INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16 and 17, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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 January 15, 2010.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of personnel records, the facility failed ensure that a employees promoted to the clinical supervisor position had a least two years of experience of clinical supervisory experience or attended the Department of Health approved core curriculum training for supervisors for one of two employees reviewed.
The finding includes:
Ten personnel records were reviewed on December 15, 2009. Core curriculum training in clinical supervision was required in one of two clinical supervisors' personnel records.
Employee #9 was hired on December 9, 2002 and, prior to being promoted to clinical supervisor on January 23, 2008, did not have the required two years supervisory experience or the core curriculum training. As of December 15, 2009, there was no documentation of the core curriculum training in the employee's personnel record.
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Plan of Correction
The Program Director and D& A training coordinator will ensure that the present clinical supervisor is enrolled in the next available clinical supervisor training course. The program director will ensure any new hire for the position of clinical supervisor or counselor promoted to lead counselor who has not functioned for 2 years as supervisors has the required core curriculum training in clinical supervision within the first year of employment.
The program should be in full compliance of regulation 704.6(c) by 3/15/10.
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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 the review of personnel records, the facility failed to document individual training plans in four of ten employee records within the time frames stipulated in the facility policy and procedure.
The finding includes:
Ten personnel records were reviewed on December 15, 2009. Individual training plans were required in all ten personnel records reviewed. Per the facilities policy and procedures; policy number 740.005; reviewed on December 14, 2009 & December 15, 2009, individual training plans are to be completed at the end of the facility's training year after documentation of the assessment of staff training needs. An interview was conducted with the Assistant Program Director on December 16, 2009. The Assistant Program Director confirmed that the individual training plans were to be documented by the end of the facility's training year, after the assessment of staff training needs was documented. The facility's fiscal year begins on July 1 of each year and ends June 30 of the following year. Individual training plans are to be documented prior to the beginning of the new training year.
Employee #1 was hired prior to the facility's current training year of July 1, 2009 to June 30, 2010. The individual training plan was not completed until August 20, 2009.
Employee #2 was hired prior to the facility's current training year of July 1, 2009 to June 30, 2010. The individual training plan was not completed until September 9, 2009.
Employee #3 was hired prior to the facility's current training year of July 1, 2009 to June 30, 2010. The individual training plan was not completed until July 15, 2009.
Employee #4 was hired prior to the facility's current training year of July 1, 2009 to June 30, 2010. The individual training plan was not completed until November 24, 2009.
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Plan of Correction
The Program Director will provide oversight with compliance to regulation 704.11(b)(1) by working with the NHS Program Evaluation Unit and Training Coordinator to review and update the program policy and procedure manual to reflect that the staff needs assessment survey will be completed by September 1 annually no later than 2/28/10.
The Program Director will then use the Microsoft Calendar Outlook Feature to post and follow-up on reminders of the staff needs assessment survey deadline. These dates will be marked as 7/1/10 and 8/1/10.
The program will be in
full compliance of regulation 704.11(b)(1) b by 9/1/10.
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704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on the review of personnel records, the facility failed to ensure that staff obtained the required six hours of training for HIV/AIDS.
The finding includes:
Ten personnel records were reviewed on December 15, 2009. HIV/AIDs and TB/STD trainings was required in all personnel records reviewed.
Employee #1 was hired on 7/15/08 and was required to obtain HIV/AIDS and TB/STD training within 1 year of the date of hire. As of 12/15/09 there was no documentation in the personnel or training record for employee #1 of the 6 hours of HIV/AIDS training.
Employee #7 was hired on 3/12/08 and was required to obtain HIV/AIDS and TB/STD within 1 year of the date of hire. As of 12/15/09 there was no documentation of HIV/AIDS training in the personnel record of employee #7.
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Plan of Correction
The Program Director will provide oversight with compliance to regulation 704.11(c)(3) & (4) by working with the NHS Training Coordinator to schedule all current employees that have not received the required HIV/AIDS trainings to attend the next available state mandated basic HIV/AIDS training session through the Behavioral Health Training & Education Network (BHTEN).
Program Director will monitor the training requriment of all new hires to ensure that they are scheduled to receive the requried HIV/AIDs and TB/STD trainings with in the first year via follow up with the clinincal supervisor during weekly supervision.
The program should be in full compliance of regulation 704.11(c) (3) & 4) by 6/30/10. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection, the facility failed to ensure that portable heaters were not permitted within the facility.
The finding includes:
The physical plant tour took place on December 21, 2009 at around 11:00 AM. During the physical plant inspection, a portable heater was found around 11:05 AM in a therapist's office, Room 219. An interview with the Facility Director was conducted on December 21, 2009. The facility director confirmed that the facility was not aware that the portable heater was in the therapist's office.
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Plan of Correction
After the completion of the interview on 12/21/09 the Program Director located the portable heater in room 219 and removed it from the building.
Moving forward the Program Director will provide oversight with compliance of regulation 705.26 (2) by reviewing this standard with staff during weekly staff meeting on 1/25/10.
Program Director and /or Clinical Supervisor will then conduct monthly inspection of the facility in order to locate and remove any portable heaters that may have been brought into the building by staff members. Violators will be subject to the appropriate corrective actions.
The program should be in full compliance of regulation 705.26 (2) by 2/28/10.
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709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on the review of the facility's annual report, the facility failed to ensure that the annual report included documentation of a financial statement of income and expenses.
The findings include:
An interview was conducted with the Project Director on December 15, 2009. The Project Director confirmed that the annual report for the fiscal year July 1, 2008 through June 30, 2009 did not include documentation of the financial statement of income and expenses.
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Plan of Correction
NHS Human Services will make unaudited financial reports specific to Parkside Reccovery,Germantown in future annual inspections. These reports will show income and expenses for the annual year.
The project Drirector will ensure that NHS will continue to also audited statements available.
The program should be in full compliance of regulation 709.22(e)(2) by 2/29/10.
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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 completely document psychosocial evaluations in nine out of nineteen client records.
The findings included:
Nineteen client records were reviewed on 12/21/09. Psychosocial evaluations were required in nineteen records. Per facility policy, psychosocial evaluations are to be completed within thirty days of admission. Client records # 6, 10, 13 did not include documentation of psychosocial evaluations.
Client #6 was admitted on 2/4/09. The psychosocial evaluation was to be completed by 3/4/09. There was no documentation of a psychosocial evaluation as of 12/21/09.
Client #10 was admitted on 6/22/09. The psychosocial evaluation was to be completed by 7/22/09. There was no documentation of a psychosocial evaluation as of 12/21/09.
Client #13 was admitted on 4/5/09. The psychosocial evaluation was to be completed by 5/5/09. There was no documentation of a psychosocial evaluation as of 12/21/09.
In addition, client records #2, 3, 4, 5, 7, 8 and 16 were reviewed for the client's psychosocial evaluations. The facility failed to document psychosocial evaluations that were evaluative and failed to include all components as per the facility's policy and procedure in seven of nineteen records reviewed.
The psychosocial evaluation in client record # 2 failed to include an evaluation of the client's problem/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and the counselor's conclusions and impressions.
The psychosocial evaluation in client record #3 failed to include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and the counselor's conclusions and impressions.
The psychosocial evaluation in client record #4 failed to include an evaluation of the client's problem/needs, assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
The psychosocial evaluation in client record #5 failed to include an evaluation of the client's coping mechanisms, negative factors, attitude toward treatment and the counselor's conclusions/impressions.
The psychosocial evaluation in client record #7 failed to include an evaluation of the client's assets/strengths, coping mechanisms, negative factors and attitude toward treatment.
The psychosocial evaluation in client record #8 failed to include an evaluation of the client's assets/strengths, support systems, attitude toward treatment and the counselor's conclusions/impressions.
The psychosocial evaluation in client record #16 failed to include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, and the counselor's conclusions and impressions.
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Plan of Correction
The Program Director will provide oversight with compliance of regulation 709.91(b) (6) by working with the NHS Training Coordinator and the Clinical Supervisor to provide staff with a clinical documentation training on 2/22/10 covering the essential elements needed to document and complete the psychosocial evaluation with special emphasis on assets/strengths, support systems, coping mechanisms, negative factors, and the counselor's conclusions and impressions.
The Clinical Supervisor will be responsible for reviewing the patient record to confirm that the psychosocial evaluation was completed within the required timeframe and contain essential elements needed to document and complete the psychosocial evaluation before placing it into the patient record.
The program will be in full compliance of regulation 709.91(b) (6) by 2/28/10.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records the facility failed to document completed aftercare plans in two of three client records.
The findings include:
Three client records were reviewed for aftercare plans. Client records # 9 and 13 did not contain completed aftercare plans.
The aftercare plan in client record #9 did not include goals with time frames.
Client record #13 did not contain an aftercare plan.
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Plan of Correction
The Program Director will provide oversight with compliance of regulation 709.93(a)(9)by working with the NHS Training Coordinator and the Clinical Supervisor to provide staff with a clinical documentation training on 2/22/10 that will cover the essential elements needed to complete an aftercare plan for the patient record.
The Clinical Supervisor will utilize the weekly counselor supervision session to review, correct, and document the completion of the aftercare plan in the client record over the next 12 months.
The Program Director will work with the NHS Program Evaluation Unit on a monthly basis to conduct audits of the client records in order to evaluate the programs compliance to regulation
The program will be in full compliance of regulation 709.93(a)(9)by 2/28/10.
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