INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 1, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, GPHA Al-Assist Behavioral Health Care Center 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 3, 2010.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position.The findings include:Three personnel records for counselors were reviewed for qualifications on September 1, 2010. The facility failed to ensure that each counselor met the qualifications for the position. One of three records reviewed lacked documentation verifying that employee # 6 had the required had one year of clinical experience.Employee # 6 was hired June 2010 and has a Bachelor's Degree in Psychology.Employee # 6 personnel record did not include documentation of one year of clinical experience in a health or human service agency at the time of review on 9/1/10.
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Plan of Correction
Standard in Noncompliance
704.7(b)Counselor Qualifications
In effort to comply with regulation 704.7(b), the written findings from September 1, 2010 were discussed with employee #6 during a supervision session meeting. At which time employment status has been demoted to Counselor Assistant effective October 18, 2010 with the understanding that upon completion of the following specification employment status will return to Counselor III. An individual training plan was outlined to achieve counseling competencies in chemical dependency issues. The training plan includes obtaining 25 hours of alcohol and other drug specific topics. In addition, documentation of close supervision and direct observation of clinical documents such as progress note and treatment plans will continue to be completed on a weekly supervision form that briefly addresses the content of the session. The written training plan will be submitted to Facility Director for review and any revisions will be submitted within 5 days of submission. A finalized copy of written training plan will be sent to the credentialing department to be placed in employee's file. Coordinator of Behavioral Healthcare will monitor documentation of supervision sessions weekly until 25 hours are completed.
Correction time: 6/1/2011
Monitoring weekly until 25 hours are completed
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection and an interview with the Facility Director, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.The findings include:A physical plant inspection was conducted on September 1, 2010 at approximately 9:30 AM. It was observed that counseling sessions could be seen outside of the counseling rooms. An interview with the Facility Director confirmed that the counseling sessions could be seen outside of the counseling room and lacked proper window treatment.
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Plan of Correction
Standard in Noncompliance
705.23(3) Counseling or activity areas and office space:
In an effort to comply with regulation 705.23(3) the written findings from September 1, 2010 were discussed between the Facility Director and the Chief Executive Officer of the Agency. The Agency's Confidentiality Policy and Procedures supportive of standard 705.23(3) were reviewed to reiterate assurance of privacy so that counseling sessions cannot be seen or heard outside the counseling room. At which time it was determined that a letter will be submitted to the Pennsylvania Department of Health requesting a waiver for 705.23(3) with the assurance that sessions are not heard outside the counseling room and that offices will be arranged to ensure clients are not directly seen during counseling sessions. This letter will also detail past experiences that served as reasons why observation windows had been installed with added reasoning to assure the safety of our consumer and therapist.
In the event that the exception is not granted, adequate drappery will be installed to cover the glass panel within 10 business days of the noted rejection of exception.
Correction time: October 20, 2010
Monitoring on-going
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records and a review of the facilities policy and procedures manual, the facility failed to document a consent to treatment.The findings include:The facilities policy titled "Informed Consent Policy" states:Individuals seeking admission or readmission must meet the following:...Must complete all necessary consent to treatment forms and the intake process....A copy of the signed informed consent is maintained as part of the client's record.The client is offered a copy of the signed informed consent form for their personal file.Seven client records were reviewed on September 1, 2010 for documentation of consent to treatment. The facility failed to document a consent to treatment in one of seven client records reviewed, specifically, client record # 3.Client # 3 was admitted to the program on 3/1/10.The facility failed to document a signed consent to treatment and whether client # 3 accepted or denied a copy of the consent to treatment as of 9/1/10.
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Plan of Correction
Standard in Noncompliance
709.91(b)(4) Intake admission
In effort to comply with regulation 709.91(b)(4) the written findings from the September 1, 2010 were discussed with Clinical Staff during staff meeting on September 17, 2010. At which time the Clinical Coordinators reviewed the Informed Consent Policy which states "that individuals seeking admission or readmission must sign necessary consent forms, a copy of consents are maintained as part of the client record and a copy is offered to the consumer". Clinical Staff will continue to review and sign consent to treatment form with individuals seeking treatment. In addition, Clinical Coordinators are to review intake records daily to ensure compliance with standard 709.91(b)(4). Feedback will be given from these reviews to ensure Clinical Staff remain in compliance of regulation 709.91(b)(4). Clinical Staff found noncompliant of this regulation will receive additional support from the Clinical Coordinator during weekly supervision sessions. Consent forms will also be randomly audited by Medical Records Clerks to ensure compliance.
Correction time: September 17, 2010
Monitoring is on-going
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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 and a review of the facilities policy and procedures manual, the facility failed to document an individual treatment and rehabilitation plan.The findings include:The facilities policy titled "Comprehensive Treatment Planning" states:The Comprehensive Treatment plan shall be developed within 15 workdays of admission. The Physician, Clinical Supervisor, Primary Clinician, and the client must sign the plan.Seven client records were reviewed on September 1, 2010 for documentation of an individual treatment and rehabilitation plan.Five client records required documentation of an individual treatment and rehabilitation plan.The facility failed to document a treatment and rehabilitation plan in two of five records reviewed, specifically, client records #1 and 2.Client # 1 was admitted to the program on 3/19/10.A late individual treatment plan was documented on 5/10/10.Client # 2 was admitted to the program on 1/20/10.A late individual treatment plan was documented on 6/22/10; in addition the plan was not signed or dated by the client or counselor.
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Plan of Correction
Standard in Noncompliance
709.92(a) Treatment and rehabilitation services
In an effort to comply with regulation 709.92(a) the written findings from September 1, 2010 were discussed with all Clinical Staff during September 17, 2010 staff meeting. At which time the Clinical Coordinators reviewed the facilities policy and procedures on Comprehensive Treatment Planning which states "that the Comprehensive treatment plan must be completed within 15 working days of admission and must be signed by Physician, Clinical Supervisor, Primary Counselor, and Client". Clinical Staff will continue to compose a comprehensive treatment plan with client within 15 working days of admission and obtain signatures from client, Primary Counselor, Clinical Supervisor, and Physician. In addition, Clinical Coordinators are to review Counselor's records weekly to ensure compliance with standard 709.92(a). Feedback will be given from these reviews to help Clinical Staff better understand the intent of regulation 709.92(a). Clinical Staff found noncompliant of this regulation will receive additional support from the Clinical Coordinator during weekly supervision sessions. Client records will also be randomly audited by Medical Records Clerks to ensure standard 709.92(a) will be followed properly.
Correction Time: September 17, 2010
Monitoring is on-going
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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 and a review of the facilities policy and procedures manual, the facility failed to document treatment and rehabilitation plan updates at least every 60 days.The findings include:The facilities policy titled "Treatment Plan Update" states:The treatment plan update shall be developed every 60 days for outpatient substance abuse clients.Five client records were reviewed on September 1, 2010 for documentation of a treatment and rehabilitation plan update.The facility failed to document a treatment and rehabilitation plan update in two of five records reviewed, specifically, client records #1 and 4.Client # 1 was admitted to the program on 3/19/10.A comprehensive treatment plan was documented on 5/10/10.Treatment and rehabilitation plans are due every 60 days.At the time of review on 9/1/10 the facility failed to document a treatment/rehab update. Client # 4 was admitted to the program on 1/14/10.A comprehensive treatment plan was documented on 1/22/10.Treatment and rehabilitation plans are due every 60 days.At the time of review on 9/1/10 the facility documented a treatment/rehab update on 6/15/10 and 3/11/10.
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Plan of Correction
Standard in Noncompliance
709.92(b) Treatment and rehabilitation services
In an effort to comply with regulation 709.92(b) the written findings from September 1, 2010 were discussed with all Clinical Staff during September 17, 2010 staff meeting. At which time the Clinical Coordinators reviewed the facilities policy and procedures on Treatment Plan Updates which states "that the Treatment Plan Updates shall be developed every 60 days for outpatient substance abuse clients". Clinical Staff will continue to review client's progress with goals and update treatment plan every 60 days. In addition, Clinical Coordinators are to review Counselor's records weekly to ensure compliance with standard 709.92(b). Feedback will be given from these reviews to help Counselor's better understand the intent of regulation 709.92(b). Counselors found noncompliant of this regulation will receive additional support from the Clinical Coordinator during weekly supervision sessions. Client records will also be randomly audited by Medical Records Clerks to ensure standard 709.92(b) will be followed properly.
Correction Time: September 17, 2010
Monitoring is on-going
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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 and a review of the facilities policy and procedures manual, the facility failed to document a complete client record which included a case consultation note.The findings include:The facilities policy titled " Case Consultations" states:...each client's case will be discussed every 90 days while in treatment.Five client records were reviewed on September 1, 2010 for documentation of a case consultation note.The facility failed to document a case consultation note in two of five records required, specifically client records # 1 and 4.Client # 1 was admitted to the program on 3/19/10.The case consultation note is due every 90 days.The facility documented one case consult on 8/19/10 as of the date of the review on 9/1/10.Client # 4 was admitted to the program on 1/14/09.The case consultation note is due every 90 days.The facility documented one case consult on 7/15/10 as of the date the review on 9/1/10.
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Plan of Correction
Standard in Noncompliance
709.93(a)(8) Client records
Case consultation notes
In an effort to comply with regulation 709.93(a)(8) the written findings from September 1, 2010 were discussed with all Clinical Staff during September 17, 2010 staff meeting. At which time the Clinical Coordinators reviewed the facilities policy and procedures on Case Consultations which states "that each client's case will be discussed every 90 days while in treatment and documentation of clinical discussion with multi-disciplinary team will be placed in client's record". Clinical Staff will continue to document case consultation notes every 90 days. In addition, Clinical Coordinators are to review Counselor's records weekly to ensure compliance with standard 709.93(a)(8). Feedback will be given from these reviews to help Clinical Staff better understand the intent of regulation 709.93(a)(8). Clinical Staff found noncompliant of this regulation will receive additional support from the Clinical Coordinator during weekly supervision sessions. Client records will also be randomly audited by Medical Records Clerks to ensure standard 709.93(a)(8) will be followed properly.
Correction Time: September 17, 2010
Monitoring is on-going
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