INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 4, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, GPHA Al-Assist Behavioral Health Care Center 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.
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the Staffing Requirement Facility Summary Report, and a conversation with the facility director, the facility failed to ensure that one out of three counselors met the qualifications for the position of counselor.The findings include:On August 4, 2011 three personnel records for staff designated as counselors were reviewed for documentation of the qualifications for the position of counselor.The facility failed to ensure that each counselor met the qualifications for the position of counselor, specifically employee # 4.Employee # 4 was hired as an intake worker on 1/7/10, and promoted to a counselor on 1/3/11.Employee # 4 has a qualifying Bachelor's degree; however, the reviewed documentation did not indicate 1 year of clinical experience.The facility director reviewed the findings.
|
Plan of Correction
Standard in non-compliance
704.7(b) Counselor Qualifications
In an effort to address and avoid any future non-compliance of standard 704.4(b). The Director of Behavioral Healthcare Services, Coordinator of Behavioral Healthcare Services, and Clinical Coordinator held an individual meeting with the staff member identified as not meeting the educational requirements in at least one of the paragraphs of 28 Pa. Code Subsection 704.7(b). The staff member was immediately demoted from a Counselor III to a Counselor Assistant. All future/potential hires for the Drug and Alcohol program will be scrutinized based on 28 Pa. Code Subsection 704.7(b), by both the Clinical Team and the Human Resource Department. Failure to meet the educational and experience qualifications will result in a non-hiring of the applicant. This process will be monitored by the HR Director and the Director of Behavioral Healthcare Services.
Correction Time: Completed
Ongoing Monitoring
|
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
|
Observations
Based on a review of administrative documentation, and a conversation with the facility director, the facility failed to select a project director as the person officially responsible to the governing body.The findings include:On August 2, 2011 a review of administrative documentation revealed that the appointed project director, employee # 1, the medical director does not report to the governing body/Board of Directors.The facility director, employee # 2 was interviewed regarding the findings, at which time she confirmed that the project director is not officially responsible to the governing body.
|
Plan of Correction
Standard in Noncompliance
709.22(d)(1) LINCENSURE Governing Body
In effort to comply with regulation 709.22(d)(1) the written findings from August 4, 2011 were discussed with the Director of Behavioral Health, Chief Executive Officer, and the Governing Body. It was decided that the Chief Executive Officer would be the person responsible to the governing body. Based on our organization structure the Chief Executive Officer is the only positon that reports to the Board of Directors; therefore moving forward, the CEO will be the project director for our Drug and Alcohol Program.
Correction time: Completed
Monitoring is on-going
|
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:
|
Observations
Based on a review of client records, a review of clinical documents and an interview with the clinical supervisor, the facility failed to obtain an informed and voluntary consent for the disclosure of information contained in one of six client records reviewed, specifically client record # 3.The findings include:On July 4, 2011 six client records were reviewed to ensure that the facility was obtaining informed and voluntary consents to release client identifying information.Documentation in client record # 3 failed to adhere to the requirements specified at 28 Pa. Code subsection 709.28 and 42 CFR.Client # 3 was admitted to the program on 3/21/11 and discharged on 7/15/11.On 3/21/11 client # 3 signed and dated a "Consent to Request and/or Release Information" form that allowed for the release of information to a government agency.The consent to release form failed to include the information that would be disclosed and the purpose for the disclosure of that information.The clinical supervisor confirmed that the consent to release form failed to adhere to the requirements specified at 28 Pa. Code subsection 709.28 and 42 CFR.
|
Plan of Correction
Standard in Noncompliance
709.28(c) LINCENSURE Confidentiality:
In effort to comply with regulation 709.28(c), the written findings from August 3, 2011 were reviewed with the Clinical Coordinators and Counselor III's during clinical staff meeting to again review standard 709.28 (c) and the agency's confidentiality policy and procedures. The Clinical Coordinators reviewed the designated forms for consumers in the drug and alcohol outpatient program that reference specific guidelines outlined in regulation 709.28(c). The Clinical Coordinators restated the importance of accurately documenting what information is to be released, ensuring this information does not exceed the limitation set forth in 4 Pa Code subsection 255.5(b): 1. Whether the client is or is not in treatment; 2. The prognosis of the client; 3. The nature of the project; 4. A brief description of the progress of the client; and 5. A short statement as to whether the client has relapsed into drug and alcohol and frequency of such relapse. In addition, Quality Assurance Department and Clinical Staff were instructed to do away with any old blank consent to release forms that did not indicate in writing what information was to be released. Informed and voluntary consent forms will be routinely audited by the Quality Assurance Department to ensure compliance. A random audit of each therapist caseload will be conducted periodically by the Clinical Coordinator to ensure that Standard 709.28(c) is being followed properly.
Correction Time: Completed
Monitoring is on-going
|
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records, administrative documentation, and a conversation with the clinical supervisor, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one records reviewed. The findings include:On August 4, 2011, one client record requiring documentation of a notification of termination was reviewed. The facility failed to document notification of termination in client record # 1.Client # 1 was admitted to the program on 6/15/10 and discharged on 11/11/10. The facility documented on the discharge summary dated 11/11/10 that the client was involuntarily discharged from the program.The facility did not inform the client, in writing, of a decision to involuntarily terminate treatment.The clinical supervisor confirmed the findings.
|
Plan of Correction
Standard in Noncompliance
709.33(a) LICENSURE Notification of Termination
In an effort to comply with regulation 709.33(a) the written findings from August 4, 2011 were reviewed with Clinical Coordinators and Quality Assurance Department. A written Notice of Involuntary Discharge will be given to any individual who has been discharge involuntary and a copy of this written notice will be place in individual's record. Clinical Coordinator will review record for written notice at time of discharge. Counselors found non-compliant of this regulation will receive additional support from the Clinical Coordinator during weekly supervision sessions. The Quality Assurance Department will conduct random audits of discharge charts to ensure standard 709.33(a) is properly followed.
Correction Time: October 1, 2011
Monitoring is on-going
|
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
|
Observations
Based on a review of client records, administrative documentation, and a conversation with the clinical supervisor, the facility failed to provide the client with an opportunity to request reconsideration of a decision terminating treatment in one of one records reviewed.The findings include:On August 4, 2011, one client record requiring documentation that the client was given an opportunity to request reconsideration of a decision terminating treatment was reviewed.The facility failed to document allowing the client an opportunity to request reconsideration of a decision to terminate treatment in client record # 1.The facility failed to document that the client was given notification of termination and an opportunity allowing the client an opportunity to request reconsideration of a decision to terminate treatment in client record # 1.Client # 1 was admitted to the program on 6/15/10 and discharged on 11/11/10.The facility documented on the discharge summary dated 11/11/10 that client # 1 was involuntarily discharged.The facility failed to allow the client an opportunity to request reconsideration of a decision terminating treatment.The clinical supervisor confirmed the findings.
|
Plan of Correction
Standard in Noncompliance
709.33(b) LICENSURE
Notification of Termination
In an effort to comply with regulation 709.33(a) the written findings from August 4, 2011 were reviewed with Clinical Coordinators and Quality Assurance Team. Clinical staff was instructed to have all newly admitted clients read and sign client rights and responsibilities form which shall state that individuals have the right "to request reconsideration of a decision terminating treatment". All newly admitted charts will be audited by the Quality Assurance Team to ensure that standard 709.33(b) is properly followed. Counselors found non-compliant of this regulation will receive additional support from the Clinical Coordinator during weekly supervision sessions.
Correction Time: October 1, 2011
Monitoring is on-going
|
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:
|
Observations
Based on a review of client records, a review of the facilities policy and procedures manual, and a conversation with the facility director, the facility failed to develop an individualized comprehensive treatment and rehabilitation plan with the client within 15 work days according to policy and procedure.The findings include:The facilities policy titled "Comprehensive Treatment Planning" states:The comprehensive treatment plan shall be developed within 15 work days of admission The Physician, clinical supervisor, primary clinician, and the client must sign the plan.On August 4, 2011, five client records requiring individualized comprehensive treatment and rehabilitation plans were reviewed.The facility failed to document a comprehensive treatment plan within 15 work days as per policy in client records # 2, 3, and 5.Client # 2 was admitted to the program on 4/25/11 and discharged on 7/21/11.The comprehensive treatment plan was due on 5/16/11; however it was not completed until 6/7/11.In addition, the comprehensive treatment plan was complete before the medical, drug and alcohol, and personal histories as well as the psychosocial evaluation which was documented on 6/21/11.Client # 3 was admitted to the program on 3/21/11 and discharged on 7/15/11.The comprehensive treatment plan was due on 4/11/11; however it was not completed until 6/13/11.Client # 3's last date of counseling was 4/20/11, thus the comprehensive treatment plan was developed without client involvement or signature.Client # 5, an active client at the time of inspection, was admitted to the program on 5/19/11.The comprehensive treatment plan was due on 6/9/11; however it was not completed until 6/10/10.The facility director did not dispute the findings.
|
Plan of Correction
Standard in Noncompliance
709.92(a) Treatment and Rehabilitation services
In an effort to comply with regulation 709.92(a) the written findings from August 4, 2011 were discussed with all Clinical Staff during staff meeting. At which time the Clinical Coordinators reviewed the agency's policy and procedures on comprehensive treatment planning. The Clinical Coordinator reiterated that comprehensive treatment plans must be completed with the client, after the psychosocial evaluation is complete and within 15 working days of admission. In addition, Clinical Coordinators are to review Counselor's records weekly to ensure compliance with standard 709.92(a). Feedback will be given from these reviews to help Counselor's better understand the intent of regulation 709.92(a). Counselors found noncompliant of this regulation will receive additional support from the Clinical Coordinator during weekly supervision sessions. Client records will also be randomly audited by Quality Assurance Department to ensure standard 709.92(a) will be followed properly.
Correction Time: Completed
Monitoring is on-going
|