INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16-17, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on August 17, 2007.
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Plan of Correction
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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.
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Observations
The facility failed to ensure that individuals hired to fill clinical positions were qualified for those positions. Employee #6 failed to meet the qualifications for the position of counselor based on the bachelor's degree in a non-related major.
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Plan of Correction
Adult Program Director will ensure that every potential Counselor and Counselor Assistant's qualification information is submitted to the QI Department.
The Program Director will ensure that a written response is received verifying qualifications from the QI Department prior to hiring new staff.
Regional Director will monitor process for compliance. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The facility failed to provide for complete personal histories, lacking details regarding family history and relationships, employment history and job skills and recreational interests and hobbies in 2 of 4 client records reviewed, specifically client records #6 and 9. The questions posed on the intake forms often elicited only one word answers with no evident follow up by facility staff.
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Plan of Correction
On July 18, 2007 the Adult Program Director met with the two Counselors who are responsible for completing documentation of client's personal histories. Records # 6, and 9 were reviewed. Personal histories lacking details regarding family history and relationships, employment history and job skills,and recreational interests or hobbies were reviewed.
Counselors will expound on one word answers. Counselors will demonstrate evidence of follow up in documentation.
On September 18, 2007 the Adult Program Director and Regional Director will meet with the Counselors and training will be conducted at that time.
The Adult Program Director will randomly choose two records per week for review of documentation until the end of October 2007.
Beginning October 31, 2007 monthly audits will be done by the Program Director until documentation is acceptable. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluation (diagnostic summary) failed to include clinical opinions and impressions regarding problems/needs specific to the client, assets /strengths, negative factors that may effect treatment, coping mechanisms and overall conclusions in 3 of 3 client records reviewed, specifically client records # 2, 6 and 9. The evaluation consisted of historical information with client reported statements and lacked evaluative comments from facility clinical staff.
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Plan of Correction
On July 18, 2007 the Adult Program Director met with the two counselors responsible for completing the psychosocial assessments and evaluations. Records #2, 6, and 9 were reviewed. The counselors were re-educated as to the need to improve the diagnostic summary and to comply with standards.
Beginning August 1, 2007, the Adult Program Director will randomly select four Diagnostic Summaries for review and provide feedback to the Counselors.
On September 18, 2007, training will be provided for the Counselors by the Adult Program Director and Regional Director. Effective September 30, 2007 the Adult Program Director will randomly choose two charts for weekly review until the end of October 2007.
Beginning November 1, 2007, The Program Director will continue to do monthly audits for the next 12 months. |
709.83(a)(9) LICENSURE Client records
709.83. 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) Progress notes.
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Observations
The facility failed to provide for group progress notes which addressed the individual client's participation in the group. The progress notes, specifically group progress notes, failed to include individual assessments for each participating client in 4 of 4 client records reviewed, specifically client records #2, 6, 8 and 9.
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Plan of Correction
On July 18, 2007, the Adult Program Director met with the counselors. Records #2, 6, 8, and 9 were reviewed. They have been re-educated as to the need to improve the assessment section of the group progress note.
Beginning August 1, 2007, on a weekly basis (For the next month), the Adult Program Director will randomly select a note from each individual Counselor. These will be reviewed by both the Adult Program Director and the Counselor. The Adult Program Director will provide proper feedback.
Monthly chart audits will be conducted beginning October 1, 2007. The Medical Records department will randomly select 10 charts for the Adult Program Director to review. These audits will continue for the next 12 months.
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709.83(a)(10) LICENSURE Client records
709.83. 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:
(10) Discharge summary.
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Observations
The facility failed to have discharge summaries completed on a timely basis in accordance with Department approved policies and procedures. Discharge summaries were completed more than 7 days after the client was discharged from treatment in 2 of 2 client records reviewed, specifically client records #8 and 9.
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Plan of Correction
On July 18, 2007, the Adult Program Director met with the counselors. Records #8 and 9 were reviewed. They have been re-educated to the policy and procedures regarding discharge summaries.
The Adult Program Director will maintain communication with the Medical Records department regarding the status of the timelines of the discharge summaries. This will begin immediately.
The Adult Program Director and Assistant Adult Program Director will devise a monitoring tool to assist in assuring that these are completed in a timely fashion as stated by the policy and procedures. This will be completed by September 3, 2007.
On September 5, 2007, the Adult Program Director and Assistant Adult Program Director will be meeting with counselors to review the monitoring tool.
The Adult Program Director will also discuss with the Manager of Medical Records to request that dates be implemented on the discharge summary form. Dates to include: dictated date, transcribed date, counselor signature date, and doctor's signature date.
The Adult Program Director will request on a monthly basis for medical records, to pull 10 charts. These charts will be reviewed by the Adult Program Director. If issues continue, the counselor(s) will be notified and policy and procedures to be reviewed again. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply 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:
(1) Confidentiality of client identity and records.
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Observations
The facility has failed to consistently inform the client of the client's right to revoke a consent to release information. There was no documentation of the clients being informed of this right including on the "Insurance Assignment Release" form itself found in 8 of 8 client records reviewed, specifically client records #1, 2, 3, 4, 5, 6, 7, and 8.
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Plan of Correction
The Forms Committee Chairperson and the Acting Executive Director approved the revisions to the "Insurance Assignment Release" form on August 6, 2007. The revised form was emailed to the Regional Directors and Regional Administrators on August 6th and they and/or their supervisory designee will instruct staff on it's use, with the form to be implemented no later than Thursday, August 9, 2007. Beginning on September 10, 2007 compliance will be monitored monthly by random chart audits conducted by the supervisor and/or their clinical staff designee, for a minimum of three months. |
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
The facility did not consistently document consent to release information forms and did not consistently provide for complete consent to release information forms. The consent to treatment form was missing in client record #5. Consent to release information forms found in client records #6 and 8 failed to document what information was to be released.
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Plan of Correction
The Forms Committee Chairperson and the Acting Executive Director approved the revisions to the "Insurance Assignment Release" form on August 6, 2007. The revised form was emailed to the Regional Directors and Regional Administrators on August 6th and they and/or their supervisory designee will instruct staff on it's use, with the form to be implemented no later than Thursday, August 9, 2007. Beginning on September 10, 2007 compliance will be monitored monthly by random chart audits conducted by the supervisor and/or their clinical staff designee, for a minimum of three months. |
709.32(c)(2) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(2) Drug storage areas.
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Observations
The facility failed to consistently record daily temperatures for the detoxification and rehabilitation medication refrigerators.
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Plan of Correction
The Refrigerator Temperature Log was revised and implemented on all Nursing Units August 1, 2007. The revised log requires that the Nurse Manager reviews each unit log at the end of the month, signs and dates, and requires a corrective action from the appropriate unit coordinator when the standard is deficient. Nurse Manager and Unit Coordinator are the responsible staff. |
709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The facility failed to provide for complete personal histories. The personal histories (nursing assessment) failed to include information pertaining to the client's military and sexual history in each client record reviewed.
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Plan of Correction
The addition of the military and sexual history to the Nursing Assessment will be discussed at the Forms Committee meeting on August 8, 2007 and will be developed by the Nursing Leadership Committee on August 29, 2007. The Forms Committee Chairperson will present the revised form to Senior Quality Leadership Committee on September 11, 2007 for review and approval. Approved form will be distributed by September 17, 2007. Trainings by Director of Nursing or designee will be provided to clinical staff with full implementation by October 1, 2007. |
709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
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Observations
The facility failed to consistently provide for complete physical exam documentation. Physical examinations failed to include vital signs in 2 of 8 client records reviewed, specifically client records #1 and 4. The vital signs recorded on the physical examination form were copied from the nursing assessment that was completed at a different time, and often different date, in 3 of 8 client records reviewed, specifically client records #5, 6 and 7.
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Plan of Correction
Assistant Administrator sent notification via email on 7/20/07 to all medical staff that vital signs are to be assessed at the time of the physical exam. Discussion held at Medical Staff Meeting on August 1, 2007. Expectations regarding vitals were addressed by Assistant Administrator.Random audits will be done by medical secretary monthly times three to determine if medical staff are in compliance. The Medical Director, Physician, and Physician Assistants will be the responsible staff. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
The facility failed to ensure that the psychosocial evaluation was a clinical evaluation rather than a repeat of intake data. The psychosocial evaluations (nursing assessment summary) failed to include opinions and impressions regarding the client in 7 of 7 client records reviewed, specifically client records #1, 3, 4, 5, 6, 7 and 8. The summary simply restated the client's demographics, drug of choice and appropriateness for the level of care.
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Plan of Correction
Nursing staff have been re-educated as to the need to improve the nursing assessment evaluative summaries and comply with the standard via email on August 8, 2007.Education of the nursing department will also occur during the next Staff meeting on August 17, 2007.The Nursing Coordinators will review and initial each evaluative summary to ensure compliance to the requirement for three months or until improvement is noted. Responsible person is Nurse Manager. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The personal history failed to include details regarding family history and relationships, employment history and job skills and recreational interests and hobbies in 4 of 9 client records reviewed, specifically client records #2, 4, 6 and 9. The questions posed on the intake forms often elicited only one word answers with no follow up documented by facility clinical staff.
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Plan of Correction
On July 18, 2007 the Adult Program Director met with the two Counselors who are responsible for completing documentation of client's personal histories. Records # 2, 4, 6 and 9 were reviewed. Personal histories lacking details regarding family history and relationships, employment history and job skills,and recreational interests or hobbies were reviewed. Counselors will expound on one word answers. Counselors will demonstrate evidence of follow up in documentation.
On September 18, 2007 the Adult Program Director and Regional Director will meet with the Counselors and training will be conducted at that time. The Adult Program Director will randomly choose two records per week for review of documentation until the end of October 2007.
Beginning October 31, 2007 monthly audits will be done by the Program Director until documentation is acceptable. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to provide for clinical evaluations. The psychosocial evaluation (diagnostic summary) failed to include clinical opinions and impressions regarding problems/needs specific to the client, assets /strengths, negative factors that may effect treatment, coping mechanisms and overall conclusions in 9 of 9 client records reviewed, specifically client records #1, 2, 3, 4, 5, 6, 7, 9 and 10. The evaluation consisted of historical information with client reported statements rather than evaluative statements made by facility clinical staff.
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Plan of Correction
On July 18, 2007, the Adult Program Director met with the two counselors who are responsible for completing psychosocial assessments. Records #1, 2, 3, 4, 5, 6, 7, 9, and 10 were reviewed. They have been re-educated as to the need to improve the diagnostic summary to comply with the standards.
Beginning August 1, 2007, on a weekly basis (for the next month) the Adult Program Director will randomly select four psychosocials and review the charts. The Adult Program Director will provide feedback to the counselors.
On September 28, 2007, the Adult Program Director and Regional Administrator will meet with the counselors to conduct training.
On September 30, 2007 the Adult Program Director will randomly choose two charts per week until the end of October and will review.
Monthly audits will then occur on an ongoing basis for the next 12 months. These audits will be conducted by the Adult Program Director. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
The facility failed to provide for individualized group progress notes. The progress notes, specifically group progress notes, failed to include individual assessments for each participating client in 8 of 8 client records reviewed, specifically client records #1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
On July 18, 2007, the Adult Program Director met with the counselors. Records #1, 2, 3, 4, 5, 6, 7, and 8 were reviewed. They have been re-educated as to the need to improve the assessment section of the group progress note.
Beginning August 1, 2007, on a weekly basis (For the next month), the Adult Program Director will randomly select a note from each individual counselor. These will be reviewed by both the Adult Program Director and the counselor. The Adult Program Director will provide proper feedback.
Monthly chart audits will be conducted beginning on October 1, 2007. The Medical Records department will randomly select 10 charts for the Adult Program Director to review. This will continue for the next 12 months. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
The facility failed to ensure that discharge summaries were completed in accordance with Department approved policy and procedure and on a timely basis. Discharge summaries were completed more than 7 days after the client was discharged from treatment in 2 of 2 client records reviewed, specifically client records #10 and 11.
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Plan of Correction
On July 18, 2007, the Adult Program Director met with the counselors. Records #10, and 11 were reviewed. They have been re-educated to the policy and procedures regarding discharge summaries.
The Adult Program Director will maintain communication with the Medical Records department regarding the status of the timeliness of the Discharge Summaries. This will begin immediately.
The Adult Program Director and Asst. Adult Program Director will devise a monitoring tool to assist in assuring that these are completed in a timely fashion as stated by the policy and procedures. This will be completed by September 3, 2007.
On September 5, 2007, the Adult Program Director and Asst. Adult Program Director will be meeting with counselors in a meeting to review the monitoring tool.
The Adult Program Director will also discuss with the Manager of Medical Records to request the dates be implemented on the discharge summary form. Dates to include: dictated date, transcribed date, counselor signature date, and doctor's signature date.
The Adult Program Director will request on a monthly basis for medical records, to pull 10 charts. These charts will be reviewed by the Adult Program Director. If issues continue, the counselor(s) will be notified and policy and procedures to be reviewed again. |