INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30, 2011 through July 1, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD / New Start II 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.
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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 a review of personnel records and an interview with the facility director, the facility failed to document the qualifications for the position of counselor in one of three personnel records.
The findings include:
Three personnel records identified as counselors were reviewed on July 1, 2011, specifically records # 3, 4 and 5. Documentation of qualifications for the position of counselor was not included in personnel record # 5.
Personnel record # 5 contained transcripts from an accredited college, but the degree was not is in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field.
Personnel record # 5 contained transcripts from an accredited college stating a Bachelor of Arts with a major in Social Science/History.
An interview with the facility director on July 1, 2011 confirmed the findings.
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Plan of Correction
The program director reviewed personnel record #3 and met with the identified individual 8/1/11 and discussed the findings of the licensure visit. The individual stated he will provide proof of qualifications. The program director set up a meeting for 8/29/11 and at that time if the individual cannot provide proof of qualification his job duties and description will be changed to a non-counseling position within the project. To ensure future compliance the program director will review all qualification and require proof of qualification prior to hiring a counselor and will consult with the drug and alcohol licensing board if needed. |
704.11(a)(4) LICENSURE Evaluation of Overall 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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative records and an interview with the facility director, the facility failed to document an annual evaluation of the overall training plan.
The findings include:
The facility ' s administrative records were reviewed on July 1, 2011 for documentation of the annual evaluation of the overall training plan. The facility did not document an annual evaluation of the 2010 training year.
An interview with the facility director on July 1, 2011 confirmed the findings.
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Plan of Correction
Standard 704.11(a)(4)
evaluation of overall plan
Although the 2010 plan had been previously completed it was not in the facility manual at the time of the licennsing visit. The program director reviewed the plan and placed it in the manual on 7/11/11. To enusre future compliance the program director will submit the completed overall training plan to the administrative secretary who will ensure it is placed. The administrative secretary will keep additional copies on file. The program director will review the manual quarterly to ensure the plan is in place. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to store all trash, garbage and rubbish in covered containers.
The findings include:
A physical plant inspection was conducted on June 30, 2011 between approximately 9:00 AM and 10:00 AM. The facility was required to store all trash, garbage and rubbish in covered containers. At the time of inspection, the trash dumpster was missing one of its two lids.
An interview with the facility director on June 30, 2011 confirmed the findings.
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Plan of Correction
Standard 705.2(4) building exterior and grounds
On 7/1/2011 The residential supervisor placed a temporary lid onto the dumpster and ordered a new dumpster.
The program director and residential supervisor inspected the new dumpster that arrived and was placed on 7/18/2011.
To ensure on-going compliance with the standard the residential supervisor will include a visual inspection of the trash area including the dumpster, be conducted during monthly building inspections starting in August 2011. |
705.5 (j) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(j) A residential facility shall prohibit smoking and use of candles in bedrooms.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to prohibit the use of candles in client bedrooms.
The findings include:
A physical plant inspection was conducted on June 30, 2011 between approximately 9:00 AM and 10:00 AM. The facility was required to prohibit the use of candles in bedrooms. At the time of inspection, a candle was observed in client bedroom # 1.
An interview with the facility director on June 30, 2011 confirmed the findings.
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Plan of Correction
Standard 705.5(j) sleeping accomodations
The residential supervisor met with the residential staff on 7/11/11 and informed staff that there are to be no candles in the client bedrooms.
The residential supervisor conducted a meeting for all residents on 8/1/11 to inform them that they could not have candles or smoke in the bedrooms or thoughout the facility due to potential fire hazards. The residential supervisor posted signs in each bedroom prohiting the use of candles and will inspect rooms monthly to ensure on-going compliance. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to ensure that exits from the residential facility are unobstructed and operable at all times.
The findings include:
A physical plant inspection was conducted on June 30, 2011 between approximately 9:00 AM and 10:00 AM. At the time of inspection, the emergency exit window in the second floor bathroom could not be opened. Excessive paint on the window frame had sealed the window shut and this prevented it from being opened.
An interview with the facility director on June 30, 2011 confirmed the findings.
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Plan of Correction
705.10(a)(1)(i)Fire Safety
On 6/30/11 The program director instructed the facility maintenance worker to remove the excessive paint and open the window and insure its unobstructed operation. That was done and the exit was accessible.
To ensure future compliance the window will be replaced. The residential supervisor will be responsible for ensuring that all fire exits are unobstructed, accessible and operable during the monthly building inspection beginning in August 2011 and the reports will be reviewed by the program director quarterly. |
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 facility ' s fire drill log and an interview with the facility director, the facility failed to document a fire drill during sleeping hours at least every six months.
The findings include:
The facility ' s fire drill log was reviewed on July 1, 2011. The facility did not document a fire drill during sleeping hours at least every six months. The facility ' s last documented fire drills during sleeping hours were June 23, 2011 and June 3, 2010.
An interview with the facility director on July 1, 2011 confirmed the findings.
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Plan of Correction
Standard 705.10(d)(5) Fire safety
The residential supervisor reviewed the yearly fire drill schedule and adjusted the times to ensure that a fire drill will occur during sleeping hours at least every six months. The program director reviewed the calendar and the scheduled times. The residential supervisor will review the logs quarterly to ensure on-going compliance. |
709.22(e) 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:
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Observations
Based on a review of administrative records and an interview with the facility director, the facility failed to make available to the public an annual report.
The findings include:
The facility ' s administrative records were reviewed on July 1, 2011 for documentation of an annual report. The facility did not document an annual report for year 2010.
The facility ' s policy titled "709.22 (E1, 2, 3) Annual Report" states:
" The Annual Report will be made available to the public no later than three months after the close of the fiscal year. "
The facility ' s last documented annual report was for year 2009.
An interview with the facility director on July 1, 2011 confirmed the findings.
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Plan of Correction
Standard 709.23(b)(1) Project Director
The annual report had been completed for 2010 but there was no proof that it was made available to the public as outlined in the standard.
The facility will post a statement on our facility website and drug and alcohol website that the annual report for 2010 is avaiable on-site now. To ensure future compliance the administrative secretary will place a general statement on the web to let the public know that the facility's annual report will be available by 8/31 of each year. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document treatment plan updates to include an assessment of progress, in four of seven client records.
The findings include:
Seven client records requiring treatment plan updates were reviewed on July 1, 2011, specifically records # 1, 2, 3, 4, 5, 6 and 7. The treatment plan updates did not include an assessment of progress in client records # 1, 2, 4 and 5.
In client record # 1, the treatment plan updates documented on 4/29/11 and 5/27/11 did not include an assessment of progress.
In client record # 2, the treatment plan updates documented on 5/12/11 and 6/10/11 did not include an assessment of progress.
In client record # 4, the treatment plan updates documented on 5/27/11 and 6/24/11 did not include an assessment of progress.
In client record # 5, the treatment plan updates documented on 1/28/11 and 2/25/11 did not include an assessment of progress.
An interview with the facility director on July 1, 2011 confirmed the findings.
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Plan of Correction
Standard 709.52(b)Tx. Plan update
The facility failed to document the assessment on progress on all treatment goals in client records # 1,2,4 and 5.
The program director reviewed the treatment plan updates. The program director will review the updates and the regulations with the facility utilization assessor to set up a training for the counselors 8/24/11. Once the training is conducted the program director and the utilization assessor will review the treatment plan updates bi-weekly for one month, if the standard is in compliance they will be monitored monthly and at signing.
If updates are found not to be in compliance the counselor will receive one on one training by the utilization assessor and their plans will be submitted to the assessor for approbval prior to be submitted to clinical supervisor for one month.
If there is no improvement the counselor will be subject to corrective action. The program director will meet bi-weekly with the utilization assessor to ensure compliance and progress. Full compliance will be reached by 10/24/11. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document aftercare plans in two of three client records.
The findings include:
Three client records requiring aftercare plans were reviewed on July 1, 2011, specifically records # 5, 6 and 7. The facility did not document an aftercare plan in client records # 6 and 7.
The facility ' s policy titled " 709.53 (A-9) Client Records - After Care Plan " States:
Policy: Each client of New Start F.I.R. program will receive an aftercare plan to follow after they leave the program.
Procedure:
1.The After Care Plan will identify the client ' s future goals and objectives.
2.The After Care plan will focus on the continuity of care by building on the progress and achievements started at New Start FIR.
3.Each client is involved in the development of the plan along with their assigned addiction therapist.
4.The After Care will be developed 30 to 45 days before projected discharge based on client ' s level of care and the length of stay.
5.The After Care Plan will include:
a.future goals with time frames.
b.description of services that can be provided by the project after discharge.
c.method and frequency of continuing contact to provide client support.
d.criteria for re-entry into the project.
e.periodic re-evaluation and termination of the plan.
Client record #1 contained an aftercare plan, but the aftercare plan was not dated. Additionally, the aftercare plan did not contain future goals with time frames, the method and frequency of continuing contact to provide client support, and the criteria for re-entry into the project.
Client # 7 successfully completed the program and was discharged on 4/13/11, but the client ' s record did not contain an aftercare plan.
An interview with the facility director on July 1, 2011 confirmed the findings.
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Plan of Correction
Standard 709.53(a)(9) aftercare plan
The program director and counselors reviewed records # 1, 6 and 7, as well as, the aftercare plan policy and procedure. The utilization assessor will conduct a training on 8/8/11 on after care planning to ensure that the counselors have a clear understanding of the plan and the time frame expectations. The utilization assessor reviewer will review records bi-weekly for one month to ensure that the counselors are in compliance. Full compliance 9/8/11. |