INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 21, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System IOP-Cap 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 29, 2009.
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Plan of Correction
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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 comply with their policy and procedures in the completion of their training plans in three of four personnel records reviewed.
The findings include:
Four personnel records were reviewed on September 17, 2009. Training plans were documented late in three of the four personnel records where required. In accordance with the facility's policy and procedure, training plans will be developed by June 30 of each year.
Records #2, 3 and 4 were documented late.
Employee #2's training plan was completed on 9/3/09.
Employee #3's training plan was completed on 9/8/09.
Employee #4's training plan was completed on 9/3/09.
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Plan of Correction
Individual Training Plans for all the IOP/CAP staff will be developed by June 30 for each year. The Clinical Supervisor will ensure this process by reviewing the Staff Credential Charts by June 14 every year. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review personnel record, the facility failed to ensure that all staff was trained for 6 hours in HIV/AIDS and at least 4 hours of TB/STD training in the required amount of time in one of four records reviewed.
Findings:
Four personnel records were reviewed on September 17, 2009.
Employee # 4, a counselor, was hired September 12, 2008 and was required to have HIV/AIDS & TB/STD training by September 12, 2009; as of September 17, 2009 there was no documentation in that employee #4 had completed the required six hours of HIV/AIDS training.
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Plan of Correction
The counselor that was hired on 09-12-08 will be trained on HIV and TB/STD by 12/01/09. The Clinical Supervisor will ensure that the counselor is scheduled and attends the needed trainings by 12/01/09. The Clinical Supervisor will conduct Credential Charts Inspections every six months to ensure that every recently hired staff in IOP/CAP has the necessary general trainings. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure and document that the Facility Director completed at least 12 hours of training for the training year 2008.
Findings:
Four personnel records were reviewed on September 17, 2009. Twelve hours of annual training was required to be documented in two of the four records reviewed (#1 Project Director and #2 Facility Director).
The facility only documented seven hours of annual training for the 2008 training year in personnel record #2.
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Plan of Correction
Begining 11/01/09 The IOP/CAP Facility Director will be schedule to trainings to meet the necessary training hours, 25 hours. The Clinical Supervisor will conduct credential charts inspections every six months to ensure that each the Facility Director meets the necessary training hours by June 30 of every year. |
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 and document that counselors completed at least 25 hours of training for the 2008 training year.
Findings:
Four personnel records were reviewed on September 17, 2009. Twenty-five hours of annual training was required in two counselor's personnel records (employees #3 and 4).
Employee #3 only had 15.5 documented hours of training for the 2008 training year.
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Plan of Correction
The IOP/CAP staff will be schedule to trainings to meet the necessary training hours, 25 for counselors and clinical supervisor, and 16 hours for clerical staff and volunteer. The Clinical Supervisor will conduct credential charts inspections every six months to ensure that each IOP/CAP staff member meet the necessary training hours by June 30 of every year. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. 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 complete psychosocial evaluations in four of eight client records.
Findings:
Eight client records were reviewed on September 22, 2009. Psychosocial evaluations were required in eight client records. The counselors did not document a clinical evaluation and assessment in client records #2, 4, 5 and 7.
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Plan of Correction
IOP/CAP counselors will complete a clinical evaluation/assessment on every new and re-admitted client within 30 days of his/her admission. The Clinical Supervisor will ensure that this process takes place by inspecting every new client's chart within the month of that client's admission. |
711.93(a)(4) LICENSURE Progress Notes
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(4) Progress notes.
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Observations
Based on the review of client records, the facility failed to document the therapist's assessment of the individual client in the group session progress notes for seven of eight client records.
Findings:
Eight client records were reviewed on September 22, 2009. Group progress notes were required in eight client records. The facility did not have documentation of the therapist's assessment of the client in group notes in client records #1, 2, 3, 4, 5, 6 and 8.
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Plan of Correction
IOP/CAP counselors will be training on 10-22-09 on progress note documentation. IOP/CAP counselors will provide an assessment of the client's involvement of each client during the group session. This assessment will be written in the group progress note. The Clinical Supervisor will conduct weekly progress notes review to ensure that this process is taking place. By 10-26-09, any progress note that does not comply with the requirement will be returned to the counselor for correction. |