INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24 and 25, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Bucks County Council on Alcoholism and Drug Dependence 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 April 28, 2009.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of administrative documents, the facility failed to document an overall training plan for 2008/2009 which included time frames.
Findings:
The manual and overall training plan were reviewed on March 24, 2009. The facility failed to document time frames for the overall training plan for 2008/2009.
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Plan of Correction
The Human Resources Director will modify the annual staff training plan to include timeframes for when trainings are to be obtained by staff in 2008/2009. This modification will be complete on or before 4/28/2009
The Human Resource manager will ensure that each year's overall training plan inlcudes time frames for staff to obtain trainings |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the staffing form, the facility failed to document that the FTE counselor caseload for counseling did not exceed 35 active clients.
Findings:
The staffing form was reviewed on March 24, 2009. The FTE counselor caseload exceeded 35 active clients. The ratio was 60:1.
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Plan of Correction
We are reducing the designated work week to 35 hours.
We are increasing clinicians' hours to assure that we are within the 35:1 client to staff ratio.
To prevent future non-compliance and to monitor the caseloads, The Facility Director during monthly meetings with the Clinical Supervisor, will review the staff to client ratio. The Clinical Supervisor will document this in monthly supervision notes.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill records and an interview with the associate director of programming, the facility failed to document that a smoke detector was set off during each fire drill.
Findings:
The fire drill records were reviewed on March 24, 2009. The interview with the associate director of programming was conducted on March 25, 2009. According to the associate director of programming, the facility verbally announced the fire drills conducted from April, 2008 through March, 2009. The facility did not request or receive approval from the office of Drug and Alcohol Program Licensure for an alternate means of announcing fire drills.
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Plan of Correction
The Associate Director will modify the current policy and protocol for conducting fire drills and will ensure that during each fire drill that a smoke detector is set off. This corrective action will be taken on or before 4/28/2009 |
709.93(a)(2) LICENSURE Client records
709.93. 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:
(2) Medication records.
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Observations
Based on a review of client records, the facility failed to document medication records which included the dosage and name of prescriber in three of eight client records reviewed.
Findings:
Eight client records were reviewed on March 25, 2009. Medication records were required in six client records. The facility failed to document medication records which included the dosage and name of prescriber in client records #1, 3 and 4.
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Plan of Correction
The Clinical Supervisor will instruct all intake personnel that, upon scheduling appointments, the intake personnel will notify all clients that they will must bring with them a list of all medications, dosages and frequency taken and by whom prescribed. Assessors will be instructed that they are required to record this information in the appropriate sections of the assessment tool. The Clinical supervisor will review charts on a monthly basis to ensure that assessors are recording this information. This was effective immediately (3/28/09). |
709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
Based on a review of client records, the facility failed to document a consent to treatment form signed by the client and intake worker at intake in three of three client records.
Findings:
Three client records for intake, evaluation and referral activities were reviewed on March 25, 2009. Signed consent to treatment forms were required in three client records. The facility failed to document a consent to treatment form signed by the client and intake worker at intake in client records #9, 10 and 11.
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Plan of Correction
The Clinical Supervisor met with counseling staff and informed them that the Consent to Treatment form must be signed by all individuals at the time of assessment. The consent for treatment form was placed in all assessor's packets and was also placed in the master copy packet. This will ensure that each assessor will be provided a Consent to Treatment form. All outpatient treatment staff were notified via email and during a outpatient treatment meeting that protocol is to have this consent form signed before the assessment is administered. This was effective immediately (3/28/09). THe clinical supervisor will audit charts on a monthly basis to ensure compliance with the standard |
709.44(a)(3) LICENSURE Psychosocial evaluation
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(3) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in three of three client records reviewed.
Findings:
Three client records were reviewed on March 25, 2009 for intake, evaluation and referral activities. A psychosocial evaluation was required in three client records. The facility failed to document a psychosocial evaluation in client records #9, 10 and 11.
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Plan of Correction
THe clinical supervisor met with counseling staff on 4-13-09 and informed them that a psychosocial evaluation and summary must be present in all client records. All assessors were provided with an example of a non-treatment referral clinical summary. Outpatient treatment staff was notified via email and during an outpatient treatment meeting that ALL clients must have a clinical summary present in their file. This was effective immediately (4/13/09). The Clincial Supervisor will audit charts on a monthly basis to ensure compliance with the standard. |