INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25, 20011 through July 27, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Addiction Medicine and Health Advocate, 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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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy and procedure manual and an interview with the clinical supervisor, the facility failed to document when the assessment of staff training needs were completed.
The findings include:
On July 25, 2011, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, the assessment forms will be completed by each employee in December, and the forms will be returned in December. The regulation requires an assessment of staff training needs to be completed as a component of a staff development program. The facility failed to document on the assessment when they were completed, there was no date of completion to verify that is was completed in December for the January 1, 2011 through December 31, 2011 training year.
The clinical supervisor was interviewed on January 26, 2011. The clinical supervisor confirmed that the assessments didn't have the date of completion for the January 1, 2011 through December 31, 2011 training year.
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Plan of Correction
The annual training needs assessment form will be revised to reflect the date of completion by the individual staff person completing the assessment form to correspond with the dates outlined in the policy and procedure manual. The staff development coordinator will veriy and acertain that each training assessment form has a date of completion and the signature of the person completing the form. The clinical coordinator will be responsible will be responsible for compliance. |
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 the policy and procedure manual and an interview with the clinical supervisor, the facility failed to document an overall plan for addressing training needs, as required by regulation.
The findings include:
On July 26, 2011, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, a training plan will be completed after the summary of staff training needs. The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. The facility failed to document the completion of an overall training plan for training year January 1, 2011 through December 31, 2011.
The clinical supervisor was interviewed on July 26, 2011 and confirmed the findings.
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Plan of Correction
The staff development coordinator has responsibility for completion of the overall staff training plan. The clinical coordinator will monitor and verify the completion of the overall staff training plan in accordance with the agency policy and prodedure manual. This will be accomplished according to the policy and procedure due dates. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of client records, the policy and procedure manual and an interview with the clinical supervisor, the facility failed to document a mechanism to collect feedback on completed training, as required by regulation.
The findings include:
On July 26, 2011, fifteen employee records and the policy and procedure manual were reviewed. Per the agency policy and procedure manual, each employee is required to submit a feedback form after the completion of training. The regulation requires a mechanism to collect feedback as a component of a staff development program. The facility failed to document the submission of feedback forms after the completion of employee training.
The clinical supervisor was interviewed on July 26, 2011 and confirmed that feedback forms had not been submitted by each employee upon the completion of training.
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Plan of Correction
The staff development coordinator will be responsible for assuring that all staff will complete training feedback forms after the completion of all trainings attended. These feedback forms will be placed in the master training binder along with the certificate from the training. |
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 personnel records, staffing requirements facility summary report and a staff interview, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Fifteen personnel records were reviewed on July 25, 2011 through July 26, 2011. There was no documentation of HIV/AIDS or TB/STD training in two employee records. Of the two, one was to have HIV/AIDS and TB/STD training within the first year of employment and the other one was required to have HIV/AIDS and TB/STD training within the two years of employment.
Employee #5 was hired June 29, 2009 and was required to have HIV/AIDS & TB/STD training by July 29, 2010. There was no documentation of TB/STD training in the employee's record as of July 26, 2011.
Employee #15 was hired October 14, 2008 and was required to have HIV/AIDS & TB/STD training by October 14, 2010. There was no documentation of HIV/AIDS training in the employee's record as of July 26, 2011.
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Plan of Correction
Employee #5 completed TB/STD training on 12/18/2009. Her certificate of completion was placed in the master training binder, but was not placed in employees personnel record. A copy of the certificate has been placed in the employee personnel file as of 8/9/2011.
Employee #15 is scheduled to receive HIV/AIDS on 8/25/2011. After completion of the training certificates of completion will be placed in the appropriate personnel file and master training binder. The clinical coordinator will be responsible for compliance. After each training the staff development coordinator will verify that a copy of the training certificate has been obtained and given to the administrative assistant to be placed in the staff person's personnel chart. The clinical coordinator will then check the personnel charts to ensure that the certificate has been placed as per procedure. A random sample of personnel records will be reviewed as a part of quality improvement committee. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of facility staff CPR/first aid certification cards, 4 week staffing schedule and an interview facility staff, the facility failed to ensure that at least one person trained in CPR skills onsite during the project's hours of operation.
The findings include:
The updated CPR/first aid certification cards and staff schedules were reviewed on July 26, 2011. Based on a review of staff schedules and staff CPR/first aid certification cards, the facility did not have any staff trained in these skills on different days and shifts.
The facility hours of operations is Monday through Friday 7 am to 4:30 pm and Saturday 6:30 am to 12 pm. Currently four nurses and one counselor have updated CPR certification cards all other staffs CPR certifications expired June 2011.
For the week of June 27, 2011 through July 2, 2011 the following dates and hours showed no CPR coverage; July 1, 2011 did not have CPR coverage for the hours of 3:30 pm to 4:30 pm. July 2, 2011 the time sheets reviewed did not show any coverage of CPR for the hours of 6:30 pm to 12 pm.
For the week of July 4, 2011 through July 10, 2011 the following dates and hours showed no CPR coverage; July 5, 2011 through July 8, 2011 there was no CPR coverage for the hour of 3:30 pm to 4:30 pm.
For the week of July 11, 2011 through July 17, 2011 the following dates and hours showed no CPR coverage; July 11, 2011 through July 15, 2011 there was no CPR coverage for the hour of 3:30 pm to 4:30 p,. July 16, 2011 the time sheets reviewed did not show any coverage of CPR for the hours of 6:30 pm to 12 pm.
For the week of July 18, 2011 through July 24, 2011 the following dates and hours showed no CPR coverage; July 18, 2011 through July 22, 2011 there was no CPR coverage for the hour of 3:30 pm to 4:30 pm.
For the week of July 25, 2011 through July 27, 2011 the following dates and hours showed no CPR coverage; July 25, 2011 through July 27, 2011 there was no CPR coverage for the hour of 3:30 pm to 4:30 pm.
An interview with the staff on July 27, 2011 stated that there was a scheduling issue with the company that they go through to get the CPR/First Aid training's and that is why there is a gap in coverage for those hours and why staff didn't have update CPR certifications for review.
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Plan of Correction
The agency is currently negotiating with JeffStat to train the entire staff in CPR. This training will be completed by 9/30/2011. Until that time the agency will make sure that a CPR certified staff person will be available during agency hours of operation. The staff development coordinator is responsible for scheduling and compliance. The clinical coordinator will see to it that the required CPR coverage is in place during hours of operation. |
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 personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of eleven personnel records reviewed.
The findings include:
Fifteen personnel records were reviewed on July 25, 2011 through July 26, 2011. Eleven of the fifteen were counselors and of the eleven counselors only three were required to have training's reviewed, #4, 5 and 6. The facility failed to document 25 clock hours of annual training in personnel record #5.
Employee # 5 was hired on June 29, 2009. The facility training year is from January through December. The training year for January 2010 to December 2010 was reviewed. Employee # 5 only completed 8.5 clock hours of annual training in 2010.
The clinical supervisor was interviewed on July 26, 2011 and confirmed the findings.
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Plan of Correction
Each individual will be monitored to assure compliance with required training hours as indicated in their individualized training plan. The staff development coordinator will be responsible for compliance and the clinical coordinator will monitor compliance for all staff. |
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 and an interview with the facility staff, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms, and negative factors that may inhibit treatment and the counselor conclusions and or impressions of the client in fifteen of sixteen client records.
The findings include:
Sixteen client records were reviewed on July 26, 2011 through July 27, 2011. A psychosocial evaluation was required in sixteen of those records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 13, 14, 15 and 16. Per the facility policy, psychosocial evaluations are to be completed within 21 days of the clients admission date. An interview with the clinical supervisor on July 27, 2011 confirmed the findings.
Client records #1, 3, 4, 5, 6, 7, 8, 11, 12, 13 and 15 lacked an evaluation of the client's assets/strengths and how they would impact treatment.
Client records #1, 3, 4, 5, 7, 8, 11, 12, 13 and 15 lacked an evaluation of the client's support systems and how they would relate to treatment.
Client records #1, 3, 5, 6, 7, 8, 11, 12 and 13 lacked an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
Client records # 1, 3, 4, 5, 6, 7, 11, 12 and 13 lacked an evaluation of the client's negative factors and how they would impact treatment.
Also, the following client records #9, 10, 14 and 16 did not have documentation of the client's psychosocial evaluation in records reviewed.
Client #9 was admitted on March 30, 2011 and was to have had their psychosocial evaluation documented by April 20, 2011. The client was discharged on June 14, 2011 and as of the date of the clients discharge there was no documentation of the client's psychosocial evaluation.
Client #10 was admitted on October 7, 2010 and was to have had their psychosocial evaluation documented by October 28, 2010. The client was discharged on December 21, 2010 and as of the date of this inspection there was no documentation of the client's psychosocial evaluation.
Client #14 was admitted on November 9, 2010 and was to have had their psychosocial evaluation documented by November 30, 2010. The client was discharged on February 18, 2011 and as of the date of the client's discharge there was no documentation of the client's psychosocial evaluation.
Client #16 was admitted on September 22, 2010 and was to have had their psychosocial evaluation documented by October 13, 2010. Client was discharged on May 31, 2011 and as of the date of the client's discharge there was no documentation of the clients psychosocial evaluation.
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Plan of Correction
The clinical coordinator will conduct a staff training on the overall biopsychocial evaluation to include staff evaluation of patient assets/strengths/weaknesses/defense mechanisms/support systems, their possible impact on patient treatment and the basis for the staff person's assessment. Additionally, the clinical coordinator and/or the clinical supervisor will review and monitor staff compliance during individual supervision and review the biopsychosocial evaluations prior to signing off. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, and an interview with the facility director, the facility failed to provide written documentation of the proposed type of support service, in the individual treatment and rehabilitation plans, in seven of sixteen client records.
The findings include:
Sixteen client records were reviewed on July 26, 2011 through July 27, 2011. The individual treatment and rehabilitation plans were required to document proposed type of support services in sixteen records. The facility did not document proposed type of support services in client records # 1, 7, 8, 11, 12, 14 and 15.
Client # 1 was admitted on March 31, 2011. The individual treatment and rehabilitation plan was completed on April 18, 2011. There was no documentation of support services in the treatment plan.
Client # 7 was admitted on May 25, 2011. The individual treatment and rehabilitation plan was completed on June 15, 2011. There was no documentation of support services in the treatment plan.
Client # 8 was admitted on May 4, 2011. The individual treatment and rehabilitation plan was completed on May 16, 2011. There was no documentation of support services in the treatment plan.
Client # 11 was admitted on November 18, 2010. The individual treatment and rehabilitation plan was completed on December 9, 2010. There was no documentation of support services in the treatment plan.
Client # 12 was admitted on October 5, 2010. The individual treatment and rehabilitation plan was completed on October 25, 2010. There was no documentation of support services in the treatment plan.
Client # 14 was admitted on November 19, 2010. The individual treatment and rehabilitation plan was completed on November 30, 2010. There was no documentation of support services in the treatment plan.
Client # 15 was admitted on October 7, 2010. The individual treatment and rehabilitation plan was completed on October 28, 2010. There was no documentation of support services in the treatment plan.
The clinical supervisor was interviewed on July 27, 2011 and confirmed that some of the counselors were not documenting support services on the treatment plans, as required.
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Plan of Correction
A staff meeting will be conducted to remind and reinforce the importance of addressing support services, with an emphasis placed on recovery support services, and the need to include these specific items on the patient's treatment plan. The clinical coordinator and clinical supervisor will be responsible for monitoring and compliance during individual supervision. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records and an interview with the clinical supervisor, the facility failed to document a case consultation within the 90 day time frame in three of sixteen client records.
The findings include:
Sixteen client records were reviewed on July 26, 2011 through July 27, 2011. Of the sixteen client records reviewed eleven were required to have case consultations, # 1, 2, 4, 5, 6, 11, 12, 13, 14, 15 and 16. The following client records did not have documentation of case consultations, # 2, 13, 14 and 15. The findings were reviewed with the clinical supervisor on July 27, 2011. Per agency policy, case consultations shall be completed every 90 days.
Client record #2 was admitted on April 14, 2011 and their case consultation was due by July 14, 2011. As of to date there was not documentation of a case consultation on client #2.
Client record #13 was admitted on November 9, 2010 and discharged on April 29, 2011 and their case consultation was due by February 9, 2011. As of to date there was not documentation of a case consultation on client #13.
Client record #14 was admitted on November 9, 2010 and discharged on February 18, 2011 and their case consultation was due by February 9, 2011. As of to date there was not documentation of a case consultation on client #14.
Client record #15 was admitted on October 7, 2010 and discharged on June 29, 2011 and their case consultation was due by January 7, 2011 and April 7, 2011. As of to date there was not documentation of a case consultations on client #15.
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Plan of Correction
A staff meeting will be conducted to reinforce the importance of the case consultations being completed every 90 days for patients on the clinic less that one year. The clinical coordinator and clinical supervisor will monitor and assure compliance during individual staff supervision. |