notes. |