INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 4, 2012 licensure renewal inspection. The follow-up inspection was conducted on June 22, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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704.11(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 in two of two personnel records.
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.
This was still out of compliance at the time of the follow-up conducted on June 22, 2012.
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Plan of Correction
The Facility Director consulted with the agency Training Manager and outlined trainings that the staff will be enrolled in through out the year ending December 2012.
Staff have been engaged in trainings that have been conducted on site and off site to meet complaince standards.
The Facility Director will ensure that each clinician will complete at least 25 hours of required training time annually.
Project Director and Facility Director will continue to monitor for compliance. |
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 and whether the fire alarm or smoke detector was operative.
The findings include:
Fire drill records were reviewed on January 22, 2012. The records were reviewed from the period covering March 2012 to May 2012. The facility did not have documentation for the exit route used at the time of the drill and whether the fire alarm or smoke detector was operative in one of three months reviewed, specifically, May 31, 2012.
The findings were confirmed during an interview with the quality assurance manager on June 22, 2012 at approximately 12:30 P.M.
This is a repeat citation. The facility was cited on January 4, 2012 for noncompliance with this standard.
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Plan of Correction
The facility Director discussed and reviewed the corrected fire drill logs (redone for May 31, 2012 and completed for June 28, 2012)that indicated the date of the fire drills, time of the fir drills, the amount of time the fire drills took for evacuation,the exit routes used, the number of individuals that were in the facility at the time of the drill, noted any problems that may or may not were encountered and whether the fire alarms or smoke detectors or sprinklers were operative. The fire drill logs were submitted by the Captain of Security. The facility director will continue to review the completed fire drills logs to be submitted after every fire drill to ensure compliance standards are met. The Quality Assurance Management Director will also check the fire drill logs quarterly to ensure ongoing compliance. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill records, the facility failed to provide documentation that they set off a fire alarm or smoke detector during each fire drill.
The findings include:
Fire drill records were reviewed on June 22, 2012. The records were reviewed from the period covering March 2012 to May 2012. The facility did not have documentation that they set off a fire alarm or smoke detector in one of three months reviewed, specifically, May 31, 2012.
The findings were confirmed during an interview with the quality assurance manager on June 22, 2012 at approximately 12:30 P.M.
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Plan of Correction
The Facility Director reviewed the corrected fire drill logs forms submitted by the Captain of Security and the forms specified the source of activation that was used during the fire drills completed on May 31, 2012 (that form was redone)and the fire drill log submitted for the one conducted on June 28, 2012. The forms checked whether the smoke box, sprinkler system or pull box was used. The Facility Director will continue to review all fire drill logs submitted upon completion and the Quality Assurance Managment Director will continue to monitor fire drill logs quarterly to ensure complaince standards are met. |
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 that included an assessment of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
The findings include:
The facility's policy titled: "Comprehensive Bio-Psychosocial Evaluation," states:
"The Assessment & Evaluation Center's Master Level Therapist will initiate the evaluation (Part A) and or Psychologist/Psychiatrist will finalize the evaluation (Part B) or complete the entire biopsychosocial evaluation (Part A & B) within 45 days following the person in recovery admission and registration process."
On June 22, 2012, three client records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment in three of three records reviewed, specifically, client records # 6, 7, and 8.
Client # 6 was admitted April 10, 2012. The psychosocial evaluation was completed on May 26, 2012 but did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
Client # 7 was admitted March 15, 2012. The psychosocial evaluation was completed on March 1, 2012 but did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
Client # 8 was admitted March 27, 2012. The psychosocial evaluation was completed on March 9, 2012 but did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
The findings were confirmed during an interview with the facility director on June 22, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on January 4, 2012 for noncompliance with this standard.
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Plan of Correction
The Facility Director consulted with the Quality Assurance Management Director and proposed prompts to be included in the revised "CBE(s)" to specify that comprehensive assessments elaborate on any gambling issues, the PIR(s)' assets/strengths, support systems identified by the PIR(s), coping mechanisms and emphasize the PIR(s)' attitudes towards treatment. The Director of the Assessment Dept. will provide traning on site to all the evaluators to ensure the prompts are used to provide descriptive assessments. The revised CBE(s) will be presented before the clinical Review Committee in August 2012 for approval and utilization. The Facility Director will continue to monitor the completed CBE(s) to ensure compliance standards are met. The Projcet Director will monitor ongoing compliance. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan.
The findings include:
On June 22, 2012, eight records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plan were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in six of eight records reviewed, specifically, client records # 1, 2, 6, 7, 8, and 9.
Client # 1 was admitted February 15, 2012. The individual treatment and rehabilitation plan was completed on March 19, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of June 22, 2012.
Client # 2 was admitted February 23, 2012. The individual treatment and rehabilitation plan was completed on March 20, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of June 22, 2012.
Client # 6 was admitted April 10, 2012. The individual treatment and rehabilitation plan was completed on May 10, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of June 22, 2012.
Client # 7 was admitted March 15, 2012. The individual treatment and rehabilitation plan was completed on April 27, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of June 22, 2012.
Client # 8 was admitted March 27, 2012. The individual treatment and rehabilitation plan was completed on April 9, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of June 22, 2012.
Client # 9 was admitted April 3, 2012. The individual treatment and rehabilitation plan was completed on May 3, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of June 22, 2012.
The findings were confirmed during an interview with the facility director on June 22, 2012 at approximately 3:00 P.M.
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Plan of Correction
The Facility Director will coordinate a staff training inservice to outline how to document specific support services identified by the PIR(s)inclusive of faith based support, community based support services,family support systems, academic guidance support or mentoring support to be highlighted with the frequency in the PIR(s)' individual treatment plans. The Facility Director will continue to conduct bi-weekly chart reviews and monitor monthly peer chart reviews to ensure complaince standards are met. Corrected treatment plans will be placed in the PIR charts by 9/07/12. The Q & A review team will randomly review charts to communicate progress or issues with clinicians meeting complaince standards. The Project Director will continue to monitor ongoing compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a treatment and rehabilitation plan update or document a treatment and rehabilitation plan update in accordance with their policy and procedures two of five client records.
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 June 22, 2012, five client records requiring documentation of a treatment plan update were reviewed. The facility did not document a treatment plan update in two of five records reviewed, specifically, client records # 1 and 3. The facility also did not document a treatment and rehabilitation plan update according to their policy and procedures in one of five records reviewed, specifically, client record # 4.
Client # 1 was admitted February 15, 2012. The individual treatment and rehabilitation plan was completed on March 19, 2012 and the treatment plan update was due May 18, 2012; however, client record # 1 did not include documentation of a treatment plan update as of June 22, 2012.
Client # 3 was admitted February 9, 2012. The individual treatment and rehabilitation plan was completed on March 1, 2012 and the treatment plan update was due April 30, 2012; however, client record # 3 did not include documentation of a treatment plan update as of June 22, 2012.
Client # 4 was admitted February 22, 2012. The individual treatment and rehabilitation plan was completed on March 22, 2012 and the treatment plan update was due May 21, 2012. However, the treatment plan update was not completed until May 30, 2012.
The findings were confirmed during an interview with the facility director on June 22, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on January 4, 2012 for noncompliance with this standard.
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Plan of Correction
The Facility Director will coordinate a staff inservice training on the clinical expecations of reviewing progress with PIR in meeting their treatment goals outlined on the treatment plans and to monitor review dates. The Facility Director will implement a tracking system on a Supervisor's Spreadsheet to track completion by sending reminders to the assigned clinicians prior to actual review dates when the spreadsheets are reviewed or updated weekly. Ongoing bi-weekly chart reviews will continue to be done by the Facility Director and monthly peer chart reviews will be monitored to ensure compliance standards are met.The Q&A review team will do random chart reviews to comunicate progress or issues to the assigned clinicians & Facility Director. The Project Director will monitor for ongoing compliance. The missing treatment plan updates will be completed and filed in the charts by 9/07/12. |
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 a case consultation in accordance with their policy and procedures in one of four client records or document a case consultation in two other client records.
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 June 22, 2012, four client records requiring documentation of case consultations were reviewed. The facility did not document a case consultation according to their policy and procedures in one of four records reviewed, specifically, client record # 1. The facility also did not document a case consultation in two of three records reviewed, specifically, client records # 3 and 4.
Client # 1 was admitted February 15, 2012. The case consultation was due May 15, 2012. However, the case consultation was not completed until May 24, 2012.
Client # 3 was admitted February 9, 2012. The case consultation was due May 9, 2012; however, client record # 3 did not include documentation of a case consultation as of June 22, 2012.
Client # 4 was admitted February 22, 2012. The case consultation was due May 22, 2012; however, client record # 4 did not include documentation of a case consultation as of June 22, 2012.
The findings were confirmed during an interview with the facility director on June 22, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on January 4, 2012 for noncompliance with this standard.
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Plan of Correction
The Facility Director will coordinate an inservice training to the clinical staff on the completion of case consultations with PIR involvement and/or support involvement and clinical prompts during the PIR(s) individual therapy sessions. The Facility Director will also include case consulations on the Supervisor Tracking Spreadsheet to track completion and to send reminder prior to the actual dates to prompt clinicians to initiate preparations & completions. The Facility Director will continue to complete bi-weekly chart reviews and will monitor peer chart reviews to be conducted monthly to ensure compliance standards are being met.The Q&A review team will continue to do random chart reviews to communiacte any progress or issues to the staff. The Project Director will monitor for ongoing compliance. The case consulations that were missing will be completed and filed in the specified PIR(s) charts by 9/07/12. |