INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 19-20, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on August 17, 2007.
|
Plan of Correction
|
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.
|
Observations
The facility failed to meet this requirement because documentation presented for employees # 7, 8, 9 and 10 was incomplete in detailing that the appropriate number of hours of training have been completed.
|
Plan of Correction
TB/STD training will be scheduled within 30 days and all associates not in compliance of this regulation will have the appropriate amount of hours completed by 90 days. Clinical supervisor to schedule and Program Director to monitor. |
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.
|
Observations
The facility failed to meet this requirement because documentation in two employee files (6 and 7) did not support that both staff had received the required 25 hours of training for the 2006 training year.
|
Plan of Correction
Upon investigation, it was found that each associate completed the proper amount of training, however, documentation was poorly completed. Effectively immediately, proper documentation will be completed by Training Certificates/sign in sheets. Clinical Supervisor to complete and Program Director to monitor. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
The facility failed to meet this requirement because the stipulations of the September 20, 2004 exception granted by the Division for extended caseloads were not met. Two counselors (6 and 10) had more than half of their caseloads made up of individuals on a reduced schedule.
|
Plan of Correction
Clinical Supervisor will review caseloads and arrange patients to meet regulation. Program Director will monitor. |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
|
Observations
The facility failed to meet this requirement because two bathrooms did not have mirrors installed
|
Plan of Correction
This has already been resolved. Both bathrooms had mirrors installed on 07/30/07/ |
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.
|
Observations
The facility failed to meet this standard because the agency manual was not organized in a manner which allowed staff to efficiently reference policies and procedures pertinent to the discharge of their assigned duties. Language in the manual tends to be generic in nature and does not consistently meet regulatory requirements, thus fails to delineate project policies and procedures.
|
Plan of Correction
Policies will be reviewed/amended/changed/purged as needed. Director and Policy Advisor from DH Home Office will review at the Leadership University in August. DH Home Office will be responsible. |
709.28(a)(1) 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:
(1) Confidentiality of client identity and records.
|
Observations
The facility did not meet the requirements of this standard because the policy did not address 4 Pa. Code subsection 255.5 in its entirety. The policy focused only on 4 Pa. Code subsection 255.5(b). Language in the policy failed to clearly distinguish between HIPAA requirements and regulations and the federal regulations on client confidentiality in substance abuse treatment centers at 42 CFR Part 2, ( revision 13 modified 11/2006). Forms were observed in client files which still contained language inconsistent with the intent of 42 CFR Part 2, Subparts C, D and E relating to the release of information without client consent. Language in the forms stated that the client could ask for releases of information to be restricted but that the agency need not honor such requests. The referral policy stated that "..In as many instances as possible, a release of information shall be signed in order to coordinate treatment for each patient". The intent of applicable laws is that the client must consent to any releases of personal information which identifies them as a consumer of Drug and Alcohol treatment services unless excepted by 42 CFR Part II subparts D & E and as are also permitted by state law and regulation.
|
Plan of Correction
The policies will be reviewed/amended/changed/purged during the Leadership University in August. Director and Policy Advisor from DH Home Office will be responsible.
The form had already been changed to meet regulation and reviewed by Licensing Specialist. This form has just been rolled out and will continue to be used. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
The facility failed to meet this requirement because medical histories were incomplete in 6 of 15 client records reviewed. Family medical history was not collected consistently in client records #1, 5, 9, 10, 11, 12 and 14.
|
Plan of Correction
In Service training will be conducted with Medical Director to meet regulations. Clinical Supervisor will review via Clinical/Medical Chart Audits. Program Director will monitor. |
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.
|
Observations
The facility failed to meet this requirement because personal histories were missing or incomplete in 10 of 15 client records reviewed, (#1, 2, 4, 5, 8, 10, 11, 12, 13 and 15).
Personal histories should collect as much personal information about a client as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated.
|
Plan of Correction
In service training will be conducted on date identified with clinical associates by Clinical Supervisor. Program Director will monitor progress. |
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.
|
Observations
The facility failed to meet the requirements of this regulation because copies of all client related correspondence were not kept on file in the client record. 4 Pa. Code subsection 255.5 (a)(10) states that "Project shall keep and maintain a written record of all information which are disclosed under this section. " Information released to entities addressed under 4 Pa. Code was not on file in client records on a consistent basis. Client records # 1, 3, 4, 6, 7, 8, 9, 11, 14 and 15.
|
Plan of Correction
In service training will be conducted with all Associates to meet compliance with this regulation by Program Manager by specified date. Clinical Supervisor will document and Program Director will monitor. |
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.
|
Observations
The facility failed to meet the requirements of this regulation because after care plans did not address each of the required components specified. Specifically, contact person and reentry process were not documented as part of the aftercare planning process. This was noted in 9 of 9 applicable client records.
|
Plan of Correction
Training conducted on 07/26/2007 to meet compliance. Clinical Supervisor will monitor through clinical/medical chart audits and Program Director will oversee. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
|
Observations
The facility failed to document compliance with 55 Pa. Code relative to the Medical Assistance Manual.
|
Plan of Correction
Program Director will work with Provider Relations Supervisor to ensure this regulation is in compliance. DH Home Office will be responsible. |