INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 2-3, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Nuestra Clinica Rehabilitacion was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
Based on a review of the personnel and training records, the facility failed to document that a core curriculum in clinical supervision was completed in one of two records.
The findings include:
Six personnel and training records were reviewed on December 2, 2013. One clinical supervisor's record was required to include documentation of the supervisory core curriculum training.
Employee #2 was hired on February 17, 2010 and was promoted on April 2012. No documentation was available to show the employee functioned for 2 years as a supervisor in the provision of clinical services. No documentation was available to show the employee completed the core curriculum in clinical supervision training.
The findings were reviewed with the project director/facility director on December 2, 2013 and were not disputed.
|
Plan of Correction
The project director has scheduled the core curiculumn training offered by the Department of Health for the acting cliical supervisor to take place the week of January 6th throught 10, 2104. The project director will also attend the training to ensure that the clinic has an individaul trained in the core curriculm at all times. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
|
Observations
Based on a review of personnel records, the facility failed to demonstrate that performance evaluations were conducted semi-annually for counselor assistants.
The findings were:
Six employee records were reviewed on December 2, 2013. Employee record #5 contained only one performance evaluation for October 9, 2012. Employee #5 was hired on October 19, 2009 and promoted to counselor assistant on February 8, 2012. A conversation with the project/facility director on December 2, 2013 confirmed that no performance evaluation was conducted semi-annually for Employee #5.
|
Plan of Correction
The clinical supervisor will assume responsibility for ensuring that all counselor assitants have semi-annual evaluations going forward. To ensure quality control the clinical supervisor will sign off on the evaluations. The project director will complete monthly employee file audits to verify compliance. The counselors in supervisory positions were met with and the process was explained to each one. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
|
Observations
Based on a review of staff development records, the facility failed to document the completion of 40 clock hours of annual training required for counselor assistant in one of two personnel records reviewed.
The findings included:
Six personnel records were reviewed on December 2, 2013. Two of the personnel records were counselor assistants. One personnel record was required to document the completion of 40 clock hours of annual training. The facility failed to document 40 clock hours of annual training in personnel record # 5.
Employee # 5 was hired on November 19, 2009 and promoted to counselor assistant on February 8, 2012. Employee # 5 only completed 12 clock hours of training in 2012-2013.
An interview with the project/facility director on December 2, 2013 confirmed the findings.
|
Plan of Correction
the project director and the clincialssupervisor met with the clinicians to advise that them of the training requirements for counselor assistants. The project director will schedule trainings that meet the required 40 or 30 hours respectively. Documentation will be placed in the employee file. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of one client records.
The findings include:
Ten client records were reviewed on December 3, 2013. Five of the client records reviewed were that of discharged clients. One of the discharged clients was involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 8.
Client # 8 was involuntarily terminated from the project on September 17, 2013 . There was no documentation of written notification provided to the client as of the on-site inspection which was conducted on December 2-13, 2013.
An interview with the project/facility director on December 3, 2013 confirmed the findings.
|
Plan of Correction
To ensure complice the clincial supervisor will perform random chart audits weekly for the next 3 months, then bi-weekly for an additional 3 months. If the charts appear complete the audits will decrease to monthly random audits to ensure complaince. Staff was met with and the termination forms were explained, the need for all forms be filled out completly and signed where indicated. |
709.53(a) LICENSURE Complete Client Record
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:
|
Observations
Based on a review of client records on December 2-3, 2013, the facility failed to have a complete record in five of ten records reviewed.
The findings include:
Ten client records were reviewed on December 2-3, 2013. Five of the ten client records required documentation of discharge summaries and follow-up information, #6, 7, 8, 9 and 10. The discharge summaries failed to include the clients' reasons for treatment and the clients' response to treatment in records #6 and 7. Client records #9 and 10 did not include documentation of a discharge summary.
Client #9 was discharged on May 15, 2013 and as of the day of the licensing inspection there was no documentation of client #9's discharge summary.
Client #10 was discharged on August 7, 2013 and as of the day of the licensing inspection there was no documentation of client #10's discharge summary.
Additionally, client records s #7 and 8 did not include documentation of a follow-up. Client #7 was discharged on June 25, 2013 and at the time of the licensing inspection there was no documentation of a follow-up attempt.
Client #8 was discharged on September 17, 2013 and at the time of the licensing inspection there was no documentation of a follow-up attempt.
This was discussed and confirmed by the project/facility director on December 3, 2013.
|
Plan of Correction
The staff met with clincial supervisor and project director regarding the proper documentation of discharge summaries. The staff completed the re-training. To ensure complice the clincial supervisor will also monitor completion of discharge summaries during the random chart audits weekly for the next 3 months, then bi-weekly for an additional 3 months. If the charts appear complete the audits will decrease to monthly random audits to ensure complaince. Staff was met with and the termination forms were explained, the need for all forms be filled out completly and signed where indicated |