INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 11 to February 13, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, JF Kennedy Community MH/MR Center 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 the inspection and a plan of correction is due on March 20, 2008.
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Plan of Correction
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of administrative documents and staff interview, the facility failed to document that the project director is responsible for the overall management of the project and staff and reports directly to the governing body.
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Plan of Correction
Our Project Manual has been updated to reflect that the project director is responsible for the overall management of the project and staff and reports directly to the governing board.In addition, a new project director is going to be identified. |
704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
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Observations
Based on a review of administrative documents and employee records on 2/11/08, the facility failed to document the supervisor's positive assessment of employee #6's skill level before the assignment of a full caseload.
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Plan of Correction
On March 3, 2008 the Clinic Supervisor completed a positive performance evaluation on this employee. The employee's skill level meets agency standards.In the future, the Clinic Director will be responsible for completing a performance evaluation on counselor-assistant staff that is at least satisfactory before assigning a full caseload. The Division Director will monitor these evaluations to ensure compliance. |
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 employee records on 2/11/08, the facility failed to document TB/STD training in four of four employee records reviewed, #1, 2, 3 and 5. Additionally, documentation of HIV/AIDS training was missing for employee #3.
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Plan of Correction
TB/STD training and HIV/AIDS training has been completed for the identified staff members. A certificate for each staff member is on file in our training manual. The Division Director will be responsible for ensuring that all staff receive this training in a timely manner and for securing the certificates in our training manual. |
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 on 2/11/08, the facility failed to document 12 hours of training for the 2006/2007 training year in one of one record reviewed, #2.
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Plan of Correction
This employee has completed 12 hours of training for the 2007/2008 training year. The Division Director will ensure this supervisor consistently meets training requirements. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of employee records on 2/11/08, the facility failed to document 25 hours of training for the 2006/2007 training year in three of three records reviewed, #3, 4 and 5.
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Plan of Correction
These employees have completed 25 hours of trainiing for the 2007/2008 training year. The division Director is responsible for ensuring that these and all staff consistently meet their annual training requirement. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the physical plant inspection on 2/13/08, the facility failed to ensure privacy in the group room as one of the doors had an uncovered window.
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Plan of Correction
The Director of Environmental Services will install a permanent covering over window to ensure privacy in the group room by 04/21/2008. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection on 2/13/08, two counselor's offices, #17 and #19, had space heaters which were not permanently mounted or installed.
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Plan of Correction
The two space heaters have been removed form offices #17 and #19. All staff have been reminded that space heaters are not permitted at our facility. The Clinic Director will inspect staff offices periodically to ensure compliance. |
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on a review of administrative documents, the governing body failed to document that a project director is selected as the person officially responsible to the governing body.
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Plan of Correction
The President was appointed as the project director effective immediately and will report directly to the Board. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document complete psychosocial evaluations in nine of nine client records reviewed #1, 2, 3, 4, 5, 6, 7, 8 and 9. The evaluations did not provide a clinical assessment of how assets/strengths, support systems and negative factors impact the potential for treatment.
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Plan of Correction
The Division Director will provide three staff training sessions designed to improve our clinical assessment of how assets/strengths, support systems and negative factors impact the potential for client's treatment. The Clinic Director will review each psychosocial evaluation to ensure compleance. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of facility policy and procedure and client records, the facility failed to document preliminary treatment plans in nine of nine client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8 and 9. The facility's policy stated that preliminary treatment plans were to be documented within 15 days. Preliminary treatment plans were not documented.
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Plan of Correction
The completion of a preliminary treatment plan has been deleted from our policy because a comprehensive treatment plan is completed within 48 hours of admission. This action is representative of our practice. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment plan in nine of nine client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8 and 9. Treatment plans were not individualized; the first two goals for each client were identical and the third goal was one of two statements: keep psychiatric evaluation appointment or develop support system.
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Plan of Correction
The Division Director will conduct a training session for staff to assist them to develop an individualized treatment plan. Individualization will be reflected primarily in the third goal which will be selected from the client's problem list and unique to each client. The Clinic Director will review all comprehensive treatment plans to ensure compliance. |