INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 21 and 22, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, McP/Caring Together 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 May 19, 2008.
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records on April 21, 2008, the facility failed to document that one counselor met the qualifications for the position of counselor, #5.
|
Plan of Correction
The counselor cited is a Master's candidate intern carrying a two client caseload who should have been designated a counselor assistant. In the future, any Master's degree candidates who intern and provide client treatment will be designated by the program manager as counselor assistants and program will ensure all appropriate protocol for same will be followed. |
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.
|
Observations
Based on a review of training records on April 21, 2008, the facility failed to document 12 training hours for the 2006/2007 training year for one of two records reviewed, #2.
|
Plan of Correction
Going forward, program manager will ensure that the project director (program manager) and facility director receive the requisite 12 hours of training during each training year (July 1 - June 30). PM will review status of staff training hours on a monthly basis to monitor progress and ensure compliance. |
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.
|
Observations
Based on the physical plant inspection on April 21, 2008, the facility had a space heater in the large group room next to the children's play room.
|
Plan of Correction
Going forward, program manager will ensure that all space heaters will be prohibited in the facility. PM will review with staff the prohibition on space heaters and PM will visually inspect program areas daily to ensure compliance. |
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.
|
Observations
Based on a review of personnel records on April 21, 2008, the facility failed to document that all staff were instructed in the use of the fire extinguisher. Documentation of fire extinguisher training was missing in one of six records reviewed, #5. Fire extinguisher training was not documented within the required time frame in two of six records reviewed. #4 and 6.
|
Plan of Correction
Program Manager will continue to ensure that proper extinguisher training is provided within the specified time frames to all staff. PM will work with Drexel University's public safety office and give them advance notice prior to any new hire so that the proper extinguisher training can be provided to the new hire within the required time period of 7 days. |
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.
|
Observations
Based on a review of personnel records on April 21, 2008, the facility failed to document that all staff were trained to perform assigned tasks during emergencies. Emergency training was not documented in one of six records reviewed, #5. Emergency training was not document within the required time frame in two of six records reviewed, #4 and 6.
|
Plan of Correction
Program Manager will continue to ensure that proper emergency training is provided within the specified time frames to all staff. PM will work with Drexel University's public safety office and give them advance notice prior to any new hire so that the proper emergency training can be provided to the new hire within the required time period of 7 days. |
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.
|
Observations
Based on a review of the fire drill record on April 21, 2008, the facility failed to document that alternate exit routes were used during fire drills from July 2007 through April 2008.
|
Plan of Correction
Going forward program manager will ensure that alternate exit routes are practiced during fire drills. An exception request is being submitted regarding this practice during fire drills i.e. leading the drill to the alternate exit without using it so as not to set off alarm) and document practice of alternate route drills in fire drill record. In the event that the exception is not granted, PM will negotiate with the landlord and the new tenants in the adjoining space to use their space for monthly drills. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records on April 22, 2008, the facility failed to document complete psychosocial evaluations in five of five records reviewed, #1, 2, 3, 4 and 5. Psychosocial evaluations were a repeat of historical data and did not include a clinical assessment of client problems/needs, coping mechanisms, assets/strengths, support systems and negative factors that may inhibit treatment.
|
Plan of Correction
Program Manager will review with staff and provide training, oversight and written prompts regarding these aspects of the psychosocial. Initial training will be provided by the end of May 15, 2008. PM will review charts on a monthly basis to determine compliance. Ongoing training will also be provided as needed based on PM's and peer review of biopsychosocials. |
711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
|
Observations
Based on the physical plant inspection on April 21, 2008, the facility failed to ensure confidentiality of client identity and records as client records were stored in unlocked file cabinets. The door to the file room was unlocked and the file cabinet was also unlocked.
|
Plan of Correction
Program Director shall review with staff the confidentiality requirements, in particular regarding keeping the file room door locked at all times and institute a regular daily spot check of file room door to ensure compliance. |