INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 23-24, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Case De Consejeria Drug and Alcohol Counseling Program, 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 October 28, 2008.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of five personnel records on September 23, 2008, the facility failed to document monthly supervision meetings of a clinical supervisor for the first six months of employment in one of one personnel records where required.Findings:The facility did not document monthly supervision for the first six months of employment for a clinical supervisor in client record # 2.
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Plan of Correction
Clinical Supervisors will participate in documented monthly meetings with the Program Director during the first six months of employment. All supervision documentation will be signed by both the clinical supervisor and Program Director and maintatined by the Program Director. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of five personnel record on September 24, 2008, the facility failed to maintain documentation for a counselor assistant working toward counselor status in one of one personal records where required.Findings:The facility lacked documentation from the counselor assistant showing evidence that they were working toward counselor status in personnel record # 4.
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Plan of Correction
Effective 10/6/2008 the Counselor Assistant is no longer employed at our facility. Employee decided to resign. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of five personnel record and administrative documentation on September 23, 2008, the facility failed to document a complete assessment of staff training needs in five of five personnel records reviewed.Findings:The facility did not document a training needs questionnaire completed by staff as stated in the facility ' s policy and procedures manual in personnel records #s 1, 2, 3, 4 and 5.
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Plan of Correction
An annual training needs questionnaire lacked in all personnell records provided during the audit visit. A questionnaire will be completed by each employee and reviewed by the Clinical Supervisor for the 2009 year. Clinical supervisor will meet with each clinician individually to discuss the information. The employee will sign the docment verifying the information provided is accurately and clinical supervisor will sign the document certifying that it was reviewed. |
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 five personnel records on September 23, 2008, the facility failed to document a complete written individual training plan in five of five personnel records, #s 1, 2, 3, 4 and 5. Findings:The facility did not document an individual training plan to include potential resources for training subjects in personnel records #s 1, 2, 3, 4 and 5.
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Plan of Correction
CCSI understands the importance and need for training and continuing education, and supports all employees who wish to increase their knowledge and education. Based on the employee's responsibilities and skill level, a written individualized training plan for each counselor and/or assistant counselor will be developed by the employee and the supervisor. This wil be completed with clinical supervisor and coordinated with HR. Clinical staff shall continue to attend recommended Department of Health training and provide documentation in required areas. This will be monitored by HR on an annual basis. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on an inspection of the facility's physical plant on September 24, 2008 the facility failed to ensure that all exits are unobstructed and operable at all times. Findings:The facility did not maintain an unobstructed alternate exit in the basement. The alternate exit was obstructed by a table and it was concealed with a black plastic covering.
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Plan of Correction
At this time the table and plastic covering has permanently been removed from the exit path. Staff was instructed of this as well so that the exit does not get obstructed in the future without our knowledge. This action has been taken by Birma Montes, Executive Director and Farelen Gonzalez, Programs Coordinator. |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on an inspection of the facility ' s physical plant on September 24, 2008 the facility failed to clearly indicate exits by the use of signs. Findings:The facility did not display an exit sign in the basement to indicate the alternate exit. The exit sign for the second floor alternate exit was obscured by being placed above a tall cabinet beside the exit.
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Plan of Correction
At this time new exit signs are in the process of being purchased and placed in appropritae locations on both floors. On the second floor, the cabinet has been moved further to the right in order for the exit sign to be seen clearly by everyone. The purchase of the signs will be completed by the programs coordinator and placed in appropriate location by a member of our maintenance team. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on an inspection of the facility ' s physical plant on September 24, 2008, the facility failed to maintain all portable fire extinguishers on each floor.Findings:The facility provided a fire extinguisher in the basement that was not wall mounted, and although the extinguisher had an inspection date of August 2008, the gauge indicated it was not correctly charged.
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Plan of Correction
At this time we are not sure why the fire extinguisher was not charged when they were inspected in August 2008. The programs coordinator will call the company that inspects the extinguishers in order for them to rectify the problem. Also, this extiguisher will be mounted on the wall by a member of our maintenance team. |
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
Based on an inspection of the facility ' s administrative documentation on September 24, 2008, the facility failed to prepare alternate exit routes to be used during fire drills. Findings:The facility did not document, in the fire drill log, alternate exit routes other than first floor front and rear exit. During the period of January 2008 through September 2008 the facility did not document evacuation from the basement exit or from the 2nd floor exit.
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Plan of Correction
Eventhough these exits have been used during fire drills in the past, they have not been used as frequently as they need to be. During the next year all exits during fire drills will be used in order to train all staff on how to evacuate the building in case of an emergency accordingly. This will be appropriately documented by one of our administration support staff members when drills are completed. |
709.22(e)(1) 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:
(1) Activities and accomplishments of the preceding year.
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Observations
Based on a review of the facility ' s 2007 annual report on September 23, 2008, the facility failed to document a report to include the activities and accomplishments of the preceding year.Findings: The facility did not include the activities and accomplishments of 2007 in the annual report.
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Plan of Correction
The next annual report due, the facillity will make sure that they elaborate more on activities and accomplishments for the year 2008. The report will be completed by the Executive Director. |
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 a review of the facility ' s 2007 annual report on September 23, 2008, the facility failed to document a report to include a financial statement of income and expenses.Findings:The facility did not include a financial statement of income and expenses of 2007 in the annual report.
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Plan of Correction
The facility had many staff changes during the last year and obtained an extension from the IRS through our certified public accontant for a november 2008 extension. In the future, 2009 year, the financial report will be completed no later than six months from the close date of that previous year. This was the first time this had occurred in our facility. Financial statement will be completed by CPA. |
709.22(e)(3) 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:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of the facility ' s 2007 annual report on September 23, 2008, the facility failed to document a report to include a statement disclosing the names of officers, directors and principal shareholders. Findings:The facility did not include a statement disclosing the names of officers, directors and principal shareholders in the 2007 annual report.
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Plan of Correction
As far as the facility is concern, a statement was provided with the names of officers and directors of the agency. We currently have this updated list and we will make sure that during the next audit visit we will make more visible in order to prevent this oversight. This list will be provided by the Executive Director or Programs Coordinator. |
709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
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Observations
Based on a review of the facility ' s administrative documentation on September 23, 2008, the facility failed to obtain letters of written agreement or understanding with primary referral sources. Findings: The facility documented only one current letter of agreement with North Philadelphia Health System. All other documented letters of agreement with primary referral sources were not completed within the last two years.
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Plan of Correction
The facility lacked to provide most updated agreements with primary referral sources. Updated needed agreements will be obtained by the Executive Director jointly with the Programs Coordinator. At this time primary referral sources have to be reviewed and determined if those agencies will be utilized by our facility at this time. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation on September 23, 2008, the facility failed to obtain the services of an independent public accountant for an annual audit of all financial activities associated with the project ' s drug/alcohol abuse services.Findings:The facility did not document an annual financial audit for the budget year of 2007. The facility ' s last documented financial audit was for the budget year of 2006.
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Plan of Correction
The facility had many staff changes during the last year and obtained an extension from the IRS through our certified public accontant for a november 2008 extension. In the future, 2009 year, the financial report will be completed no later than six months from the close date of that previous year(2008). This was the first time this had occurred in our facility. Financial statement and audit for the budget year 2007 (will be completed by 11/30/2008)and 2008 will be completed by CPA no later than July 31, 2009. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of six client records on September 24, 2008, the facility failed to correctly document informed and voluntary consent forms with specific client information to be released in four of six client records #s 3, 4, 5 and 6. Findings:The facility documented informed and voluntary consent forms releasing specific client information that exceeded 4 Pa Code 255.5 regulations in client records #s 3, 4, 5 and 6. Client record # 3 documented a release of urine drug screens to CBH and to Health Partners. Client record # 4 documented a release of urine drug screens to Probation, to CBH and to DPW. Client record # 5 documented a release of " records pertaining to treatment " to Probation and Parole and to DUI Program. Client record # 6 documented a release of " records pertaining to treatment " to CBH and Keystone Mercy.
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Plan of Correction
The clinical supervisor will hold an in service training to discuss essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2. The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be released, to whom, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether client received a copy will be discussed in addition to other privacy practices outlined in CCSI confidentiality policy and procedures.
Clinical staff shall continue to attend recommended Department of Health training and provide documentation in areas such as confidentiality and client recordkeeping. This will be monitored by HR on an annual basis.
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. 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 a review of six client records on September 24, 2008, the facility failed to document a complete drug and alcohol history in four of four client records where needed.Findings:The facility did not document a drug or alcohol history to include lengths and patterns of use in client records #s 1, 2, 3 and 4.
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Plan of Correction
The clinical supervisor will hold in service trainings regarding the documentation of comprehensive assessments which will include all drug and alcohol histories. These trainings will emphasize on the importance of capturing all client information containing substances most frequently abused, length and patterns of use, prior treatment episodes, perception of their effect on his/her social, physical, and mental states, and/or substance abuse history within the family or significant others. Trainings will be supplemented with targeting client problems and frame them according to context and dimensions of the client's life. In addition to focusing on the frequency, duration and severity of the D/A seeking behaviors, individual characteristics, age of onset, history of antisocial behavior or psychiatric problems, vocational and social instability, adverse consequences of use, and access to resources will also be considered. Service provision will attempt to foster a climate of realistic expectations regarding what incremental treatment can and should be expected to do. The use of biochemical D/A testing will continue to be used as an objective, measurable indicator of treatment outcomes as well as other outcome measures like GAF, self rating scales, number of consecutive days of attendance, return to work, increased participation in community activities, payment of fines and restitution, self reported increased social functioning, verified compliance with court and DHS orders, etc.
Training should be geared to (1) assisting the client to explore thought processes associated with relapse, (2) assisting the client to increase communication skills by telling his/her "story", including any regret and anger, (3) helping the client understand his/her addiction and identify the consequences of substance use, (4) helping the client to negotiate any housing, healthcare, personal, family, or pending legal problems, (5) identifying triggers or psychosocial stressors exacerbating substance use (6) allowing the client to examine the role of family and peers in substance abuse, (7) helping the client increase self monitoring skills and reduce exposure to substances, (8) helping the client to recognize and cope with cravings and negative affect, (9) confronting client ambivalence and resistance to treatment (10) increasing linkage with needed resources and positive peer supports .
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. 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 a review of six client records on September 24, 2008, the facility failed to document a complete personal history in four of four client records where needed. Findings:The facility did not document a complete employment history in client records #s 1, 2, 3 and 4. Client records #s 1, 2, 3 and 4 documented only the current or most recent employment and did not provide a complete employment history. The facility did not document a complete legal history in client records #s 1, 2 and 3.Client record #1 indicated six arrests but did not document the reasons for the arrests.Client record #2 indicated a DUI arrest but did not document the date of the arrest. Client record #3 indicated incarceration for four days but did not document the reason for incarceration.
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Plan of Correction
The clinical supervisor will hold in service trainings regarding the documentation of comprehensive assessments by 2/28/09. The nature of this training is as follows:
Assessments should be more comprehensive as well as specific in nature: the presenting problem will be established through the client's chief complaint, collateral reports, referral source information, review of admission documents, results of drug/alcohol screens as indicated. Drug and alcohol usage will be prioritized, with special attention given to type of substance, length and pattern of use, age of onset and treatment history. Precipitants of use will be identified, including any peer and family involvement. The client's own assessment of his/her problem will be indicated as well as what treatment worked (or did not work) and for how long. Psychological problems including current suicidal/homicidal risk, ability to control impulses, MH treatment history, current provider, diagnoses, medication, including dosage/frequency of use and over the counter drugs will be identified. The client's early family history, present support system and significant relationships will be identified in addition to sources of income, impact of D/A on relationships, exposure to substances. An employment history will be taken identifying current employer or employment needs, history and patterns of problems, skills, training, impact of D/A use on vocational functioning. The legal history including cases pending, specific charges, length, dates, reason and number of incarcerations, PO will be indicated. A military history will be obtained, including the dates of service, exposure to violence or trauma, type of discharge. The educational history, client literacy, current educational needs or special needs will be identified. Other indicators including the client's cultural history, level of acculturation, religious affiliation, self care ability, medical needs, and ability to manage money, safe sex practices, access to transportation and recreation will be identified and assessed.
Clinical staff shall continue to attend recommended Department of Health training and provide documentation in areas such as client recordkeeping, drug and alcohol assessment, on an annual basis. This will be monitored by HR on an annual basis.
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709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of six client records on September 24, 2008, the facility failed to document a physical examination by the 15th working day as stated in the facility ' s policy and procedures manual in four of four client records where required. Findings: The facility did not document a physical examination by the 15th working day as stated in the facility ' s policy and procedures manual in client records #s 1, 2, 3 and 4.
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Plan of Correction
The policy and procedure manual will be amended to state that although annual physical examinations are recommended for our clients, that a physical examination is not required at the point of admission. This will be completed by Program Director and sent to the board of directors for approval. |
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
Based on a review of six client records on September 24, 2008, the facility failed to document dosage and frequency of use for all medications being taken in three of three client records where required. Findings:The facility did not document the dosage and frequency of use for the current medications indicated in client records #1, 2 and 3.
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Plan of Correction
As part of the comprehensive medical history, the client's current medications including name, dosage/frequency of use and over the counter drugs will continue to be identified in the medical history. Clients will continue to be asked to bring copies of their prescriptions at intake and during the course of treatment by clinical staff. This indicator will be included in comprehensive assessment in service to be completed by the supervisor by 12/31/08. Also, a script will be completed for receptionist to remind all new admissions clients to bring their medication information as well as other documentation that is needed. |
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 six client records on September 24, 2008, the facility failed to document discharge follow-up information in two of two client records where required.Findings: The facility did not document, in a progress note, a follow-up phone call or follow-up letter after discharge as stated in the facility ' s policy and procedures manual in client records #s 5 and 6.
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Plan of Correction
The agency discharge policy will be amended to include a termination notice or letter to the client within seven (7) days of discharge. This will be done by 2/28/09 by the program manager.
The clinical supervisor will hold an in service training on the elements of comprehensive discharge planning and aftercare planning with special emphasis on the documentation of the discharge progress note and use of the termination letter. The body of the note will include the client's behavior and attitude upon discharge, treatment outcomes, resolution of psychosocial problems and information regarding client awareness of follow up appointments.
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