INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 30 - 31, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, 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 and a plan of correction is due on October 3, 2010.
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Plan of Correction
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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 and an interview with the Facility Director, 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 August 31, 2010 at approximately 3:30 PM. It was observed that counseling sessions could be seen outside of all of the counseling rooms. An interview with the Facility Director confirmed that the counseling sessions could be seen outside of the counseling room and lacked proper window treatment.
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Plan of Correction
Standard in Noncompliance
705.23(3) Counseling or activity areas and office space:
In an effort to comply with regulation 705.23(3) the written findings from August 31, 2010 were discussed between the Facility Director and the Chief Executive Officer of the Agency. The Agency's Confidentiality Policy and Procedures supportive of standard 705.23(3) were reviewed to reiterate assurance of privacy so that counseling sessions cannot be seen or heard outside the counseling room. At which time it was determined that a letter will be submitted to the Pennsylvania Department of Health requesting a waiver for 705.23(3) with the assurance that sessions are not heard outside the counseling room and that offices will be arranged to ensure clients are not directly seen during counseling sessions. This letter will also detail past experiences that served as reasons why observation windows had been installed with added reasoning to assure the safety of our consumer and therapist.
In the event that the exception is not granted, adequate drappery will be installed to cover the glass panel within 10 business days of the noted rejection of exception.
Correction time: September 3, 2010
Monitoring on-going
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the fire drill log and an interview with facility administrative staff, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.The findings include:The facility's fire drill log was reviewed on August 31, 2010 for the period of September 2009 through August 2010. The facility documented fire drills at 3:00 PM for nine out of eleven months. An unannounced fire drill was conducted while this surveyor was on-site for a licensing inspection on August 31, 2010 and it was noted that the fire drill was initiated at exactly 3:00 PM.In addition, the facility failed to document fire drills on different staffing shifts.An interview was conducted with the facilities administrative staff, and they confirmed that the fire drills were conducted at 3:00 PM.
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Plan of Correction
Standard in Noncompliance
705.28(d)(6) Fire Safety
In effort to comply with regulation 705.28(d)(6), the written findings from August 31, 2010 were discussed between the Administrative Staff, Safety Committee, and the Environment of Care Committee on September 3, 2010. At which time standard 705.28(d)(6) was reviewed and the process of how future fire drills will be conducted was discussed. All future fire drills will remain unannounced, and conducted on different days of the week, at different times of the day and during different staffing shifts. All fire drill will continue to be documented and placed in the fire drill log book for review and compliance. A copy of the fire drill log will be presented to the Environment of Care Committee Quarterly for on-going monitoring.
Correction time: September 3, 2010
Monitoring on-going
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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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 consent to treatment in one of four client records reviewed.The findings include:Four client records were reviewed on August 31, 2010 for documentation of a consent to treatment. The facility failed to document a consent to treatment in client record # 4.Client # 4 was admitted to the program on 2/17/10 and discharged on 5/25/10.There was no documentation of a consent to treatment in client record #4 at the time of review on 8/31/10.The clinical supervisor reviewed the record and confirmed that client # 4 did not have documentation of consent to treatment.
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Plan of Correction
Standard in Noncompliance
709.91(b)(4) Intake admission
In effort to comply with regulation 709.91(b)(4) the written findings from August 31, 2010 were discussed during Clinical Staff meeting on September 17, 2010. At which time the Clinical Coordinators introduced a combined consent to treatment form for co-occurring clients to avoid any future mishaps of a mental health consent being in the record verses a substance abuse consent being in the record. The revised combine consent was implemented on Monday September 20, 2010. The Clinical Coordinators reviewed the form along with the Informed Consent Policy. In addition, Clinical Coordinators are to review intake records daily to ensure compliance with standard 709.91(b)(4). Feedback will be given from these reviews to ensure Clinical Staff remains in compliance of regulation 709.91(b)(4). Clinical Staff found noncompliant of this regulation will receive additional support from the Clinical Coordinator during weekly supervision sessions. Consents forms will also be audited daily by Medical Records Clerks to ensure compliance.
Correction time: September 17, 2010
Monitoring is on-going
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records and a review of the facilities policy and procedures manual, the facility failed to document treatment and rehabilitation plan updates at least every 60 days.The findings include:The facilities policy titled "Treatment Plan Update" states:The treatment plan update shall be developed every 60 days for outpatient substance abuse clients.Four client records were reviewed on August 31, 2010.Two client records required documentation of a treatment and rehabilitation plan update.The facility failed to document a treatment and rehabilitation plan update every 60 days as per policy in client records #1 and 2.Client # 1 was admitted to the program on 2/26/10.A comprehensive treatment plan was documented on 3/3/10.Treatment and rehabilitation plans are due every 60 days.At the time of review on 8/31/10 the facility documented one treatment/rehab update on 6/15/10. Client #2 was admitted to the program on 11/30/09. A comprehensive treatment plan was documented on 12/15/09.Treatment and rehabilitation plans are due every 60 days.At the time of review on 8/31/10 the facility documented treatment/rehab updates on 2/15/10, 5/5/10, and 8/13/10.
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Plan of Correction
Standard in Noncompliance
709.92(b) Treatment and rehabilitation services
In an effort to comply with regulation 709.92(b) the written findings from August 31, 2010 were discussed with all Clinical Staff during September 17, 2010 staff meeting. At which time the Clinical Coordinators reviewed the facilities policy and procedures on Treatment Plan Updates which states "that the Treatment Plan Updates shall be developed every 60 days for outpatient substance abuse clients". Clinical Staff will continue to review client's progress with goals and update treatment plan every 60 days. In addition, Clinical Coordinators are to review Counselor's records weekly to ensure compliance with standard 709.92(b). Feedback will be given from these reviews to help Clinical Staff better understand the intent of regulation 709.92(b). Clinical Staff 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 Medical Records Clerks to ensure standard 709.92(b) will be followed properly.
Correction Time: September 17, 2010
Monitoring is on-going
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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 a review of the facilities policy and procedures manual, the facility failed to document a complete client record which included a case consultation note.The findings include:The facilities policy titled " Case Consultations" states:...each client's case will be discussed every 90 days while in treatment.Four client records were reviewed on August 31, 2010.Two records required documentation of a case consultation note.The facility failed to document a case consultation note within 90 days as per policy in client records # 1 and 2.Client # 1 was admitted to the program on 2/26/10.The case consultation note is due every 90 days.The facility documented one case consult on 6/15/10 at the time of review on 8/31/10.Client # 2 was admitted to the program on 11/30/09.The case consultation note is due every 90 days.The facility documented case consults on 6/19/10 and 3/20/10 at the time of review on 8/31/10.
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Plan of Correction
Standard in Noncompliance
709.93(a)(8) Client records
Case consultation notes
In an effort to comply with regulation 709.93(a)(8) the written findings from August 31, 2010 were discussed with all Clinical Staff during September 17, 2010 staff meeting. At which time the Clinical Coordinators reviewed the facilities policy and procedures on Case Consultations which states that "each client's case will be discussed every 90 days while in treatment and documentation of clinical discussion with multi-disciplinary team will be placed in client's record". Clinical Staff will continue to document case consultation notes every 90 days. In addition, Clinical Coordinators are to review Counselor's records weekly to ensure compliance with standard 709.93(a)(8). Feedback will be given from these reviews to help Clinical Staff better understand the intent of regulation 709.93(a)(8). Clinical Staff 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 Medical Records Clerks to ensure standard 709.93(a)(8) will be followed properly.
Correction Time: September 17, 2010
Monitoring is on-going
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records and a review of the facilities policy and procedures manual, the facility failed to document a complete client record which included a discharge summary.The findings include:The facilities policy titled "Discharge Policy" states:The primary counselor completes the following documents within 7 days of notifying the clinical coordinator in preparation for discharge and to provide accurate discharge status information to aftercare providers in a timely manner.Two client records were reviewed for documentation of discharge summaries on August 31, 2010.The facility failed to document a discharge summary per policy in one of two client records reviewed, specifically client record # 4.Client # 4 was admitted to the program on 2/17/10.Client # 4 was discharged on 5/25/10, per progress note and termination letter.No further client engagement was documented after the termination letter was issued. The discharge summary is due within 7 days.The facility documented the discharge summary on 8/27/10.
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Plan of Correction
Standard in Noncompliance
709.93(a)(10) Client records
Discharge Summary
In an effort to comply with regulation 709.93(a)(10) the written findings from August 31, 2010 were discussed with all Clinical Staff during September 17, 2010 staff meeting. At which time the Clinical Coordinators reviewed the facility's Discharge Policy which states that "the Primary Counselor completes the following documents within 7 days of notifying the Clinical Coordinator in preparation for discharge and to provide accurate discharge status information to aftercare providers in a timely manner". Clinical Staff will continue to document discharge summary within 7 days of client being discharged. Also, Clinical Staff will document follow-up 6 months after discharge. In addition, Clinical Coordinators are to review Counselor's discharge records weekly to ensure compliance with standard 709.93(a)(10). Feedback will be given from these reviews to help Clinical Staff better understand the intent of regulation 709.93(a)(10). Clinical Staff 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 Medical Records Clerks to ensure standard 709.93(a)(10) will be followed properly.
Correction Time: September 17, 2010
Monitoring is on-going
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704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to document a written individual training plan.The findings include:Seven personnel records were reviewed on August 31, 2010 for documentation of an individual training plan.The facility failed to document an individual training plan upon hiring staff in two of seven records reviewed, specifically personnel records # 4 and 5.Employee # 4 was hired December 2009.An individual training plan is to be documented within 30 days of hire.The facility documented an individual training plan on 8/23/10.Employee # 5 was hired July 2009.An individual training plan is to be documented within 30 days of hire.The facility documented an individual training plan on 11/28/09.An interview with the facility director was conducted on August 31, 2010.The facility director confirmed that an individual training plan had not been documented upon hiring employees # 4 and 5.
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Plan of Correction
Standard in Noncompliance
704.11(b)(2)&(3) Basis of Training Plan
In effort to comply with regulation 704.11(b)(2)&(3), the written findings from August 31, 2010 were discussed with Administrative staff on September 7, 2010 during the Clinical Supervisory Team meeting. At which time regulation 704.11(b)(2)&(3)and licensing alert 03-05 was reviewed. As part of the staff development program all supervisors were instructed to ensure that all newly hired individuals would receive a self assessment worksheet at the end of orientation. The self-assessment worksheet is to be completed within 7 days of hire. By the 3rd supervision session Clinical Coordinator will compose and develop a written training plan which is based on the staff's self-assessment and job performance. In addition, as part of the training plan each employee will be expected to complete the minimum training hours as listed in standard 704.11(d)-(g). Written training plans will be submitted to Facility Director for review no later than 15 days after hire date. Any revisions will be submitted within 5 days of submission. The written training plan shall be completed within the first 30 days of employment. A finalized copy of the written training plan will be sent to the credentialing department to be placed in employee's file.
Correction time: September 7, 2010
Monitoring weekly until 100 hours are completed
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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 the Staffing Requirements Facility Summary Report, and an interview with the Facility Director on August 31, 2010, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training within the first year of employment for clinical staff and within two years of employment for non-clinical staff.The findings include:Training records for seven employees were reviewed on August 31, 2010 for documentation of the mandatory HIV/AIDS and TB/STD trainings.The facility lacked documentation verifying that employees completed the mandatory training in one of seven records reviewed.Employee # 5 failed to complete the training within the allotted timeframe.Employee # 5 was hired in July, 2009.Employee # 5 is a counselor.At the time of review on August 31, 2010, employee # 5 had not received the STD/TB training.The Facility Director confirmed that employee # 5 was hired as a contract employee in July 2009 and failed to complete the required training within the first year of employment.
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Plan of Correction
Standard in Noncompliance
704.11(c)(1) Mandatory Communicable Disease training
In effort to comply with regulation 704.11(c)(1), the written findings from August 31, 2010 were discussed with Administrative staff on September 7, 2010 during the Clinical Supervisory Team meeting. At which time regulation 704.11(c)(1) was reviewed. As part of the staff development program all supervisors will continue to ensure that all newly hired individuals will develop a written training plan that would but would not be limited to include scheduling for 4 training hours of tuberculosis, sexually transmitted diseases and other department approved curriculum to be completed within the first year of hire. Training will be scheduled based on BHTEN's training schedule. If trainings are not offered within the allotted timeframe through BHTEN training will be sought after through accredited medical training facilities. In addition, the written training plan will be submitted to Facility Director for review no later than 15 days after hire date. Any revisions will be submitted within 5 days of submission. The final written training plan will be completed within the first 30 days of employment. The Clinical Coordinator will monitor the completion of these trainings during weekly supervision sessions. Upon completion of these trainings a copy of the certificates will be sent to the credentialing department to be placed in employee's file.
As for employee #5 STD/TB raining will be completed within the next 60 days through BHTEN or a credentialed/ certified medical trainer.
Correction time: December 5, 2010
Monitoring bi-weekly until 4 hours are completed
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