INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on June 13, 2007 through June 14, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on July 6, 2007.
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Plan of Correction
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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
The facility's informed and voluntary consent forms included language to "obtain" information as well as to disclose information in five of six client records reviewed, #1, 2, 3, 4 and 5. The "obtain" language must be removed from the consent form since the law and regulation does not address or regulate entities wanting to obtain information. Entities may obtain information without any procedures or requirements.
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Plan of Correction
Director of Outpatient Services removed the "obtain or request" language from all consents. A clinical meeting was held on 6/18/07 to discuss this matter. All clinical staf were given new consent forms and directed to destroy all previous versions. The new consents were also placed in the master client chart. The Dir of Op Services will monitor for future compliance during chart reviews. |
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
The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one client record reviewed, #6.
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Plan of Correction
At the clinical meeting on 6/18/07, Employee #1, met with staff to discuss involuntary termination of a client from treatment. The staff was educazted on procedures - a letter must be sent to the client outlining the reasons for the termination. It was further stated that the Dir of OP Services must approve all involuntary discharges prior to client notification. The Director will at this remind the counselor about the letter and will review said letter prior to mailing. In addition, Director did mail a letter to client #6 on 6/18/07 and a copy has been placed in the file. |
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
The facility failed to instruct the staff on the use of fire extinguishers within seven days of the date of employment in one of four staff records reviewed, #3.
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Plan of Correction
Employee #3 met with Human Resource Spec on 6/21/07 to go over use of fire extinguishers. Employee #3 signed paper to evidence this instruction. Compliance for this section will be maintained by the Human Resource Specialist who was made aware that proper documentation of this is necessary in all personnel records. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to document unannounced fire drills at least once a month. More specifically, there was no documentation to support that a fire drill was conducted in May 2007.
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Plan of Correction
The Director of OP Services develop a form that icluded the different exits to be used during fire drills. A calendar was develop to conduct fire drill in differents days of the week and different times. Each month the Director will complete the proper documentation to support that a fire drill was conducted. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
The facility failed to document that alternate exit routes were used during fire drills.
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Plan of Correction
The Director of OP Services will alternate exit routes by utilizing different exits monthly. The Director will utilized the newly implemented form that states the use of the different exits. The Director of OP Services is responsible to make sure this happens by following the new form. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
The facility failed to conduct fire drills on different days of the week. Fire drills were conducted on the same two days of the week in ten of twelve documented fire drills.
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Plan of Correction
The Director created a calendar to facilitated using differnt days of the week the fire drill will be conducted.
The Director is responsible for the calendar. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to document the frequency of treatment and rehabilitation services on the individual treatment plan in two of six client records reviewed, #2 and 3.
The facility failed to document the type of treatment and rehabilitation services on the individual treatment plan in one of six client records reviewed, #6.
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Plan of Correction
The Director of OP Services met with staff on 6/18/07, and re-educate staff
on the requirement to complete on the treatment plan the frequency of treatment and rehabilitation services. The Director will monitor when signing the treatment plans. The staff will be warned in written for non- compliance if this continues to be an issue.
The Director of OP Servicews met with staff on 6/18/07, to re-educate on the required documentation on client treatment plan of the type of treatment on the client treatment plan.
The Director will monitor this issue during the signing of treatment plans and will give written warnings to staff who continue to repeat this violation. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
The facility failed to document medication records in two of two client records reviewed, #4 and 5. More specifically, the name of the medication, the dosage and the frequency taken was missing in client record #4. The dosage of the medication was missing in client record #5.
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Plan of Correction
The director of OP Services met with staff on 6/18/07. Staff was re-educated when taking information from client. The receptionis will be monitored by the Director of OP when completing the intake sheet. The question on the intake sheet most be completed by asking the client if they are taking any medication and if they are the need to be instructed to give the information by phone are to bring the information to the appointment. The counselor completing the D/A Evaluation should document the information and if the client forget to bring the information or don't know the information at the time of the evaluation the counselor should report that client fail to give the information. |
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
The facility failed to document case consultation notes in two of three client records reviewed, #5 and 6.
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Plan of Correction
The Director of OP Services met with staff and re-educate staff on the use of Case consultation. The Director gave out a Memo to staff with new information on when to conduct Case consultations. Case Consultation will no longer be done every ninety days as stipulated befor. Case Consultations will be conducted each time a case is discussed. If client is waiting to start treatment, client progress in treatment, during supervision when a client is discussed. During case reviews and discharge. The director will monitor case reviews of client by singning off on each case review. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
The facility failed to document support services on the aftercare plan in two of two client records reviewed, #5 and 8.
The facility failed to include measurable and realistic goals with time frames on the aftercare plan in two of two client records reviewed, #5 and 8.
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Plan of Correction
The Director of OP met with staff on 6/18/07 to re-educate on documentation of support services on aftercare plans. The Director will monitor counselors by signing the aftercare plans and reviewing the aftercare plan for support services.
The director met with staff to re-educate on aftercare plans. The Director will monitor documentation on goals realistic to clients. |
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
The facility failed to document follow-up information, as per the facility's policy, in three of four client records reviewed, #6, 7 and 8.
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Plan of Correction
The Director re-educate counselors and the receptionist to follow up on clients. The director will monitor each chart to confirm proper documentation. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
The facility failed to ensure that the counselor hired met the qualifications for the position of counselor.
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Plan of Correction
Employee #2 did not meet qualifications for position of counselor. The Director Of Op Services will review all applicants for clinical positions requesting copies of education documentation, transcripts, certifications prior to making an offer of employment. If there appears to be any question as to the qualifications information will be forward to the Division for review.
Employee #2 job title as been changed to counselor assistant. This employee is looking into CAC certification requirements. She will keep the Dir of Op Services informed as to her progress in obtaining qualifications of counselor. |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
The facility failed to ensure that the counselor assistants were supervised by a full-time clinical supervisor or a full-time counselor.
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Plan of Correction
The counsleor assistant from the outpatient program is being transferred to inpateint. In the inpatient program there will be 2 full-time counselors and 2 full-time counselor assistance maintaining compliance in the inpatient program. The remaining counselor assistant in the outpatient program has completed all needed direct and cclose supervision. Documentation is in the personel file of the counselor assistant. This counselor assistant will be supervised by the director of outpatient and the CEO who will be available during his work hours. Colonial HOuse is interviewing a full time counselor on Friday 7/20/07. This individual meets the qualifications for the full-time counsleor psotion. At the time of the inital communciation this person appears interested. Colonia House is asking for 2 weeks to become fully compliant in this area. The director of outpatient will insure complete compliance with respect to this matter. |
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
The facility failed to ensure that all counselors and counselor assistants had at least four hours of TB/STD training within the first year of employment. More specifically, the four hours of TB/STD training was missing in for employee #4.
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Plan of Correction
The Director of OP Services register
employee # 4 for TB/STD training for July 18, 2007. The Director will monitor employee attendance to training by a follow up of training evaluation and a copy of certicate will be filed in employees chart.
The Director of OP Services will monitor the Employees required trainings chart with each individual
employee on a monthly basis. |