INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 4-7, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Trehab 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(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 40 clock hours of annual training required for counselor assistants during the first year of employment in one of one counselor assistant's personnel record reviewed.
The findings included:
The personnel record of employee #4, a counselor assistant was reviewed on February 5, 2013. Employee #4 was a counselor assistant hire on 7/1/11 and would have been required to complete 40 hours training during the July 2011 - June 30 , 2012 training year. who The facility failed to document the completion of 40 clock hours of annual training in personnel record # 4. The facility was only able to provide documentation of 31.75 hours of annual training for Employee # 4.
The Clinical Supervisor confirmed the findings.
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Plan of Correction
Counselor assistant's failure to complete 40 clock hours of training for fiscal/training year July 1, 2011 -June 30, 2012 was an oversight of project compliance by Clinical Supervisor. Clinical Supervisor discussed the regulation with licensing agent at the time of inspection as well as Trehab's Project Manager/Executive Director and Lead Counselor upon completion of the inspection. It was determined that Clinical Supervisor would put the following activities in place to more effectively track employee #4 annual training hours: Counselor Assistant was made aware of the oversight by Clinical Supervisor and Lead Counselor, who is Counselor Assistant's direct task supervisor. Counselor Assistant was given a copy of the regulation and the regulation was explained in full. Clinical Supervisor added "training hours tracking" to Counselor Assistant's weekly supervision form/agenda making this a focus area to allow greater real time tracking of training hours and time to address a lack of hours if Counselor Assistant becomes off target. Clinical Supervisor requested Lead Counselor support Counselor Assistant with carrying out his training plan developed at the beginning of the fiscal/training year. Finally, Clinical Supervisor and Lead Counselor will provide 8-12 hours of in-house training for the remaining four months of the fiscal/training year to assist Counselor Assistant, as well as other staff, with completion of required trainings. |
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 the fire drill logs, the facility failed to maintain a written fire drill log that include the exit route used, problems encountered, the time of the drill, and/or the amount of time it took for evacuation
The findings include:
The fire drill logs from February 2012-January 2013 were reviewed on February 4, 2013.
The facility failed to include the exit route used, problems encountered, the time of the drill, and the amount of time it took for evacuation on the log for 2/14/12. The facility failed to document the exit route used, the time of the drill, and the length of the drill for the fire drills conducted on 3/27/12 and 4/18/12. The facility failed to complete the time of the drill on the log for 5/18/12.
The Clinical Supervisor confirmed the findings.
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Plan of Correction
After reviewing the deficiency with Project Manager/Executive Director, Clinical Supervisor has addressed the program's incomplete fire drill logs in the following manner:
1. The oversight as well as the licensing regulation was reviewed with all clinical staff (counselors)who conduct fire drills
2. Clinical Supervisor introduced a new fire drill log. This updated log provided separate areas/lines for date and time of drills at the top of the form to ensure both were provided. Previous log had combined the date and time on one line.
3. The exit route area of the log was reviewed; it was impressed upon clinical staff the importance of filling out log entirely.
4. Clinical Supervisor will review logs monthly during supervision meetings at both sites to ensure staff are following procedures and filling out forms completely.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records and administrative policy and procedures, the facility failed to complete a preliminary treatment and rehabilitation plan as per facility policy, in one of one client record.
The findings include:
Facility policy labeled "Treatment Plan" states: A Preliminary Treatment Plan or a Comprehensive Treatment Plan is developed jointly by the evaluating counselor and the client during the initial assessment/evaluation meeting and is the basis of the course of treatment. Procedure states that if a client is to be evaluated over 2 separate appointments, he/she will be provided with a Preliminary Treatment Plan after the first evaluative appointment.
One client record requiring documentation of a Preliminary Treatment Plan was reviewed on February 5, 2013. The facility failed to complete a Preliminary Treatment Plan at admission, as per agency policy, in one of one client records, specifically client record # 3.
Client # 3 was admitted into treatment on 6/29/12 and was still an active client at the time of the inspection. The Comprehensive Treatment Plan for this client was completed on 7/5/12, therefore, the assessment took more than 2 days. The facility failed to provide documentation of a Preliminary Treatment Plan for this client, as per policy, the Preliminary Treatment Plan should have been developed at the conclusion of the first appointment.
The Clinical Supervisor confirmed the findings.
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Plan of Correction
Project Manager/Executive Director and Clinical Supervisor discussed the oversight of documentation as observed by licensing agent on 2/5/13 regarding treatment planning policy. In response to the failure of staff to complete a preliminary treatment plan as outlined in facility policy, the following activities were implemented as a plan of correction: Project Manager/Executive Director reviewed the written policy with Clinical Supervisor and discussed any barriers/problems with the policy as stated. Once it was clarified this was a sound, effective and workable policy meeting standards and regulations for quality of care, Clinical Supervisor was instructed to review this policy with clinical staff. Over the course of two different meetings, Clinical Supervisor completed this task and it was determined clinical staff had an understanding of the policy and was consistently following this policy when a client is evaluated over 2 separate appointments(consistency was supported by pulling and reviewing 4 charts that fall into this category). To ensure compliance with policy and to address instances of oversight, Clinical Supervisor will review this policy quarterly with clinical staff. |