INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23-24, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health- Pa, Inc. 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 May 22, 2009.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of the agency manual during the onsite inspection of April 23-24, 2009 the facility failed to document a training procedure which included who is responsible and the timeframes for the required components.
The findings include:
The agency training policy and procedure was reviewed during the annual licensing inspection. The procedure did not document who, by job title, is responsible for the completion of the annual training plan. The procedure did not document timeframes for completion of each of the required components of the staff development program.
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Plan of Correction
The Operation and Corporate Compliance Department will review and amend policy and procedure to identify who, by job title, is responsible for the completion of the annual training plan as well as identify the time frames for which the staff development plan is completed. Program Director will be responsible to ensure this citation is brought up to compliance with regulations. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the employee training records during the onsite licensing inspection of April 20-22, 2009, the facility failed to document an individual training plan for each employee.
The findings include:
Twelve employee records were reviewed on April 20 - 22, 2009. There was no documentation of an individual training plan employee record # 5.
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Plan of Correction
An individual training plan will be created by employee #5 and sent to facility to be filed in training assessment binder. Program Director will be responsible to ensure this citation is brought up to compliance with regulations. Program Director will obtain a copy of employee #5's training plan annually to be included and updated with all other Associates. |
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 personnel and training records during the onsite licensing inspection of April 23-24, 2009, the facility failed to ensure that each counselor received the mandatory 25 annual training hours for the 2008 training year.
The findings include:
Twelve employee training records were reviewed during the annual licensing inspection. One record (# 8) had only 22.5 hours documented for the 2008 training year.
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Plan of Correction
Clinical supervisor has been directed to review individual training plans for Associates in supervision to ensure all Associates obtain the required amount of training hours a year. Associate #8 will be offered extra training to compensate for deficient hours last year. Program Director will be responsible to ensure this citation is brought up to compliance with regulations. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the 2007 annual report during the onsite licensing inspection of April 23 - 24, 2009, the facility failed to document a financial statement of income and expenses in the body of the report
The findings include:
The annual report was reviewed during the licensing inspection. No financial statement of income and expenses was documented.
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Plan of Correction
Project Director is in the process of requesting a waiver from the PA Department of Health to remove finanical statement of income and expenses. Approval or disapproval to this waiver is projected to be obtained by 05/29/09.
If waiver is granted, Program Director will be responsible to ensure the waiver is followed as outlined by the PA Department of Health.
If waiver is not approved, arrangements for an audit will be made within 90 days of notification of denial to bring facility up to compliance with regulations. Program Director will oversee. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of the policy manual during the onsite licensing inspection of April 23-24, 2009, the facility failed to document a manual which addressed the requirements of 28 Pa. Code Chapter 709.
The findings include:
The policy and procedure for 709.26(b)(10) - Confidential maintenance of personnel records - did not document the method for the release of employee information from the record or indicate who, by job title, was responsible for maintaining the records.
709.28 (a)(1)- Confidentiality of client identity and records.- The policy and procedure documented inaccurate language as it pertained to HIPAA, (allowing for the re release of client identifying information without the client's specific written consent) and conflicting with 42 CFR Part 2, Subpart C requirements which prohibit the re release of client identifying information. The language in this policy blends the two laws together, when they are, in fact, distinct laws and must be addressed separately.
709.28(a)(2)- Staff access to client records- The procedure does not document a method for accessing client records. The policy and procedure is not specific to Pennsylvania.
704.11(a)- Staff development policy- The procedure does not document who is responsible for formulating the training plan and does not document the timeframes for the completion of each component. The policy and procedure is not specific to Pennsylvania.
The policies and procedures contain generic language which does not document specific requirements as detailed in 28 Pa. Code Chapters 704 and 709, specific examples are listed below:
page 61- " Each clinic will have a person designated to provide clinical supervision. This person will meet the clinical supervisor requirements for the State. Supervision will be provided to each counselor as required by state regulation and licensure requirements. The policy and procedure is not specific to Pennsylvania.
page 118 - "Assessments will be conducted by qualified persons as determined by state regulations and standards." The policy and procedure is not specific to Pennsylvania.
page 186- "In states where required for minors the release would include the dated signature of the patient's guardian." The policy and procedure is not specific to Pennsylvania.
Page 207- "Individual (treatment) plans will be reviewed periodically. At least annually or more frequently as required by state standards or as required by changes in the patients life situation and needs." The policy and procedure is not specific to Pennsylvania.
The last section of the manual talks about providing co- occurring services. Discovery House programs in Pennsylvania are not providing co- occurring services and do not maintain the required dual licensure to do so.
This is a repeat citation from 2008.
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Plan of Correction
Operations and Compliance will review and amend policy and procedure to:
1. indicate the method of release of employee information (709.26 (b)(10))
2. identify specific method for Associate's access to patient records (709.28 (a)(2))
3. identify which Associate is responsible for formulating training plan and timeframes for completion of training plan (704.11 (a))
Each plan will address procedure specific to Pennsylvania.
Operations and Compliance has submitted amended policy for PA DOH's review to address confidentiality laws separately (709.28)(a)(1).
Project Director will be responsible approve amendments. Program Director will be responsible to ensure this citation is brought up to compliance with regulations
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative materials, the facility failed to document an annual fiscal audit for the fiscal year.
The findings include:
The agency training manual, appendices manual and other materials were reviewed on April 23-24, 2009 and presented no documentation of the required annual fiscal audit.
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Plan of Correction
Discovery House Policy had been changed to allow for 180 days after beginning of a new year to submit annual fiscal audit. Annual fiscal audit for 2008 will be made available before 06/29/09. Program Director will be responsible to ensure this citation is brought up to compliance with regulations.
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709.26(b)(1) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(1) Confidential maintenance of personnel records.
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Observations
Based on the review of the agency manual and the associate handbook, the facility failed to document a complete policy addressing confidential maintenance of personnel records.
The findings include:
The agency policy manual and Associate Handbook were reviewed on April 23-24, 2009. The policy and procedure did not document, by job title, who is responsible for maintaining employee records or the procedure to follow if records of employees are to be released.
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Plan of Correction
Operations and Compliance will review and amend policy and procedure to clearly identify which Associate is responsible to maintain Associate records and the procedure to follow if Associate records are to be released. Program Director will be responsible to ensure this citation is brought up to compliance with regulations. |
709.28(a)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(2) Staff access to client records.
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Observations
Based on a review of the agency policy manual the facility failed to document a complete policy and procedure stating how staff may access patient records.
The findings include:
The procedure in the agency policy manual was reviewed on April 23-24, 2009. The policy did not document the methods used by staff to access patient records.
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Plan of Correction
Operations and Compliance will review and amend policy and procedure to clearly identify which Associates (according to job title) have access to patient records. The method to obtain patient access to records will also be included in policy review.
Policy will also address who, by job title, has access to patient records from Smart Management.
Program Director will be responsible to ensure this citation is brought up to compliance with regulations. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of the agency's 2007 annual report and patient records during the April 23-24, 2009 annual inspection, the facility failed to obtain an informed consent to release information from each patient for each release of information, as documented in two of eighteen patient records.
The findings include:
During the onsite licensing inspection eighteen patient records were reviewed. One patient record (#5) was that of a client whose picture, full name and personal information was published in a nationally circulated annual report for the Discovery House system. No specific consent to release this information was documented for this client. A file note on 1/29/09 in patient record # 11 documented a family session with this client's significant other. No consent to release information to the significant other was documented in the client record.
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Plan of Correction
Clinical Supervisor conducted a training on 05/07/2009 specific to patient confidentiality. Training included how to properly complete a media release when patients are spotlighted in publications to prevent this citation from every happening again.
Clinical Supervisor responsible for chart audits to monitor and ensure proper releases are in place for patients participating in couple session. Program Director will be responsible to ensure this citation is brought up to compliance with regulations.
At the Corporate Level, the Patient Advocate will be responsible for coordinating interviews between patient, clinic and public relations. The Patient Advocate will be responsible for checking the patient file for the appropriate release before allowing information to be shared. |
715.29(4) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(4) The narcotic treatment program shall maintain documentation of the Department 's approval of an exception.
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Observations
Based on a review of administrative materials during the onsite licensing inspection of April 23-24, 2009, the facility failed to maintain documentation of the Department's approval of an exception.
The findings include:
During the annual onsite licensing inspection, the Facility director presented an exception to the outpatient caseload regarding reduced counseling patients that would allow the facility to assign more than 35 patients to a counselor's caseload. The exception was addressed to another facility within the Discovery House project. There was no documentation of a specific exception for the Cranberry Township clinic. The stipulations of the exception were not adhered to as regarded compliance with the requirement that "No more than one half of a caseload may include patients on a reduced schedule...". The intent of this exception is that not more than one half of the actual caseload carried by a given counselor may be counted on a reduced schedule. Counselor # 9 had a caseload of 43 clients at the time of the inspection and 23 were identified as being on a reduced schedule. Counselor # 8 had 45 clients on her caseload at the time of the inspection and 25 were identified as being on a reduced schedule.
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Plan of Correction
Program Manager and Clinical Supervisor reviewed caseloads to identify caseloads which do not meet compliance with waiver. Plan has been made to arrange caseloads so that no more than one half of a caseload includes patients on a reduced schedule. Program Director has contacted PA Department of Health to obtain documentation specific to Cranberry Township. Program Director will be responsible to monitor and ensure this citation is brought up to compliance with regulations. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of patient records on April 23-24, 2009, the facility failed to document complete personal histories in 15 of 18 patient records.
The findings include:
Eighteen client records were included in the sample reviewed. Each patient record was required to include documentation of a complete personal history. The family history did not include pertinent family dynamics in patient records # 1, 2, 3, 4, 5, 6, 7, 8, 10, 13, 15, 16, 17 and 18. Employment histories included only the most recent positions held and failed to document complete employment histories in patient records # 1, 3, 6, 7, 12, 15 and 16.
Patient records # 11 and 15 were those of clients that either transferred into the program or were readmitted. The required update of personal history information on these clients was not documented.
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Plan of Correction
Patient family dynamics will be added into patient records #1, 2, 3, 4, 5, 6, 7, 8, 10, 13, 15, 16, 17 and 18.
Complete employment histories will be added into patient records #1, 3, 6, 7, 12, 15, and 16.
Updated personal history will be completed for patient records #11 and 15.
Clinical Supervisor will perform a training for clinical associates so that this citation does not occur again.
Primary Counselor is responsible for updating above mentioned patient records and Clinical Supervisor will monitor to ensure these charts are brought to compliance. Program Director will oversee. |
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 the review of patient records on April 23-24, 2009, the facility failed to document complete psychosocial evaluations in 14 of 18 patient records.
The findings include:
Eighteen patient records were reviewed on April 23 - 24, 2009. Each patient record was required to have documentation of a complete psychosocial evaluation. An evaluation of the patients' support systems were not documented in patient records # 1, 3, 4, 6, 10, 11, 16 and 17. An evaluation of the patients' coping mechanisms were not documented in patient records # 1, 2, 3, 4, 6, 7, 8, 9, 10, 12, 14 and 16. There was no documentation of psychosocial evaluations in patient records # 11 and 17.
This is a repeat citation from 2008.
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Plan of Correction
Patient support systems will be added into patient records #1, 3, 4, 6, 10, 11, 16 and 17.
Patient coping mechanisms will be added into patient records #1, 2, 3, 4, 6, 7, 8, 9, 10, 12, 14, and 16.
Psychosocial evaluations will be completed for patient records #11 and 17.
Clinical Supervisor will perform a training for clinical associates so that this citation does not occur again.
Primary Counselor is responsible for updating above mentioned patient records and Clinical Supervisor will monitor to ensure these charts are brought to compliance. Program Director will oversee. |
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 the review of patient records on April 23-24, 2009, the facility failed to document individualized treatment goals on each comprehensive treatment plan as required by agency policy and this regulation in six of fifteen patient records.
The findings include:
Eighteen patient records were reviewed during the annual licensing inspection. Fifteen of these were required to have individualized, comprehensive treatment plans documented. Individualized treatment goals were not documented in the following patient records reviewed: # 1, 9, 11, 15, 16 and 18. The treatment plans were generic and standardized.
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Plan of Correction
Clinical Supervisor to conduct a training for clinical associates on how to complete treatment plans that are individual to patient's needs and assessment.
Clinical Supervisor will not approve treatment plans unless the treatment plans are specific to patient and address issues that were mentioned in patient's assessment.
Clinical Supervisor will review treatment plans from records #1, 9, 11, 15, 16, and 18 with respective counselors to ensure the updated plans are brought up to compliance with regulations.
Program Director to oversee. |
709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
Based on a review of client records during the onsite licensing inspection of April 23- 24, 2009, the facility failed to document client related correspondence to insurance companies which included information disclosed.
The findings include:
Eighteen client records were reviewed during the annual onsite licensing inspection. Eight of these clients were funded through a third party payer. Client related correspondence regarding the releases of information, in accordance with 4 Pa. Code subsection 255.5(a)(10), was not documented in the following patient records : # 8, 9, 14 and 17.
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Plan of Correction
Training conducted with all Associates on proper disclosure correspondence to insurance companies. Documentation identifying client related correspondence will be documented in each of our patient charts. Associates will either utilize the "disclosure" feature in software, document the information released in patient's chart, or attach the information along with fax confirmations and file in patient paper chart.
Program Manager is charged to conduct chart audits to ensure training is effective and regulation is being followed.
Program Director to oversee. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of patient records during the onsite licensing inspection of April 20-22, 2009, the facility failed to document aftercare plans within the fourteen day timeframe specified in the documented agency policy.
The findings include:
Eighteen client records were reviewed during the onsite licensing inspection. All of these clients were in treatment long enough to require aftercare plans, which was within fourteen days of admission as stated in agency policy. Thirteen of the applicable records did not document aftercare plans within the timeframes specified in documented agency policy. These are the records that were non-compliant with the policy based on the documented dates on the aftercare plans in each patient record:
Patient record #1 - admitted 3/4/08- aftercare plan dated 4/9/08
Patient record #3- admitted 2/4/09- aftercare plan not documented as of 4/24/09
Patient record #5- admitted 3/21/05 - aftercare plan dated 4/21/05 - annual update 3/ 21/08, none for 2009
Patient record #6 - admitted 3/17/08 - aftercare plan dated 4/17/08
Patient record #7 - admitted 3/31/09 - aftercare plan not documented as of 4/24/09
Patient record #8 - admitted 12/10/08 - aftercare plan dated 1/14/09
Patient record #9 - admitted 11/26/08 - aftercare plan dated 8/26/06
Patient record # 10 - admitted 7/26/06 - no plan documented as of 4/20/09
Patient record # 12 - admitted 4/2/09/ - aftercare plan dated 4/20/09
Patient record # 14 - admitted 5/22/08 - aftercare plan dated 6/22/08
Patient record #16 - admitted 1/8/08 - aftercare plan dated 2/8/08
Patient record # 17 - admitted 10/27/08 - aftercare plan dated 11/27/08
Patient record # 18 - admitted 12/15/08 - aftercare plan dated 1/15/09
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Plan of Correction
Program Director requested from Computer Support Department that the Aftercare Plans are prompted within 14 days of a patient's admission (previous to inspection, Aftercare Plans were prompted for 30 days after admission).
Clinical supervisor will review "services due" report to ensure aftercare plans are being completed as policy identifies completion.
Program Director will oversee to ensure policy is being followed by all Associates. |