INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 9, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Dolminis 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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704.6(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 Reports, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.The findings include:The Staffing Requirements Facility Summary Reports for the project's 14 facilities were reviewed on October 15, 2013. The project employed the equivalent of 105.275 full-time counselors, which would require the project to have at least 13 full-time clinical supervisors. The project failed to employ a full-time clinical supervisor for every eight full-time counselors as the project only employed 7 full-time clinical supervisors as of October 15, 2013.
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Plan of Correction
The Vice President of Clinical Services will ensure that the ratio of Clinical Supervisors for the project is within the defined regulation of 1 fulltime clinical supervisor for every 8 fulltime counselors or counselor assistants. The Project will re-evaluate its current system and restructure the project to include the appropriate number of clinical supervisors. Human Resources coordinators will identify the number of clinical supervisors, counselors, and counselor assistants within the system on a quarterly basis. Vice President of Clinical Services will be responsible to review staffing hours quarterly to ensure that ratio is maintained. Program Directors will notify the Vice President of Clinical Services should any changes in the ratio per site occur during the quarter. Restructuring of the Clinical Supervisor ratio will begin December 1, 2013. Clinical Supervisor ratio will be in 100% compliance by January 1, 2014. |
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 employee records, the facility failed to document the completion of 12 clock hours of annual training required for project directors in one of one employee records.The findings include:The facility training year runs from July 1 through June 30. Seven employee records were reviewed on October 9, 2013. One employee record pertained to the project director and required the documentation of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in employee record # 1.Employee # 1 has been the project director since July 1, 1999. The facility failed to document 12 clock hours of annual training for employee # 1 for the July 2012 - June 2013 training year as the record only contained documentation of 10.5 hours of training. This is repeat citation from the October 16, 2012 licensing inspection.
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Plan of Correction
Project Manager will complete 12 hours of training annually. Project Manager will ensure needed documentation of completed trainings is presented to Human Resources to be recorded in Personnel File. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance. |
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, the facility failed to document an individual treatment and rehabilitation plan that included short and long-term treatment goals in six of eleven client records. The findings include:Thirteen client records were reviewed on October 7-8, 2013. Eleven client records required treatment plans that included short and long-term treatment goals. The facility did not document short and long-term treatment goals on individual treatment plans contained in client records # 5, 6, 8, 9, 10 and 11. Client # 5 was admitted on June 25, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on June 25, 2013, did not include documentation of short and long-term treatment goals. Client # 6 was admitted on July 9, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on July 9, 2013. did not include documentation of short and long-term treatment goals. Client # 7 was admitted on July 10, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on July 10, 2013. did not include documentation of short and long-term treatment goals. Client # 8 was admitted on March 18, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on March 18, 2013, did not include documentation of short and long-term treatment goals.Client # 9 was admitted on April 29, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on April 29, 2013, did not include documentation of short and long-term treatment goals.Client #10 was admitted on February 20, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on February 20, 2013, did not include documentation of short and long-term treatment goals.Client #11 was admitted on November 13, 2012. The individual treatment and rehabilitation plan, signed by the client and staff on November 13, 2012, did not include documentation of short and long-term treatment goals. The Facility Director was interviewed on October 8, 2013 and confirmed the findings.
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Plan of Correction
A new treatment plan form is currently being developed. Staff training and implementation will occur by 11/18/13.
The new format will clearly identify treatment plan short/long term treatment goals.
Implementation of the new form will provide for correction of current deficient treatment plans.
Program director and clinical supervisor will monitor accuracy when reviewing treatment plans during random monthly chart audits.
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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan that included the type and frequency of treatment and rehabilitation services in six of eleven client records. The findings include:Thirteen client records were reviewed on October 7-8, 2013. Eleven client records required documentation of individual treatment plans that included the type and frequency of treatment and rehabilitation services. The facility failed to document the type and frequency of treatment and rehabilitation services on individual treatment plans contained in client records # 5, 6, 8, 9, 10 and 11. Client # 5 was admitted on June 25, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on June 25, 2013, did not include documentation of the type and frequency of treatment and rehabilitation services. Client # 6 was admitted on July 9, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on July 9, 2013, did not include documentation of the type and frequency of treatment and rehabilitation services. Client # 8 was admitted on March 18, 2013. The treatment plan, signed by the client and staff on March 18, 2013, did not include documentation of the type and frequency of treatment and rehabilitation services. Client # 9 was admitted on April 29, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on April 29, 2013, did not include documentation of the type and frequency of treatment and rehabilitation services. Client #10 was admitted on February 20, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on February 20, 2013, did not include documentation of the type and frequency of treatment and rehabilitation services. Client #11 was admitted on November 13, 2012. The individual treatment and rehabilitation plan, signed by the client and staff on November 13, 2012, did not include documentation of the type and frequency of treatment and rehabilitation services. The Facility Director was interviewed on October 8, 2013 and confirmed the findings.
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Plan of Correction
A new treatment plan form is currently being developed. Staff training and implementation will occur by 11/18/13.
The new format will clearly identify type and frequency of treatment and rehabilitative services.
Implementation of the new form will provide for correction of current deficient treatment plans.
Program director and clinical supervisor will monitor accuracy when reviewing treatment plans during random monthly chart audits. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to review and update treatment and rehabilitation plans every 60 days in six of eleven client records. The findings include:Thirteen client records were reviewed on October 10, 2013. Eleven client records reviewed required treatment and rehabilitation plan updates. The facility failed to update the treatment and rehabilitation plan at least every 60 days in client records # 4, 5, 6, 8, 9 and 10.Client # 4 was admitted on June 10, 2013 and the individual treatment and rehabilitation plan was signed by the client and staff on June 11, 2013. The facility failed to complete the August 11, 2013 treatment and rehabilitation plan update until September 12, 2013. Client # 5 was admitted on June 25, 2013 and the individual treatment and rehabilitation plan was signed by the client and staff that same day. The facility failed to complete the August 25, 2013 treatment and rehabilitation plan update until September 6, 2013.Client # 6 was admitted on July 9, 2013 and the individual treatment and rehabilitation plan was signed by the client and staff that same day. The facility failed to complete the September 9, 2013 treatment and rehabilitation plan update until October 8, 2013. Client # 8 was admitted on March 18, 2013 and the individual treatment and rehabilitation plan was signed by the client and staff that same day. The facility failed to complete the May 18, 2013 treatment and rehabilitation plan update until June 5, 2013. Client # 9 was admitted on April 29, 2013 and the individual treatment and rehabilitation plan was signed by the client and staff that same day. The facility failed to complete the June 29, 2013 treatment and rehabilitation plan update until July 13, 2013. Client #10 was admitted on February 20, 2013 and the individual treatment and rehabilitation plan was signed by the client and staff that same day. The facility failed to complete the April 20, 2013 treatment and rehabilitation plan update until May 1, 2013. The Facility Director was interviewed on October 9, 2013 and did not dispute the findings.
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Plan of Correction
The implementation of the referenced new treatment plan format will ensure that treatment plan implementation dates are accurate thus ensuring treatment plan updates occur within 60 days.
Program director and clinical supervisor will monitor accuracy and timely completion of treatment plan updates during random monthly chart audits.
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