INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 26-28, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Stairways Behavioral Health Outpatient Drug and Alcohol Program 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 June 1, 2010.
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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 and an interview with the project/facility director, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of three personnel records.
The findings include:
Five personnel records were reviewed on April 26, 2010. Four personnel records pertained to counselors. One personnel record required the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 4.
Employee # 4 was hired on July 11, 2007.. The facility training year is from January through December. Employee # 4 had 4.5 hours of training documented for the 2009 training year.
An interview with the project/facility director on April 27, 2010, confirmed that employee # 4 completed only 4.5 clock hours of annual training from January to December 2009.
This is a repeat deficiency from the licensing inspection conducted on March 5, 2009.
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Plan of Correction
Scheduled training hours for employee #4 for calendar year 2010 will exceed the requirement of twenty-five(25) hours of annual training. The Project Director will oversee employee #4's adherence to meeting her 2010 Trainig Plan.
The Project Director revised the Annual Assessment of Individualized Training Needs on 5/18/2010 to include external trainings that will meet the regualtion.
This will be completed by all employees in 12/2010 for the 2011 training year and annually thereafter. The Project Director will monitor the completion of the Annual ASsessment of Individualized Training Needs.
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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 and an interview with the assistant compliance officer, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in one of two personnel records.
The findings include:
Five personnel records were reviewed on April 26, 2010. Two personnel records required fire extinguisher training within 7 days of hire. The facility failed to document the completion of fire extinguisher training in personnel record # 2.
Employee # 2 was hired on February 1, 2010. Employee # 2 did not have documentation of the required fire extinguisher training.
An interview with the assistant compliance officer on April 28, 2010 confirmed the employee records did not contain documentation that the employee had received instructions in the use of the fire extinguisher upon staff employment
This is a repeat deficiency from the licensing inspection conducted on March 5, 2009.
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Plan of Correction
Employee #2 completed Fire Extinguisher trainning on 5/5/2010.
The New Hire Training Procedures have been unpdated to include the requirement of attending and successfully completing Fire Extinguisher Training within seven (7) days of hire. Oversight of this function will be the responsibility of the Project 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 and an interview with the assistant compliance officer, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in one of two personnel records.
The findings include:
Five personnel records were reviewed on April 26, 2010. Two personnel records were reviewed for ensurance that all personnel on all shifts were trained to perform assigned tasks during emergencies. The facility failed to document that all personal on all shifts were trained to perform assigned tasks during emergencies in personnel record # 2.
Employee # 2 was hired on February 1, 2010. There was no documentation provided that showed the employee had been trained to perform assigned tasks during emergencies.
An interview with the assistant compliance officer on April 28, 2010 confirmed there was no documentation that the employee had been trained to perform assigned tasks during emergencies.
This is a repeat deficiency from the licensing inspection conducted on March 5, 2009.
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Plan of Correction
Employee #2 compelted Emergecny Procedures training on 5/5/2010.
New hire training procedures have been updated to ensure that all new hires will attend and successfully complete Emergency Procedures Trainig within seven (7) days of hire. Oversight of this process will be the responsibility of the Project Director. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs and an interview with the project/facility director, the facility failed to document that alternate exit routes were used during fire drills.
The findings include:
Fire drill logs were reviewed on April 26, 2010. The fire drill logs, reviewed from April 2009 to December 2009, did not document which exits were used during the fire drills.
On April 27, 2010, the project/facility director was interviewed and confirmed that the exit routes used during fire drills were not documented.
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Plan of Correction
The Director of Agency Opperational Support Services (coordinator of all agency fire and emergency drill procedures) was notified by the Project Director of the requirements of Fire and Emergency Drills in PA Drug and Alcohol programs on 4/29/2010 n(705.28(d)(5)). A new form was created to include documentation of alternate exits used throughout the year when completing Fire and Emergency Drills.
During the May 2010 Fire Drill at the Stairways Drug and Alcohol Outpatient Clinic the exit used was documented using the new form.
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709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on the review of the policy and procedure manual, organizational chart, by laws, personal records, an interviews with the project director, compliance officer and assistant compliance officer, the facility failed to document the duties of the governing body included selecting a project director as the person officially responsible to the governing body nor that the project director performs the job duties required for the project director position.
The findings include:
The policy and procedure manual, organizational chart, by laws and personnel records were reviewed on April 26-27, 2010. Interviews with the project director, compliance officer and assistant compliance officer occurred on April 28, 2010. The policy and procedure manual did not document that the governing body selected the project director as the person officially responsible to the governing body.
The organizational chart documented that the project director reports to the chief operating officer. The chief operating officer reports to the CEO, who is a member of the board.
An interview with the project director and assistant compliance officer on April 28, 2010 confirmed that the policy and procedure manual nor by law documented that the governing body was responsible for the selection of the project director.
The compliance officer confirmed on April 28, 2010, that the Board meeting minutes did not document that the Board selected the project director as the person officially responsible to the governing body.
Personnel records were reviewed on April 27, 2010. The job description in personnel record #1 did not include all required job duties of the project director. The job description did not include the authority to execute contracts, establishing wage scales and manage fiscal matters.
An interview with the project/facility director on April 28, 2010 confirmed the job duties of the project director did not included the authority to execute contracts, establishing wage scales and manage fiscal matters.
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Plan of Correction
A new policy was created (A07.02003 Board of Directors Druga and Alcohol Program Responsibilities) that outlines the requirement for the Board of Directors of Stairways Behavioral Health to appoint the Project Director of Drug and Alcohol Programs. A Board meeting is scheduled for 5/28/2010 and included on the Agenda is the official appointment of the Project Director. |
709.22(e) 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:
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Observations
Based on a review of the 2008- 2009 annual report and an interview with the compliance officer, the governing body failed to make available to the public the 2008- 2009 annual report.
The findings include:
The 2008- 2009 annual report was reviewed on April 26, 2010. The facility is publicly funded and required to make available to the public an annual report. The 2008-2009 fiscal year ended on June 30, 2009. The governing body failed document that the 2008 - 2009 annual report was made available to the public, as required.
An interview with the compliance officer on April 26, 2010 confirmed that the 2008 - 2009 annual report was not made available to the public, as required.
This is a repeat deficiency from the licensing inspection conducted on March 5, 2009.
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Plan of Correction
A notice was made in the Erie Times News on 4/28/2010 that the Stairways Behavioral Health Annual Drug and Alcohol Report was available to the public.
In future, it is the responsibility of the Project Director to ensure that the public notice of the availiability of the Stairways Behavioral Health Durg and Alcohol Annual Report is made in a timely manner and according to regulation 709.22(e). |
709.22(e)(3) 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:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of the 2009 annual report and an interview with the project/facility director, the governing body failed to make available to the public an annual report which included a statement disclosing the names of officers, directors and principal shareholders, as required by regulation.
The findings include:
The 2009 annual report was reviewed on April 26, 2010. The facility is publicly funded and required by regulation to make available to the public an annual report which includes a statement disclosing the names of officers, directors and principal shareholders. The 2009 annual report did not include a statement disclosing the names of officers, directors and principal shareholders .
On April 27, 2010 the project/facility director was interviewed. The project/facility director confirmed that a statement disclosing the names of officers, directors and principal shareholders had not been included in the annual report.
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Plan of Correction
The Stairways Behavioral Health Drug and Alcohol Annual Report will be completed by September 15, 2010 by the Project Director and will include the names of officers, directors, and principal stakeholds of the organization. It is the responsibility of the Project Director to ensure the required information is included in the report. |
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 the review of client records, the facility failed to document an informed and voluntary consent for the disclosure of information contained in the client record was obtained from the client in 12 of 12 client records.
The findings include:
Twelve client records were reviewed on April 27-28, 2010. Consents to release information were reviewed in twelve client records. The facility did not document an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.
In client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12, the consent to release information forms documented in the client records and signed by the client, contained the statement that "the information released under this authorization is governed by Federal HIPAA guidelines. (the Health Insurance Portability and Accountability Act of 2001). Under certain circumstances, the information could potentially be re-disclosed by the person receiving the information and may no longer be subject to the privacy protection provided to me by law".
This statement exceeds 42 CFR Part II subpart C 2.32.
An interview with the project/facility director on April 27, 2010 confirmed the releases of information forms used by the facility and documented in the client records contained the above statement.
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Plan of Correction
On 4/27/2010 the electronic Release of Information for Drug and Alcohol programs was edited. The statement "the information released under this authorization is governed by Federal HIPAA guidelines. (the Health Insurance Portability and Accountability Act of 2001). Under certain circumstances, the information could potentially be re-disclosed by the person receiving the information and may no longer be subject to the privacy protection provided to me by law" was removed and was replaced by:
"I understand that information released under this authorization is governed by Federal HIPAA guidelines (the Health Insurance Portability and Accountability Act of 2001) & 42 CFR Part 2."
The use of the corrected form is to be monitored by the Project Director as well as the compliance office of Stairways Behavioral Health.
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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client records, an interview with the project/facility director and the assistant compliance officer, the facility failed to document that the clients were informed of the required rights in twelve of twelve client records.
The findings include:
Twelve client records were reviewed on April 27-28, 2010. Twelve client records were required to have documentation that the clients were informed of their rights. The facility did not document that the clients were informed of the required client rights in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.
In client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12, there was no documentation provided that showed the clients were informed of the rights in 709.30 (3) (4) (5) and (6).
709.30. Client rights.
(3) A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
709.30. Client rights.
(5) The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
709.30. Client rights.
(6) The client has the right to submit rebuttal data or memoranda to his own records.
The interviews with the project/facility director and assistant compliance officer on April 28, 2010 confirmed there was no documentation in the client record that the clients had been informed of their rights, nor were the client rights posted within the facility.
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Plan of Correction
The Program Handbook was updated by the Assistant Compliance Officer of Stairways Behavioral Health to comply with 709.30 (3), (4), (5), and (6) regarding client rights and notification to client's of their rights, on 4/27/2010. Client's sign for receipt of the Program Handbook at intake and are informed of their rights during their initial intake appointment by the client's drug and alcohol therapist.
The Program Director posted the client rights in the waiting room on 5/24/10 with notice of changes made for current clients to be made aware of them. |
709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
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Observations
Based on the review of the policy and procedures manual and an interview with the project/facility director, the facility failed to document a policy that stated that the project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client.
The findings include:
The policy and procedure manual was reviewed on April 26, 2010. The policy documented that the facility director may temporarily remove portions of the records prior to the inspection by the client if the facility director determines that the information may be detrimental if presented to the client.
An interview with the project/facility director on April 27, 2010 confirmed the policy and procedures manual stated that the facility director may temporarily remove portions of the records prior to the inspection by the client if the facility director determines that the information may be detrimental if presented to the client in.
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Plan of Correction
On 4/26/2010, policy # A09.04007 Clinical Records - Access to Client Records by Staff and Clients, was updated by the Assistant Compliance Officer/Policy and Prcedure Commitee Chairperson to include the following information:
C. A DRUG AND ALCOHOL CLIENT may
access his/her CLINICAL
RECORDS that have been
generated by Stairways through
the following procedure:
1. A written or verbal
request must be
submitted/made to the
Project Director.
a. The Project Director
may temporarily remove
portions of the
records prior to the
inspection by the
client if the Director
determines that the
information may be
detrimental if
presented to the
client.
b. Reasons for removing
sections shall be
documented and kept on
file.
c. The client has the
right to appeal a
decision limiting
access to his/her
records to the Project
Director.
d. The client has the
right to request the
correction of
inaccurate,
irrelevant, outdated
or incomplete
information from
his/her records.
e. The client has the
right to submit
rebuttal data or
memoranda to his own
records.
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709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on the review of the policy and procedures manual and an interview with the project/facility director, the facility failed to document a policy that stated the client had a right to appeal a decision limiting access to his records to the project director.
The findings include:
The policy and procedures manual was reviewed on April 26, 2010. The policy stated that the client had the right to appeal a decision limiting access to his records to the facility director.
An interview with the project/facility director on April 27, 2010 confirmed the policy and procedures manual stated that the client had the right to appeal a decision limiting access to his records to the facility director
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Plan of Correction
On 4/26/2010, policy # A09.04007 Clinical Records - Access to Client Records by Staff and Clients, was updated by the Assistant Compliance Officer/Policy and Prcedure Commitee Chairperson to include the following information: C. A DRUG AND ALCOHOL CLIENT may access his/her CLINICAL RECORDS that have been generated by Stairways through the following procedure: 1. A written or verbal request must be submitted/made to the Project Director. a. The Project Director may temporarily remove portions of the records prior to the inspection by the client if the Director determines that the information may be detrimental if presented to the client. b. Reasons for removing sections shall be documented and kept on file. c. The client has the right to appeal a decision limiting access to his/her records to the Project Director. d. The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his/her records. e. The client has the right to submit rebuttal data or memoranda to his own records. |
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 the review of client records, the facility failed to document an individual treatment and rehabilitation plan was developed with a client, per policy, in eight of twelve client records.
The findings include:
Twelve client records were reviewed on April 27-28, 2010. Twelve were required to have an individual treatment and rehabilitation plan shall be developed with a client. Policy states the treatment and rehabilitation plan shall be developed by the third individual session. The facility did not document that the treatment and rehabilitation plan was completed by the third individual session in client records # 1, 5, 6, 8, 9, 10, 11 and 12.
Client #1 was admitted on February 2, 2010. The third individual session occurred on March 3, 2010. The treatment plan was completed on March 31, 2010.
Client #5 was admitted on January 18, 2010. The third individual session occurred on February 3, 2010. The treatment plan was completed on February 12, 2010.
Client #6 was admitted on January 21, 2010. The third individual session occurred on February 8, 2010. The treatment plan was completed on February 17, 2010.
Client #8 was admitted on March 8, 2010. The third individual session occurred on March 25, 2010. The treatment plan was completed on April 13, 2010.
Client #9 was admitted on December 6, 2009. The third individual session occurred on December 22, 2009. The treatment plan was completed on January 13, 2010.
Client #10 was admitted on November 25, 2009. The third individual session occurred on December 23, 2009. The treatment plan was completed on January 6, 2010.
Client #11 was admitted on January 26, 2010. The third individual session occurred on February 8, 2010. The treatment plan was completed on March 1, 2010.
Client #12 was admitted on November 25, 2009. The third individual session occurred on January 6, 2010. The treatment plan was completed on January 24, 2010.
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Plan of Correction
Prior to the April 2010 inspection of the Stairways Behavioral Health Drug and Alcohol Outpatient Clinic,the policy regarding Treatment Plan completion stated that the Treatment Plan will be completed no later than the third (3rd) individual appointment with the Drug and Alcohol Outpatient Clinic. On 4/28/2010, the Assistant Complaince Officer/Policy and Procedure Committee Chairperson updated policy #O00.72002 SBH Outpatient Drug and Alcohol Program to include the following: "Typically, the full intake/assessment process will be completed in one to three one-hour individual appointment sessions. These sessions will focus on gathering the required data needed to complete the individualized treatment plan and bio-psycho-social evaluation. The Treatment Plan will be completed during the fourth (4th) Individual Appointment." It is the resopnsibility of the Project Director to ensure that all Individualized Treatment Plans are completed no later than the fourth (4th) individual session with the Drug and Alcohol Outpatient Clinic. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of client records and an interview with he project/facility director, the facility failed to document an individual treatment and rehabilitation plan that identified short and long-term goals for treatment as formulated by both staff and client in twelve of twelve client records.
The finding include:
Twelve client records were reviewed on April 27-28, 2010. Twelve client records were required to have an individual treatment and rehabilitation plan that identified short and long-term goals for treatment. The facility did not document short and long term goals for treatment in client records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.
In client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12 the treatment and rehabilitation plan did not identify the goals developed with the client as short or long term goals.
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Plan of Correction
A training is scheduled for 6/3/2010 to be co-facilitated by the Project Director and Assistant Compliance Director to review treatment planning. Content of the training will be: writing detailed Problem Statements; creating long- and short-term goals; creating behavioral, measurable and attainable objectives; and including staff interventions. This is a mandatory training and will be atteded by all Drug and Alcohol Outpatient Clinic program clinical staff.
It is the combined responsibility of the Project Director and Assistant Complaince Officer to review and monitor Treatment Plans to ensure compliance with 709.92(a)(1) |
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 the review of cleint records and an interview with the project/facility director and assisitant compliance officer, the facility failed to document follow up information per policy, in three of four client records.
The findings include:
Twelve client records were reviewed on April 27-28, 2010. Four client records reviewed were required to have follow up information. The policy states that for both referred and non referred clients, follow up is to occur within 7 days. The facility did not document follow up in client records # 9, 11 and 12.
Client # 9 was admitted on December 6, 2009 and discharged on February 25, 2010. Follow up was due April 4, 2010. There was no documentation that follow up had been completed.
Client # 11 was admitted on and discharged January 26, 2010 and dischrged on March 23, 2010. Follow up was due March 30, 2010. There was no documentation that follow up had been completed.
Client # 12 was admitted on November 4, 2009 and discharged on February 18, 2010. Follow up was due Febuary 25, 2010. There was no documentation that follow up had been completed.
This was confirmed by the project/facility director and the assisitant compliance officer.
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Plan of Correction
At the Drug and Alcohol Outpatient Clinic General Staff meeting facilitated by the Project Director and attended by all program staff, a notice was made regarding the requirements of 709.93(a)(11). Program staff were informed of their responsibility to make appropriate follow-up communication with disharged clients. Oversight of client follow-up will be the responsibility of the Project Director. |