INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19-21, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Treatment Program 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on the review of the Project ' s Staffing Requirements Facility Summary Reports, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the project.
The findings include:
The Project ' s Staffing Requirements Facility Summary Reports were reviewed by licensing staff from July 5-July 26, 2011 . Per regulation, a drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both. The review of the Project ' s Staffing Requirements Facility Summary Reports identified that the facility had 22 full time equivalent counselors in the project, which would require 2 full time clinical supervisors. The documentation showed that the project employed 1 full time clinical supervisor.
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Plan of Correction
The project has hired 6 staff in order to provide supervision of 22 counselors. The Project Director and Program Managers will ensure that two supervisors are dedicated to provide only supervision duties and have no other assigned duties. The Program Managers will review supervisory duties each quarter to ensure that they do not exceed supervision activities.
The Project Director will follow-up with the Program Managers to ensure that 2 Supervisors have only supervision duties by September 15, 2011.
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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 a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
The findings include:
A physical plant inspection was conducted on July 21, 2011. During the course of the inspection, it was observed that two counseling offices had windows which were not frosted or covered. One of the counseling offices was occupied at the time and a counseling session was taking place. The licensing specialist had a clear view of the room and its occupants.
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Plan of Correction
Program Director or his designee Office Manager will purchase window blinds and arrange for installation to be completed by 8/15/11 to ensure privacy during counseling sessions. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) 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 and interviews with the clinical supervisor, the facility failed to document an individual treatment and rehabilitation plan within 30 days of admission, as per facility policy, in three of eight client records.
The findings include:
Fourteen client records were reviewed on July 19-21, 2011. Eight of the clients reviewed were active clients and their individualized treatment and rehabilitation plan was reviewed. Individualized treatment and rehabilitation plans were due to be completed within 30 days of admission, as per facility policy, in all eight client records. Client records # 1, 4 and 6 did not contain individualized treatment and rehabilitation plans that were completed within 30 days of admission.
Client #1 was admitted on November 10, 2010. The individualized treatment and rehabilitation plan was due to be completed by December 10, 2010. The individualized treatment and rehabilitation plan was completed on December 17, 2010.
Client #4 was admitted on April 12, 2011. The individualized treatment and rehabilitation plan was due to be completed by May 12, 2011. The individualized treatment and rehabilitation plan was completed on May 20, 2011.
Client #6 was admitted on January 7, 2011. The individualized treatment and rehabilitation plan was due to be completed by February 7, 2011. The individualized treatment and rehabilitation plan was completed on July 7, 2011.
Interviews with the clinical supervisor took place multiple times on July 21 and 22, 2011. The aforementioned information was confirmed and no additional documentation was provided.
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Plan of Correction
Program Director or his designee will meet with clinical team and provide training and review by 8/15/11. Training will include review of the regulations re:completion of comprehensive treatment plan within 30 days of admission. Program Supervisor will monitor all new patient admissions on a monthly basis to ensure compliance treatment complettion within 30 days of admission and will reports reults to the Program Director on a monthly basis. |
711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records and interviews with the clinical supervisor, the facility failed to document the type and frequency of treatment and rehabilitative services on the individualized treatment and rehabilitation plan in four of eight client records, as required by regulation.
The findings include:
Fourteen client records were reviewed on July 19-21, 2011. Eight of the clients reviewed were active and their individualized treatment and rehabilitation plan was reviewed. All eight client records required documentation of the type and frequency of treatment and rehabilitative services on the individualized treatment plan. Per regulation, an individualized treatment and rehabilitation plan shall be developed with a client to include the type and frequency of treatment and rehabilitative services. The facility failed to document the type and frequency of treatment and rehabilitative services in client records # 5, 6, 7 and 8.
Client # 5 was admitted to the program on November 9, 2010. The individualized treatment and rehabilitation plan was completed on November 22, 2010. The individualized treatment plan did not include the type of therapy sessions that would be provided, only that the client would receive 2.5 hours per month.
Client # 6 was admitted to the program on January 7, 2011, The individualized treatment and rehabilitation plan was completed on July 7, 2011. The individualized treatment plan did not include the type or frequency of counseling sessions.
Client # 7 was admitted to the program on December 15, 2010. The individualized treatment and rehabilitation plan was completed on January 14, 2011. The individualized treatment plan did not include the type of therapy sessions that would be provided, only that the client would receive weekly sessions.
Client # 8 was admitted to the program on April 18, 2011. The individualized treatment and rehabilitation plan was completed on May 11, 2011. The individualized treatment plan did not include the type of therapy sessions that would be provided, only that the client would receive 2.5 hours per month.
The clinical supervisor was interviewed multiple times on July 21 & 22, 2011. The clinical supervisor confirmed the aforementioned information and had no additional documentation to provide for review.
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Plan of Correction
Program Director or his designee will meet with clinical staff by 8/15/11 to re-train staff on treatment plan development regarding need to include type and frequency of services. Program Supervisor will monitor ongoing compliance through chart audits and individual supervision on amonthly basis and will reports results to the Program Director monthly. |
711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) 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 interviews with the clinical supervisor, the facility failed to document the proposed type of support service on the individualized treatment and rehabilitation plan in three of eight client records, as required by regulation.
The findings include:
Fourteen client records were reviewed on July 19-21, 2011. Eight of the clients reviewed were active and their individualized treatment and rehabilitation plan was reviewed. All eight client records required documentation of the proposed type of support service on the individualized treatment plan. Per regulation, an individualized treatment and rehabilitation plan shall be developed with a client to include the proposed type of support service. The facility failed to document the proposed type of support service in client records # 1, 2 and 8.
Client # 1 was admitted to the program on November 10, 2010. The individualized treatment and rehabilitation plan was completed on December 17, 2010. The individualized treatment plan did not include the proposed type of support service.
Client # 2 was admitted to the program on May 5, 2011. The individualized treatment and rehabilitation plan was completed on May 31, 2011. The individualized treatment plan did not include the proposed type of support service.
Client # 8 was admitted to the program on April 18, 2011. The individualized treatment and rehabilitation plan was completed on May 11, 2011. The individualized treatment plan did not include the proposed type of support service.
The clinical supervisor was interviewed multiple times on July 21 & 22, 2011. The clinical supervisor confirmed the aforementioned information and had no additional documentation to provide for review.
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Plan of Correction
Program Director or his designee shall meet with clinical staff by 8/15/11 to re-educate staff on the documentation procedures for including proposed type of support services on the individualized treatment and rehabilitation plan. Program Supervisor shall oversee ongoing compliance through chart audits and individual supervision with therapy team on a monthly basis. Program Supervisor will report results to the Program Director on a monthly basis. |
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records and an interview with the clinical supervisor, the facility failed assure that the counseling services were provided according to the individual treatment and rehabilitation plan in three of eight client records.
The findings include:
Fourteen client records were reviewed on July 19-21, 2011. Eight clients reviewed were active and their individualized treatment and rehabilitation plan was reviewed. All eight client records reviewed required documentation that counseling services were provided according to the individual treatment and rehabilitation plan. The facility did not document that services were provided according to the individual treatment and rehabilitation plan in client records # 2, 3 and 5.
Client # 2 was admitted on May 5, 2011. The treatment plan, completed on May 31, 2011, stated that the client was to receive individual and group counseling totaling 2.5 hours per month. The client was last seen in a counseling session on May 31, 2011. No counseling sessions have been completed, nor were they scheduled since that date.
Client # 3 was admitted on March 3, 2011. The treatment plan, completed on March 25, 2011, stated that the client was to receive 2.5 hours of counseling per month. The client has not completed a session since 5/12/11. Individual treatment sessions were scheduled for 6/16/11 and 7/11/11; however, the client did not present for the appointments. There were no additional appointments scheduled.
Client # 5 was admitted on November 9, 2010. The treatment plan, completed on November 22, 2011, stated that the client was to receive 2.5 hours of therapy per month. The client did not have any completed or scheduled therapy sessions for the month of December 2010. Also, the client did not receive 2.5 hours of counseling for the months of January, February, March, May and June 2011.
Multiple interviews with the clinical supervisor took place on July 21 & 22, 2011. The aforementioned information was confirmed and there was no additional documentation presented for review.
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Plan of Correction
Program Director or his designee shall meet with clinical staff by 8/15/11 to re-educate staff on adherance to providing counseling serives according to the individual treatment and rehabilitation plan.Program Supervisor shall oversee ongoing compliance through the use of a Weekly Therapy Compliance report, chart audits and individual supervision. Program Supervisor will report results to the Program Director on a monthly basis.
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711.92(f) LICENSURE Couns. Prov.- Reg & Sched.
711.92. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records and an interview with the clinical supervisor, the facility failed to provide counseling on a regular and scheduled basis in three of eight client records.
The findings include:
Fourteen client records were reviewed on July 19-21, 2011. Eight clients reviewed were active and their individualized treatment and rehabilitation plans were reviewed. Counseling which is provided on a regular and scheduled basis was required in all eight client records. Client records # 2, 3 and 5 did not have documentation that clients were provided counseling on a regular and scheduled basis.
Client # 2 was admitted on May 5, 2011. The client was last seen in a counseling session on May 31, 2011. No counseling sessions have been completed, nor were they scheduled since that date.
Client # 3 was admitted on March 3, 2011. The client has not completed a session since 5/12/11. Individual treatment sessions were scheduled for 6/16/11 and 7/11/11; however, the client did not present for the appointments. There were no additional appointments scheduled.
Client # 5 was admitted on November 9, 2010. The client did not have any completed or scheduled therapy sessions for the month of December 2010. Also, the client did not receive or have scheduled 2.5 hours of counseling for the months of January, February, March, May and June 2011.
Multiple interviews with the clinical supervisor took place on July 21 & 22, 2011. The aforementioned information was confirmed and there was no additional documentation presented for review.
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Plan of Correction
Program Director or his designee shall meet with clinical staff by 8/15/11 to provide re-training on the requirement to provide counseling on a regular and scheduled basis. The Program Supervisor shall oversee ongoing compliance through the use of a Weekly Therapy Compliance report, chart audits and individual supervision and will report results to the Program Director on a monthly basis.
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