INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 24 - 25, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Colonial House Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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
Based on the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of three records reviewed.
Findings:
Nine personnel records were reviewed on April 24, 2012. Three of the nine was reviewed for the counselor position, # 4, 5 and 6. In personnel record #6, the counselor did not meet the qualifications for the position of counselor based on not having the required two year clinical experience.
An interview with the project director and facility director on April 25, 2012 confirmed the findings.
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Plan of Correction
On April 27, 2012 the director of residential services demoted counselor (employee # 6) to counselor assistant. The counselor assistant ( employee # 6) will not be promoted to counselor until they meet the qualifications for the position of counselor by having the required two years clinical experience or a Bachelor degree and one year clinical experience. Employee # 6 will receive supervision from the clinical supervisor. Promotion will be approved by CEO and director of residential services. |
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 personnel records, the facility failed to document the completion of 12 clock hours of annual training required for facility director in one of two personnel records.
The findings include:
Nine personnel records were reviewed on April 24, 2012. One personnel record pertained to the facility director. Two personnel records required the completion of 12 clock hours of annual training, #1 and 2. The facility failed to document 12 clock hours of annual training in personnel record #2.
Employee # 2 has been the facility director since June 1, 2010. The facility training year is from April 1, 2010 through March 31, 2011. Employee #2 had documentation of 6 training hours documented for the 2010-2011 training year.
An interview with the facility director on April 25, 2012 confirmed the findings.
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Plan of Correction
On April 30, 2012 the CEO met with the director of residential serivces to discuss a plan to ensure compliance. The CEO will monitor the facility directors training hours quarterly to insure that all training hours are completed within the annual training year. The facility director currently has obtained 30 training hours since April 20, 2012. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill record, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
The fire drill record was reviewed on April 24, 2012. A fire drill conducted during sleeping hours is required once every six months. The fire drill record was reviewed from the last survey, May 2011 to April 2012. During that time frame, the facility documented only two fire drill during sleeping hours August 2011 and April 2012 which was 7 months apart.
An interview with the project director and facility director on April 25, 2012 confirmed the findings.
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Plan of Correction
The Executive Assistant is responsible for maintaining the fire drill logs. The Director of Residential Services met with The Executive Assistant on May 1, 2012 and discussed fire drill procedures. The Executive Assistant was instructed on fire drill procedures. A written schedule was developed that included scheduling a fire drill at least every six months during sleep hours. Additionally, varying routes of exits were included. This will be monitored by the Director of Residential Services. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document components of the physical exams in five of six client records.
The findings include:
Six client records were reviewed on April 26, 2012. The physical examination documentation was required in six client records, #1, 2, 3, 4, 5 and 6. The physical exams are required to have the following documentation; date of the exam, vital signs, review of the client's organ system, client's general appearance and the physician's impressions of the client. The following client records failed to have the general appearance and the physician's impression of the client documented on the physical exams, #1, 2, 3, 4 and 6.
An interview with the project director and facility director on April 26, 2012 confirmed the findings.
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Plan of Correction
On May 1, 2012 the director of residential services provided clarification to this process. All physicals must have date of the exam, vital signs, review of the client's organ system, client's general appearance and the physician's impressions of the client. The executive assistant and clinical coordinator were advised of this and directed to pay close attention to the physicals received from other entities. If inadequate, a new physical examination will be performed by Main Street Family Practice. The clinical supervisor will review each physical examination upon admission and completion to ensure the standard is upheld. If standard is not upheld, the director of residential services will consult with Main Street Family Practice for corrective measures. |
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
Based on a review of client records, the facility failed to provide a psychosocial evaluation that included all assessment components may in six of six client records.
The findings include:
Six client records were reviewed on April 26, 2012. A psychosocial evaluation was required in six client records, #1, 2, 3, 4, 5, and 6. Although a psychosocial evaluation was documented in each of the client records reviewed, the facility failed to provide a complete assessment in the following records.
The psychosocial evaluations in client records #1, 2, 4, 5 and 6 did not include an evaluation of the client's problems and needs and how they would impact treatment.
The psychosocial evaluations in client records #3, 5 and 6 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5 and 6 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5 and 6 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5 and 6 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records #4, 6 did not include an evaluation of the counselors conclusions/impressions of the client.
Also, client records #1, 2 and 4 had identical evaluations. The document was changed to reflect the name of the client and the drug of choice.
An interview with project director and facility director on April 26, 2012 confirmed the findings.
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Plan of Correction
At staff meeting on May 9,2012, the Clinical Supervisor provided training to clinical staff on effective psycho-social evaluation, including appropriate clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment and overall impressions/conclusions. Examples of satisfactory psycho-social evaluations and composites will be provided to clinicians. The Clinical Supervisor will randomly review at least two files at each supervisory session, for each clinician, biweekly to ensure quality and compliance. |