INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Project Transition 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to insure that the staff person appointed to the facility director/clinical supervisor position met the appropriate educational requirements.
The findings were:
Personnel records were reviewed on September 3, 2013. The personnel record for Employee #2, the facility director/clinical supervisor, lacked documentation verifying that the employee met the educational requirements for the position. The documentation for the indicated the employee #2 has a BA degree that does not meet for a facility director/clinical supervisor position.
The findings were forwarded to a project representative and were not disputed.
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Plan of Correction
The Findings were reviewed with the Project Director. Effective 11/1/13, VP of Administration will be temporarily assigned as Facility Director for the Greenbriar Program until a qualified Facility Director is identified. The new Facility Director is a Licensed Social Worker, with both the required education and clinical experience. |
704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the staffing requirements facility summary report, the facility failed to employ a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The facility's staffing requirements facility summary report was reviewed on September 6, 2013. The summary report indicated that the project had 11.8 full-time equivalent (FTE) counselors or counselor assistants, or both. The facility currently has five facility directors/clinical supervisors and none acting in a full time capacity of a clinical supervisor.
The findings were forwarded to a project representative and were not disputed.
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Plan of Correction
Findings were reviewed with Senior Administration and a subsequent reorganization of duties was implemented to be effective 11/1/13. The CEO will assume Project Director Responsibilities. The VP's of Program Operations and of Quality have been re-assigned as Clinical Supervisors. A new Director of Quality/Licensing has been retained to start duties on 10/21/13.
Person Responsible: Project Director
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor began participating in monthly meetings with their supervisor, upon being promoted, in accordance with the standards in one of one personnel records reviewed.
The findings include:
Personnel records were reviewed on September 6, 2013. One personnel record reviewed was that of employee #2, facility director/clinical supervisor. Employee # 2 was hired at the project on September 22, 2008 and was promoted to the position of clinical supervisor on May 26, 2013. The facility failed to document a monthly supervision meeting for the month of June in personnel record # 2.
The facility director/facility director confirmed that there was not a supervisory meeting in June of 2013.
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Plan of Correction
Findings reviewed with both Project and Facility Directors. It is agreed that documentation of supervision in the month of June was not available. The Project Director will provide an additional month of supervision to make up for the missed supervision in June.
The Project Director has responsibility to document supervision of the Clinical Supervisor on at least a monthly basis and to document this. Personnel files will be audited quarterly by the HR Director for compliance.
Person Responsible: Project Director
Timetable: Immediate |
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 of the facility's staffing requirements facility summary report, the facility failed to provide documentation of six hours of HIV/AIDS and/or at least four hours of TB/STD training in five of eleven records reviewed.
The findings include:
The facility's staffing requirements facility summary report was reviewed on September 6, 2013 as part of an administrative review. The facility failed to ensure that employees # 2, 6, 9, 10 and 11 received a minimum of six hours of HIV/AIDS and/or at least four hours of TB/STD training within the required time frame.
Employee #2 was hired to the project on September 22, 2008 and to the position as facility director/clinical supervisor on May 26, 2013. Employee #2 was required to obtain 4 hours of TB/STD the training by September 22, 2010. Employee # 2 failed to obtain the training as of the date of the inspection.
Employee # 6, a counselor, was hired on October 17, 2011 and was required to obtain six hours of HIV/AIDS and four hours of TB/STD training's by October 17, 2012. Employee # 6 failed to obtain the training's as of the date of the inspection.
Employee # 9, a support staff person, was hired March 3, 2010 and was required to obtain six hours of HIV/AIDS and 4 hours of TB/STD the training's by March 3, 2012. Employee # 9 failed to obtain the training's as of the date of the inspection.
Employee # 10, a support staff person, was hired March 1, 2011 and was required to obtain six hours of HIV/AIDS and 4 hours of TB/STD the training's by March 3, 2013. Employee # 10 failed to obtain the training's as of the date of the inspection.
Employee # 11, a support staff person, was hired October 29, 2007 and was required to obtain six hours of HIV/AIDS and 4 hours of TB/STD the training's by October 29, 2009. Employee # 11 failed to obtain the training's as of the date of the inspection
The findings were forwarded to a project representative and were not disputed.
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Plan of Correction
Findings were reviewed with Manager of Training and Education and Project Director. The Manager of Training and Education has identified HIV/AIDS and TB/STD trainings for all employees who have not received these trainings within the required time periods. These trainings will be completed by 12/15/13 under direct responsibility of the Manager of Training/Education. Additionally, a Human Resources Manager has been hired as of 10/1/13 to audit personnel/training files to ensure compliance for current and new employees |
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, the facility failed to document the instruction of staff in the use of a fire extinguisher upon staff employment, in two of eight personnel records reviewed.
The findings include:
Eight personnel records were reviewed on September 6, 2013, four of which were for newly hired staff and required documentation that fire extinguisher training had been provided in accordance with the standard. The facility failed to document the completion of fire extinguisher training upon employment in personnel records # 4 and 5.
Employee # 4 was hired on March 25, 2013. The training was not documented as of the date of the licensing inspection.
Employee # 5 was hired on July 1, 2013. The training was not documented as of the date of the licensing inspection.
The findings were forwarded to a project representative and were not disputed.
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Plan of Correction
Findings reviewed with Manager of Training and Education. Identified employees will receive documented training in fire safety and use of fire extinguisher by 10/31/13. Manager of Training and Education will verify completion and documentation of this training. Additionally, the Manager of Training and Education will ensure all new employees receive this training prior to assuming program related duties. Timetable: immediate |
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, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies, in two of eight personnel records reviewed.
The findings include:
Eight personnel records were reviewed on September 6, 2013, four of which were for newly hired staff and required documentation that staff were trained to perform tasks during emergencies in accordance with the standard. The facility failed to document the completion of training in personnel records # 4 and 5.
Employee # 4 was hired on March 25, 2013. The training was not documented as of the date of the licensing inspection.
Employee # 5 was hired on July 1, 2013. The training was not documented as of the date of the licensing inspection.
The findings were forwarded to a project representative and were not disputed.
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Plan of Correction
Findings review with Manager of Training and Education. Identified staff members will receive documented emergency procedures training by 10/31/13 under supervision of the Manager of Training and Education. This Manager will also ensure that all new employees receive this documented training prior to assuming any program related duties. |
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 record, the facility failed to document the use of alternate exit routes during fire drills.
The findings include:
A review of the fire drill record for the period of August 2012 - August 2013 was conducted on August 30, 2013. The facility failed to alternate exits as they documented " front door and rear door " for every fire drill for the months of August 2012 - August 2013.
The findings were forwarded to a project representative and were not disputed.
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Plan of Correction
Findings reviewed with Facility Director. Effective immediately, Facility Director will ensure that alternate doors and exits are used and identified during fire drills. These will be audited during Program Quality Reviews every 6 weeks |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the fire drill record, the facility failed to ensure that fire drills were conducted at different times of the day.
The findings include:
A review of the fire drill record for the period of August 2012 - August 2013 was conducted on August 30, 2013.
The facility's hours of operation are from 8:00 AM until 9:00 PM. The facility failed to document fire drills between the hours of 3:00 PM - 9:00 PM. All drills were documented before 3:00 PM.
The findings were forwarded to a project representative and were not disputed.
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Plan of Correction
Findings were reviewed with the Facility Director. Facility Director will immediately implement a rotating time of Fire Drills to encompass hours from 8am to 9pm. This will be verified through quality program audits every six weeks.
Person Responsible: Facility Director
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709.82(d) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
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Observations
Based on a review of client records and clinical documentation, the facility failed to ensure that group counseling was provided at least twice weekly in two of four records reviewed.
The findings include:
Four client records requiring documentation of group counseling at least twice weekly were reviewed on September 12, 2013. The facility failed to ensure group counseling was conducted at least twice weekly in client records # 2 and 4.
Client # 2 was admitted on 7/16/13 and was still an active client on 9/12/13. Group counseling is required at least twice weekly; however the facility failed to ensure that client # 2 received group counseling at least twice weekly. The facility documented 4 group sessions on 7/18/13, 7/25/13, 8/1/13, and 8/8/13.
Client # 4 was admitted on 7/15/13 and was still an active client on 9/12/13. Group counseling is required at least twice weekly; however the facility failed to ensure that client # 4 received group counseling at least twice weekly. The facility documented 4 group sessions on 7/18/13, 7/25/13, 8/1/13, and 8/8/13.
The Quality Assurance Director did not dispute the findings.
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Plan of Correction
Findings reviewed with Facility Director. Program Schedule has been revised effective 10/7/13 to ensure provision of at least two group counseling sessions per week.
Service Log will be reviewed weekly to ensure compliance in delivery of services. Facility Director will direct that all group leaders have a coverage plan in case of absence.
Person Responsible: Facility Director |
709.26(d)(1) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(1) The application for employment.
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Observations
Based on a review of personnel records, the facility failed to document annual staff work performance evaluations in three of eight personnel records.
The findings include:
Eight personnel records were reviewed on September 6, 2013. Annual staff work performance evaluations were required in three personnel records. The facility did not document annual staff work performance evaluations in personnel records # 6, 7 and 8.
Employee # 6 was hired on October 17, 2011. The annual work performance evaluation for 2012 was due by October 17, 2012. The facility failed to document an annual work performance evaluation.
Employee # 7 was hired on April 2, 2012. The annual work performance evaluation for 2013 was due by April 2, 2013. The facility failed to document an annual work performance evaluation.
Employee # 8 was hired on June 28, 2012. The annual work performance evaluation for 2013 was due by June 28, 2013. The facility failed to document an annual work performance evaluation.
The findings were forwarded to a project representative and were not disputed.
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Plan of Correction
Findings reviewed with Facility Director. Missing evaluations to be completed by 10/31/13. Additionally, the HR Manager will audit personnel files quarterly to ensure completion of all required items. Person Responsible for Evaluations: Project Director
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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 a review of client records and clinical documentation, the facility failed to obtain an informed and voluntary consent for the disclosure of information in client record # 1.
The findings include:
Four client records requiring documentation of an informed and voluntary consent were reviewed on September 12, 2013. The facility failed to obtain a valid informed and voluntary consent for the disclosure of client information in client record # 1.
Client # 1 utilizes intensive case management services and is involved with the department of human service. Per documentation in a progress note, the clinician advised client # 1 to call and speak with both governmental agencies during a counseling session. However, client # 1's record did not have documentation of an informed and voluntary consent for either agency. Therefore, the facility failed to document or verify that client # 1 was informed of her rights as stipulated at 4 Pa. Code 255.5.
The clinician and Facility Director confirmed the findings.
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Plan of Correction
Findings reviewed with Project Director and Clinician who violated protocol. Facility Director has retrained that employee effective 10/1/13. Manager of Training and Education will ensure that all employees receive full confidentiality training as part of orientation.
Program Administrative Coordinator audits client records monthly to ensure completion of releases of information. |