INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 3, 2012 through January 4, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WES Corporation 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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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
Based on an interview with the project director, the facility failed to provide a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served.
The findings include:
On January 3, 2012 and January 4, 2012, the Licensing Specialist asked to see the facility's policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. A policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served was not presented for review.
The findings were confirmed during an interview with the project director on January 4, 2012 at approximately 10:00 A.M.
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Plan of Correction
The Project Director and Facility Director revised a Substance Abuse Hiring policy to be used by WES Human Resources for recruitment that was done on 1/4/12 and as the policy indicated will be appropriate to the population served in the substance abuse programs.
The policy will be presented to the governing body for approval by 3/30/12. The Human Resources Director and Project Director will monitor for ongoing compliance. |
704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of the facility's policies and procedures, the project director failed to 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 overall training plan to address staff training needs. Also, the project director failed to develop a policy and procedures for individual training plans.
The findings include:
The facility's policies and procedures were reviewed on January 3, 2012. The policy and procedures on staff development did not indicate who is responsible for completing an overall plan to address staff training needs. Also, on January 3, 2012 and January 4, 2012, the Licensing Specialist asked to see a copy of the facility's policy and procedures for individual training plans. A copy of the facility's policy and procedures for individual training plans was not presented for review.
The findings were confirmed during an interview with the project director on January 4, 2012 at approximately 10:00 A.M.
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Plan of Correction
The Facility Director will update the Substance Abuse Division Staff Development Policy to include that the Facility Director is responsible for the completion of the Overall and Individual Training Plans for the substance abuse staff, the Facility Director's individual plan will be done by Project Director and the Project Director will be done by CEO/Board President by the last day of January annually. The revised staff development policy is planned to be presented to the Board of Directors for approval at the next Board Meeting planned to be held by March 30, 2012. The policy will be maintained in place in the manual at the facility by the Facility Director. Project Director will monitor ongoing compliance. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's administrative documentation, the facility failed to document an overall plan for addressing staff training needs in accordance with policy and procedures. Also, the facility failed to comply with the staff development program relating to documentation of an overall plan for addressing staff training needs.
The findings include:
The facility's policy titled: "Substance Abuse Division Staff Development Program," states:
"2. The overall training plan is developed by the end of January for the current training year."
The facility's administrative documentation was reviewed on January 4, 2012. The facility was required to complete an overall training plan that included the trainers of training subjects and proposed dates of training by the end of January 2011. The document presented at the time of review as the overall training plan for addressing staff training needs was not completed until July 6, 2011. Also, the overall training plan did not include the trainers of the training subjects and proposed dates of training.
The findings were confirmed during an interview with the facility director on January 4, 2012 at approximately 3:00 P.M.
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Plan of Correction
The Facility Director will complete the Overall Training Plan by January 31st annually. The Training Plan will be inclusive of Trainings occurring from January through December of the training year. The Overall Training Plan will also include the training subjects and the proposed dates of training. The Overall Training Plan has noted the identified trainers anticipated to facilitate the trainings and was completed by 1/31/12. The Project Director will monitor for compliance. |
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 records and the facility's Staffing Requirements Facility Summary Report form, the facility failed to develop an individual training plan at the beginning of the training year for existing employees. Also, the facility failed to document an individual training plan for existing employees.
The findings include:
On January 4, 2012, four personnel records of existing employees requiring documentation of an individual training plan were reviewed. The facility failed to document an individual training plan at the beginning of the training year for existing employees in two of four personnel records reviewed, specifically, personnel records # 3, and 5. Also, the facility failed to document an individual training plan for existing employees in one of four personnel records reviewed, specifically, personnel record # 8.
Employee # 3, a counselor, was hired January 4, 2012. An individual training plan was due at the beginning of the facility's training year by January 31, 2011. However, the facility did not document an individual training plan for employee # 3 until June 3, 2011, more than thirty days from the beginning of the training year.
Employee # 5, a counselor, was hired December 18, 2006. An individual training plan was due at the beginning of the facility's training year by January 31, 2011. However, the facility did not document an individual training plan for employee # 5 until June 6, 2011, more than thirty days from the beginning of the training year.
Employee # 8, the psychiatrist, was hired July 1, 1998. An individual training plan was due at the beginning of the facility's training year by January 31, 2011. However, personnel record # 8 did not include documentation of an individual training plan as of January 4, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 1:30 P.M. to 2:30 P.M.
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Plan of Correction
The Facility Director will ensure Individual training Plans are completed for all employees by January 31st annually. The Project Director will monitor for compliance. The Facility Director will ensure that an individual training plan will be completed for all new hires within the new employees initial 30 days of hire. This issue was completed by 1/31/2012. |
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 personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of required training.
The findings include:
On January 4, 2012, two personnel records requiring documentation of 25 clock hours of training were reviewed. The facility failed to provide documentation of 25 clock hours of training in two of two personnel records reviewed, specifically, personnel records # 3 and 5.
Employee # 3, a counselor, was hired on January 26, 2007. The facility's training year is from January 1, 2011 to December 31, 2011. Employee # 3's personnel record only had documentation of 19 clock hours of training for the January 1, 2011 to December 31, 2011 training year as of January 4, 2012.
Employee # 5, a counselor, was hired on December 18, 2006. The facility's training year is from January 1, 2011 to December 31, 2011. Employee # 5's personnel record only had documentation of 13 clock hour of training for the January 1, 2011 to December 31, 2011 training year as of January 4, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 1:30 P.M. to 2:30 P.M.
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Plan of Correction
The Facility Director will consult with the Agency Training Manager and outline specific training topics identified from individual training assessments, supervision and staff meetings to enroll counselors in thorough out the year to ensure 25 training hours are met anually. Training will occur both on and off site. Project Director will monitor for compliance. |
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on observation on January 4, 2012, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on January 4, 2012. It was observed during the inspection at approximately 1:06 P.M. that the facility had a dumpster located in one of the garages. The dumpster was not covered with lids.
The findings were confirmed during an ongoing dialogue with the quality assurance manager on January 4, 2012 from approximately 1:06 P.M. to 1:07 P.M.
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Plan of Correction
The Facility Director met with the Director of Facilities Management and was informed that the dumpster lids will be kept closed at all times by Housekeeping Staff. The Director of Facilities Management will monitor periodically throughout the day for compliance. This issue was completed on 1/4/2012 communicated by Director of Facilities Management at the follow up meeting that happened on 2/6/2012 between the Facility Director and the Director of Facilities Management. |
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
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment.
The findings include:
On January 4, 2011, four personnel records requiring documentation of fire extinguisher training were reviewed. The facility did not provide documentation that they instruct staff in the use of the fire extinguisher upon staff employment in four of four personnel records reviewed, specifically, personnel records # 2, 4, 6, and 7.
Employee # 2, the facility director, was initially hired on December 27, 2010 and rehired for her current position on May 27, 2011. Employee # 2 was due to complete fire extinguisher training by May 27, 2011. However, personnel record # 2 did not include documentation of fire extinguisher training as of January 4, 2012.
Employee # 4, a counselor, was initially hired on October 4, 2011 and rehired for her current position on October 31, 2011. Employee # 4 was due to complete fire extinguisher training by October 4, 2011. However, personnel record # 4 did not include documentation of fire extinguisher training as of January 4, 2012.
Employee # 6, a counselor, was hired on August 25, 2011. Employee # 6 was due to complete fire extinguisher training by August 25. However, personnel record # 6 did not include documentation of fire extinguisher training as of January 4, 2012.
Employee # 7, a counselor, was initially hired on May 31, 2011 and rehired for her current position on September 19, 2011. Employee # 7 was due to complete fire extinguisher training by September 19, 2011. However, personnel record # 7 did not include documentation of fire extinguisher training as of January 4, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 1:30 P.M. to 2:30 P.M.
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Plan of Correction
Employees 2&7 were trained in the use of fire extinquishers on 1/23/12. Employee #4 on 12/19/2011. Employee 6 (contracted part-time) was anticipated to be done on 2/9/12 to correct this issue. The Facility Director & Human Resources will ensure Substance Abuse staff's initial date of hire coincides with WES' Employee Orientation (Use of fire extinguishers is part of the orientation curriculum)whenevere possible or that Staff (hired outside of orientation)are instructed in the use of fire extinguishers on their initial date of hire. The Project Director will monitor compliance. The Training certificate will be placed in the employee's file by 2/29/12 since the training had to be delayed due to employee's absence due to a family emergency and will be placed in the file by the Facility Director. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
On January 4, 2011, four personnel records requiring documentation that all personnel on all shifts had been trained to perform assigned tasks during emergencies were reviewed. The facility did not provide documentation of the completion of emergency training in four of four personnel records, specifically, personnel records # 2, 4, 6, and 7.
Employee # 2, the facility director, was initially hired on December 27, 2010 and rehired for her current position on May 27, 2011. Employee # 2 was due to complete emergency training by May 27, 2011. However, personnel record # 2 did not include documentation of emergency training as of January 4, 2012.
Employee # 4, a counselor, was initially hired on October 4, 2011 and rehired for her current position on October 31, 2011. Employee # 4 was due to complete emergency training by October 31, 2011. However, personnel record # 4 did not include documentation of emergency training as of January 4, 2012.
Employee # 6, a counselor, was hired on August 25, 2011. Employee # 6 was due to complete emergency training by August 25. However, personnel record # 6 did not include documentation of emergency training as of January 4, 2012.
Employee # 7, a counselor, was initially hired on May 31, 2011 and rehired for her current position on September 19, 2011. Employee # 7 was due to complete emergency training by September 19, 2011. However, personnel record # 7 did not include documentation of emergency training as of January 4, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 1:30 P.M. to 2:30 P.M.
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Plan of Correction
Employees 2&7 were trained in Disaster Planning on 1/23/12. Employee #4 on 12/19/2011. Employee #6 (contracted part-time) was initially planned to be instructed on 2/9/2012 however employee was unable to complete training due to an unplanned emergency. The Facility Director & Human REsources dept. will ensure Substance Abuse staff's initial date of hire coincides with WES' Employee Orientation (Disaster Planning) whenever possible or that Staff (hired outside of orientation)are instructed in Disaster Planning on their initial date of hire. The Project Director will monitor for compliance. This issue will be completed by 2/29/2012 and the Disaster Planning training certificate will be placed in employees file by Facility Director. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record that included documentation of the exit route used.
The findings include:
Fire drill records were reviewed on January 4, 2012. The records were reviewed from the period covering January 2011 to December 2011. The facility did not have documentation for exit route used at the time of the drill in two of twelve months reviewed, specifically, May 10, 2011 and July 27, 2011.
The findings were confirmed during an ongoing dialogue with the quality assurance manager on January 4, 2012 from approximately 12:15 P.M. to 12:30 P.M.
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Plan of Correction
The Facility Director met with the Sargeant of Security on 2/6/12 to review the Fire Drill Documentation Process. The Sergeant of Security will ensure that the indentified exit route is included in the monthly Fire Drill Log. The Fire Drill Log will be reviewed by the Facility Director monthly and a copy of the Log will be maintained by the Facility Director on the Substance Abuse unit. The Project Director will monitor for compliance. |
709.22(c)(2) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(2) Qualifications for membership.
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Observations
Based on an interview with the project director and facility director, the facility failed to provide written policies that include qualifications for membership to the governing body.
The findings include:
On January 3, 2012 and January 4, 2012, the Licensing Specialist asked to see the facility's written policies that include qualifications for membership to the governing body. Written policies that include qualifications for membership to the governing body were not presented for review.
The findings were confirmed during an ongoing dialogue with the project director and facility director on January 4, 2012 from approximately 10:00 A.M. to 1:00 P.M.
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Plan of Correction
A Written Policy that includes the qualifications for membership to the Governing Body will be submitted by the CEO/CEO designee for approval to the Governing Body at the next scheduled meeting of the Governing Body on 3/1/12. Once approved the policy will be provided to the Project Director for inclusion in the Substance Abuse Program Manual. The Executive Management Team will ensure that the qualifications for membership of the Governing Body will be outlined for approval by 3/30/2012 and the Facility Director will ensure that the information remain in place in the manual at the facility. This issue will be completed by 3/30/12. |
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 facility's administrative documentation, the facility failed to provide the date that the project director presented the goals and objectives for the July 2011 through June 2012 fiscal year to the governing body and when the governing body approved the goals and objectives for the July 2011 through June 2012 fiscal year.
The findings include:
The facility's administrative documentation was reviewed on January 3, 2012 and January 4, 2012. The facility had documentation of a board representative approving the goals and objectives for the July 2011 through June 2012 fiscal year. However, the facility did not have documentation of the date that the project director presented the goals and objectives for the July 2011 through June 2012 fiscal year to the governing body and did not have documentation of when the goals and objectives for the July 2011 through June 2012 fiscal year were approved by the governing body.
The findings were confirmed during an interview with the project director on January 4, 2012 at approximately 10:00 A.M.
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Plan of Correction
The revised Policicy and Procedure will indicate that the Annual Goals & Objectives would be based on the Calendar year and no longer the Fiscal year and will be submitted for approval by the governing board.
The Goals and Objectives were completed by 1/31/12 by the Facilities Director. The Project Director will monitor the submission and retrieval of the Goals & Objectives after approval from the governing body by 3/31/2012. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to develop a written plan for the coordination of client treatment and rehabilitation services that accurately reflects the process for completing the psychosocial evaluation.
The findings include:
On January 3, 2012, the facility's policy and procedures manual was reviewed. The facility had two conflicting policies regarding the completion of the psychosocial evaluation.
The facility's policy titled: "Treatment And Rehabilitation Plan," states:
"The Bio-Psychosocial Evaluation will be completed within thirty (30) days of admission."
The facility has a second policy titled: "Comprehensive Bio-Psychosocial Evaluation," that states:
"The Comprehensive Biopsychosocial Evaluation must be completed by the consumer's assigned program therapist within 45 days following the consumer's admission and registration process."
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 1:30 P.M. to 2:00 P.M.
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Plan of Correction
The WES Policy for CBE completion will be reviewed and revised by WES' Clinical Working Group at the next Clinical Working Group Meeting reflect WES expectations for Comprehensive Bio-Psychosocial Evaluation (CBE) completion. The Substance Abus Program will adhere to WES' Policies and Procedures for CBE completion as reviewed and revised. The revised copy of the CBE Policy will be placed in the SA Manual. The revised policy will be submitted for approval by the Board of Directors by the Project Director by 3/30/2012. The Facility Director will enusre that the policy remain in place at the facility. |
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 an interview with the project director, the facility failed to provide an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility was required to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of their fiscal year. The facility's 2010 to 2011 fiscal year ended on June 30, 2011. On January 3, 2012 and January 4, 2012, the Licensing Specialist asked to see a copy of the facility's annual audit of financial activities associated with the project's drug/alcohol abuse services for the facility's 2010 through 2011 fiscal year. An annual audit of financial activities associated with the project's drug/alcohol abuse services for the facility's 2010 through 2011 fiscal year was not presented for review.
The findings were confirmed during an interview with the project director on January 4, 2012 at approximately 10:00 A.M.
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Plan of Correction
The Substance Abuse Program has communicated to the Fiscal Staff the need to have a copy of the Annual Audit Report available for future State Audits. Notice of upcoming audits will be communicated to the Director of finance and the CFO upon confirmatio of the State Audit dates to ensure the Report is available at the time of the Audit. A public accounting firm was engaged prior to the State Audit and the FYE 6/30/11 (the financial audit) had been completed and was on the unit by 1/6/12. The Project Director will ensure the completed audit managed by the Fiscal Finance Director is retrieved and given to Facility Director to have present on the unit moving forward. The Project Director will make sure the audits are completed on time for the upcoming fiscal years. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records, the facility failed to provide documentation for the results of reference investigations for I-9 forms.
The findings include:
On January 4, 2012, four personnel records requiring documentation of I-9 forms were reviewed. The facility failed to provide documentation of I-9 forms in four of four personnel records, specifically, personnel records # 2, 4, 6, and 7.
Employee # 2, the facility director, was initially hired on December 27, 2010 and rehired for her current position on May 27, 2011. However, personnel record # 2 did not include documentation of an I-9 form as of January 4, 2012.
Employee # 4, a counselor, was initially hired on October 4, 2011 and rehired for her current position on October 31, 2011. However, personnel record # 4 did not include documentation of an I-9 form as of January 4, 2012.
Employee # 6, a counselor, was hired on August 25, 2011. However, personnel record # 6 did not include documentation of an I-9 form as of January 4, 2012.
Employee # 7, a counselor, was initially hired on May 31, 2011 and hired for her current position on September 19, 2011. However, personnel record # 7 did not include documentation of an I-9 form as of January 4, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 1:30 P.M. to 2:30 P.M.
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Plan of Correction
As per the WES Human Rescources Director, WES will provide I-9 forms for all "Employees" if required under the regulations. The I-9 forms were completed by the Human Resources staff and placed in employees files after employee applications were completed and interviews indicated they meant the qulifications for the anticipated job postions. This issue was completed by 2/9/2012. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on a review of personnel records, the project director failed to demonstrate the project's efforts toward informing staff of employee rights.
The findings include:
On January 4, 2012, three personnel records requiring documentation that the project informed staff of employee rights were reviewed. The facility failed to provide documentation that the project informed staff of employee rights in three of three personnel records, specifically, personnel records # 2, 4, and 7.
Employee # 2, the facility director, was initially hired on December 27, 2010 and rehired for her current position on May 27, 2011. However, personnel record # 2 did not include documentation that the project informed employee # 2 of her employee rights as of January 4, 2012.
Employee # 4, a counselor, was initially hired on October 4, 2011 and rehired for her current position on October 31, 2011. However, personnel record # 4 did not include documentation that the project informed employee # 4 of her employee rights as of January 4, 2012.
Employee # 7, a counselor, was initially hired on May 31, 2011 and rehired for her current position on September 19, 2011. However, personnel record # 7 did not include documentation that the project informed employee # 7 of her employee rights as of January 4, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 1:30 P.M. to 2:30 P.M.
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Plan of Correction
New "Employees" of WES receive New Employee Oreientation. At the New Employee Orientation WES Employees are provided a copy of the Employee Handbook and sign "The Employee Handbook Receipt Form" stating they have received an employee handbook. The Employee Handbook covers the rights section noted in the regulation. The WES employment files inclusive of the "Employee Handbook Receipt Form" will be made available at SA State Audits. WES' Human Resources Director will monitor for compliance. The Employee Receipt forms are placed in the employee's records by the Human Resources staff and this issue was completed by 2/9/2012 |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on observation, on January 4, 2012, the facility failed to maintain the confidentiality of the client's identity.
The findings include:
A physical plant inspection was conducted on January 4, 2012. It was observed during the inspection at approximately 12:45 P.M. and 1:07 P.M. that the facility had client sign-in sheets in the reception area on the second and first floor. The client sign-in sheets had first and last names of clients presently or previously at the facility.
The findings were confirmed during an ongoing dialogue with the quality assurance manager on January 4, 2012 from approximately 12:45 P.M. to 1:08 P.M.
This is a repeat citation. The facility was cited on June 17, 2011 and November 23, 2010
for noncompliance with this standard.
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Plan of Correction
The Facility Director replaced the sign in sheet on the 2nd floor with "Peel off Stickers" that are to be removed as Program PIR sign in. A directive was sent to WES front desk staff to ensure all PIR sign in on the "Peel Off Stickers" and that the Peel Off Stickers be removed immediately as PIR sign in at WES buildings. Compliance will be monitored by the Facility Director,the Quality Management Director, the Captain of Security and the Project Director. The Program Support Staff will be responsible to monitor individual signing in of PIR(s) and peel off the stickers immedaitely after the signatures are done on the substance abuse unit and the security guard on duty in the lobby will be responsible for monitoring individual sign ins and peel off the individual signatures immediately afterwards in the front lobby area. This issue was completed on 1/13/12. |
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 client records, the facility failed to obtain an informed and voluntary consent form the client for the disclosure of information.
The findings include:
On January 4, 2012, four client records requiring documentation of informed and voluntary consents were reviewed. The facility released information without the client's consent in four of four client records reviewed, specifically, client records # 1, 2, 3, and 5.
Client record # 1 contained two Eligibility Verification System forms dated 9/19/11 in which the facility released information about the client to a government agency, but the facility did not document a signed consent from the client to release the information.
Client record # 2 contained one Eligibility Verification System form dated 9/26/11 in which the facility released information about the client to a government agency, but the facility did not document a signed consent from the client to release the information.
Client record # 3 contained one Eligibility Verification System form dated 9/19/11 in which the facility released information about the client to a government agency, but the facility did not document a signed consent from the client to release the information.
Client record # 5 contained one Eligibility Verification System form dated 10/7/11 in which the facility released information about the client to a government agency, but the facility did not document a signed consent from the client to release the information.
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 3:30 P.M. to 4:00 P.M.
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Plan of Correction
The Facility Director will revise policy to reflect the process of obtaining written consent from PIR to run the Eligibility Verification system or Promise on PIR calling in to WES for pre-screening for referral will be inclusive of scheduling a face to face contact prior to running an EVS or PROMISE to verify insurance status to obtain cosent to release. The consent form is completed by PIR upon their initial visit to the program. Writtent consents to run the Eligibility Verification system or Promise are being updated on Active PIR during individual sessions. The Facility Director will monitor during chart audits.The Project Director will monitor for compliance. This issue will be completed by 3/10/12. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document client medical histories in accordance with facility policy and procedures.
The findings include:
The facility's policy titled: "Treatment And Rehabilitation Plan," states:
"All histories are completed within (2) days of Intake. All Histories are contained within the Bio-Psychosocial Evaluation and become a permanent part of the client record."
On January 4, 2012, seven client records requiring documentation of a medical history were reviewed. Two out of seven records reviewed, # 1 and 7 lacked dates on the medical histories to ensure that they were completed in accordance with the facility's policy.
Client # 1 was admitted September 19, 2011. The medical history was due September 21, 2011; however, the medical history did not include a date of completion as of January 4, 2012.
Client # 7 was admitted October 19, 2011. The medical history was due October 21, 2011; however, the medical history did not include a date of completion as of January 4, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 3:30 P.M. to 4:00 P.M.
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Plan of Correction
The Facility Director will submit the Policy on "Treatment and Rehabilitation Plan" will be reviewed and revised in accordance with the WES policy on the Comprehensive Bio-Psychosocial Evaluation. The medical histories will be doucmented by licensed psychologists. The Facility Director will conduct chart reviews to ensure the medical histories are completed in accordance with the facility's policies and procedures.
The Project Director will monitor for compliance. This issue will be completed by 3/31/12. |
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 client records, the facility failed to document client drug or alcohol histories in accordance with facility policy and procedures.
The findings include:
The facility's policy titled: "Treatment And Rehabilitation Plan," states:
"All histories are completed within (2) days of Intake. All Histories are contained within the Bio-Psychosocial Evaluation and become a permanent part of the client record."
On January 4, 2012, seven client records requiring documentation of a drug or alcohol history were reviewed. Two out of seven records reviewed, # 1 and 7 lacked dates on the drug or alcohol histories to ensure that they were completed in accordance with the facility's policy.
Client # 1 was admitted September 19, 2011. The drug or alcohol was due September 21, 2011; however, the drug or alcohol history did not include a date of completion as of January 4, 2012.
Client # 7 was admitted October 19, 2011. The drug or alcohol history was due October 21, 2011; however, the drug or alcohol history did not include a date of completion as of January 4, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 3:30 P.M. to 4:00 P.M.
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Plan of Correction
The Facility Director will review completed CBE's for signatures and the date of completion of the CBE inclusive of the Alcohol History ensuring that all CBEs are completed and signed, dated in accordance with WES' policy on the completion of CBEs and Alcohol Histories.The Project Director will monitor for compliance. |
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 client records, the facility failed to document client personal histories in accordance with facility policy and procedures.
The findings include:
The facility's policy titled: "Treatment And Rehabilitation Plan," states:
"All histories are completed within (2) days of Intake. All Histories are contained within the Bio-Psychosocial Evaluation and become a permanent part of the client record."
On January 4, 2012, seven client records requiring documentation of personal histories were reviewed. Two out of seven records reviewed, # 1 and 7 lacked dates on the personal histories to ensure that they were completed in accordance with the facility's policy.
Client # 1 was admitted September 19, 2011. The personal history was due September 21, 2011; however, the personal history did not include a date of completion as of January 4, 2012.
Client # 7 was admitted October 19, 2011. The drug or personal history was due October 21, 2011; however, the personal history did not include a date of completion as of January 4, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 3:30 P.M. to 4:00 P.M.
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Plan of Correction
The Facility Director will review completed CBE's for signatures and the date of completion of the CBE inclusive of the PIR Personal History ensuring that all CBEs are completed, signed, dated in accordance with WES' policy on the completion of CBEs and PIR Personal Histories. The Project Director will monitor for compliance.
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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, the facility failed to document a psychosocial evaluation or document a psychosocial evaluation that included an assessment of the client's coping mechanisms and attitude toward treatment. Also, the facility failed to document a psychosocial evaluation in accordance with the policy and procedures.
The findings include:
The facility's policy titled: Treatment And Rehabilitation Plan," states:
"The Bio-Psychosocial Evaluation will be completed within thirty (30) days of admission."
On January 4, 2012, five client records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation in one of five records reviewed, specifically, client record # 1. The facility did not document a psychosocial evaluation that included an assessment of the client ' s coping mechanisms and attitude toward treatment in four of five records reviewed, specifically client records # 2, 3, 4, and 5. The facility did not document a psychosocial evaluation according to their policy and procedures in one of five records reviewed, specifically, client record # 3.
Client # 1 was admitted September 19, 2011. The psychosocial evaluation was due October 19, 2011; however, client record # 1 did not include documentation of a psychosocial evaluation as of January 4, 2012.
Client # 2 was admitted September 26, 2011. The psychosocial was completed on September 30, 2011 but did not include an evaluation of the client's coping mechanisms and attitude toward treatment.
Client # 3 was admitted September 19, 2011. The psychosocial evaluation was due October 19, 2011; however, psychosocial evaluation was not completed until December 1, 2011. Also, the psychosocial evaluation did not include an evaluation of the client's coping mechanisms and attitude toward treatment.
Client # 4 was admitted October 3, 2011. The psychosocial was completed on November 3, 2011 but did not include an evaluation of the client's coping mechanisms and attitude toward treatment.
Client # 5 was admitted September 28, 2011. The psychosocial was completed on September 28, 2011 but did not include an evaluation of the client's coping mechanisms and attitude toward treatment.
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 3:30 P.M. to 4:00 P.M.
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Plan of Correction
The Facility Director will review completed CBE's for signatures and the date of completion of the CBE inclusive of the PIR Coping Mechanism and will review assessments to confirm the PIR(s) attitudes towards treatment are noted ensuring that all CBEs are completed, signed, dated in accordance with WES' policy on the completion of CBEs and PIR Coping Mechanisms. The Project Director will monitor for compliance. The client # 1 was discharged from treatment for noncomplaince with responding to outreach efforts extended to reengage so PIR(s) attitude towards treatment could not be assessed to be included in another assessment. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan.
The findings include:
The facility's policy titled: "Treatment and Rehabilitation Plan", stated:
"The Comprehensive Treatment plan will be completed within (30) days of admission."
On January 4, 2012, five client records requiring documentation of individual treatment and rehabilitation plans were reviewed. The facility did not document an individual treatment and rehabilitation plan in four of five records reviewed, specifically, client records # 1, 2, 3, and 5.
Client # 1 was admitted September 19, 2011. The individual treatment and rehabilitation plan was due October 19, 2011; however, client record # 1 did not include documentation of an individual treatment and rehabilitation plan as of January 4, 2012.
Client # 2 was admitted September 26, 2011. The individual treatment and rehabilitation plan was due October 26, 2011; however, client record # 2 did not include documentation of an individual treatment and rehabilitation plan as of January 4, 2012.
Client # 3 was admitted September 19, 2011. The individual treatment and rehabilitation plan was due October 19, 2011; however, client record # 3 did not include documentation of an individual treatment and rehabilitation plan as of January 4, 2012.
Client # 5 was admitted September 28, 2011. The individual treatment and rehabilitation plan was due October 28, 2011; however, client record # 5 did not include documentation of an individual treatment and rehabilitation plan as of January 4, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 3:30 P.M. to 4:00 P.M.
This is a repeat citation. The facility was cited on June 17, 2011; February 2, 2010; July 13, 2009; February 6, 2008, September 19, 2007; April 18, 2007; and September 26, 2006 for noncompliance with this standard.
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Plan of Correction
The Facility Director will coordinate staff training with the Agency Training Manager on the completion of Comprehensive Individual Treatment& Rehabilitation Plans to ensure licensing standards are met. Facility Director will implement computerized spread sheets to track completion and remind clinicians of required completion time frames based on PIR(s)enrollment dates. Ongoing chart reviews will be done on a bi-weekly basis by staff and facility director to check compliance with tracking system. The Project Director will monitor for compliance. PIR # 1 and # 5 were discharged due to not presenting for treatment to be bale to develop any additional treatment plans. PIR # 2 and # 3 have comprehensive treatment plans in their charts and was in the charts by 1/31/2012.
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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 a treatment and rehabilitation plan update.
The findings include:
The facility's policy titled: "Treatment And Rehabilitation Plan," states:
"The Comprehensive Treatment plan will be completed within thirty (30) days of admission. Treatment plan updates occur every sixty (60) days thereafter."
On January 4, 2012, one client record requiring documentation of a treatment plan update was reviewed. The facility did not document a treatment plan update in one of one record reviewed, specifically, client record # 4.
Client # 4 was admitted October 3, 2011. The individual treatment and rehabilitation plan was completed on November 3, 2011 and the treatment plan update was due January 2, 2012; however, client record # 4 did not include documentation of a treatment plan update as of January 4, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 3:30 P.M. to 4:00 P.M.
This is a repeat citation. The facility was cited on November 23, 2010; June 18, 2010; February 2, 2010; July 13, 2009; December 30, 2008; September 19, 2007; April 18, 2007; and September 26, 2006 for noncompliance with this standard.
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Plan of Correction
The Facility Director will coordinate staff training with the Agency Training Manager on the completion of Comprehensive Individual Treatment& Rehabilitation Plans Updates to ensure licensing standards are met. Facility Director will implement computerized spread sheets to track completion and remind clinicians of required completion time frames based on PIR(s)enrollment dates. Ongoing chart reviews will be done on a bi-weekly basis by staff and facility director to check compliance with tracking system. The Project Director will monitor for compliance. PIR # 4 did not reengage in treatment to do an updated treatment plan was discharged from treatment for not responding to outreach efforts by 1/31/2012.
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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
Based on a review of client records, the facility failed to a document case consultation.
The findings include:
The facility's policy titled: "Case Consultation," states:
"The Case consultation gives a quarterly review of client progress by the Clinical Staff (therapist, case manager, clinical supervisor, program director). Case consultation is conducted every 90 days from the date of admission."
On January 4, 2012, five client records requiring documentation of case consultations were reviewed. The facility did not document a case consultation in three of five records reviewed, specifically, client records # 1, 4, and 5.
Client # 1 was admitted September 19, 2011. The case consultation was due December 18, 2011; however, client record # 1 did not include documentation of a case consultation as of January 4, 2012.
Client # 4 was admitted October 3, 2011. The case consultation was due January 2, 2012; however, client record # 4 did not include documentation of a case consultation as of January 4, 2012.
Client # 5 was admitted September 28, 2011. The case consultation was due December 27, 2011; however, client record # 5 did not include documentation of a case consultation as of January 4, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 3:30 P.M. to 4:00 P.M.
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Plan of Correction
The Facility Director will coordinate staff training with the Agency Training Manager on Clinical Documentation Protocol (inclusive of Case Consultations) to ensure staff have a better undertsanding of the case consultation documentation requirements. The Facility Director will implement computerized spread sheet to track completion and remind clinicians of required completion time frames based on PIR(s) enrollment dates. Ongoing chart reviews will be done on a bi-weekly basis by staff and facility director to check compliance. the Project Director will monitor to ensure compliance. Case consultations will be completed for PIR(s) #1, #4 and #5 even though they did not return to reengage in treatment after the audit. Issues will be completed by 2/29/12. |
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, the facility failed to document follow-up information in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Follow-Up," states
"Follow-up will occur on clients who successfully complete treatment within seven (7) days. Clients who are terminated due to non-compliance but referred will also receive follow-up within 7 days. Clients terminated and not referred will be followed up in 30 days."
On January 4, 2012, three client records requiring documentation of follow-up information were reviewed. The facility did not document follow-up information according to their policy and procedures in one of three records reviewed, specifically, client record # 8.
Client # 8 was admitted September 7, 2011 and was discharged October 7, 2011. The follow-up information was due November 6, 2011; however, the follow-up information was not completed until December 20, 2011.
The findings were confirmed during an ongoing dialogue with the facility director on January 4, 2012 from approximately 3:30 P.M. to 4:00 P.M.
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Plan of Correction
The Facility Director will cooridnate staff training with the Agency Training Manager on Clinical Documentation Protocol (inclusive of Follow Up Telephone & Corespondance) to ensure staff have a better knowledge of the required follow up process. The Facility Director will implement compuerized spread sheets to track completion and to remind
clinicains of required compl;etion time frames based on PIR(s) enrollment dates. Ongoing chart reviews will be done on a bi-weekly basis by staff and the facility director to check compliance with follow up. Project Director will monitor compliance. |