INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 18, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Jefferson Outreach Drug and Alcohol Program Central 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 a review of the "Staffing Requirements Facility Summary Reports" completed by each facility in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent counselors in the Project.The findings include:The "Staffing Requirements Facility Summary Reports" for the two facilities that make up the Project were reviewed. The "Staffing Requirements Facility Summary Reports" completed by the facilities on December 17, 2013 and December 18, 2013 listed a combined total of 18 counselors and 3 staff identified as Clinical Supervisors. However, one of the staff identified as a clinical supervisor had 13 clients on her caseload and one of the other staff identified as a clinical supervisor also serves as a facility director.The total number of drug and alcohol counseling hours per week provided by the Project equated to 17.773 FTE counselors within the Project, and therefore the project was required to have at least 2 full-time clinical supervisors. The "Staffing Requirements Facility Summary Reports" only identified 1 full-time clinical supervisor for the Project.
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Plan of Correction
It is the responsibility of the facility director(s) to ensure adequate supervisory oversight relative to the number of the project's clinical staff. Our project now has 1 full-time clinical supervisor for every eight full-time counselor. At present, there are two full-time clinical supervisors within the project. Caseloads of clinical supervisors will be monitored closely by the facility director(s) to ensure that they do not exceed the maximum number of 5 rendering us with one full-time clinical supervisor for every 8 counselors. |
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 the facility's Staffing Requirements Facility Summary Report (SRFSR) form completed on December 18, 2013, the facility failed to ensure that each counselor met the qualifications for the position of counselor in one of one personnel record reviewed.The findings include:On December 18, 2013, one personnel records and the facility's SRFSR form were reviewed for documentation of the qualifications for the position of counselor. The facility failed to ensure that each counselor met the appropriate clinical experience requirement for the position of counselor in one of one personnel record reviewed, specifically, personnel record # 4.Employee # 4 is a counselor and was hired August 20, 2013. A review of the personnel record for employee # 4 indicated that the documentation for work experience requirements for the position was insufficient. The documentation indicated that employee # 4 had a Bachelor of Arts in Psychology but only had five months of clinical experience.
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Plan of Correction
It is the responsibility of the Facility Director and Clinical Supervisor to ensure that clinical staff is sufficiently credentialed. In this instance, counselor #4 is a graduate student performing a supervised practicum on-site. As a result, we are seeking an exception that will allow us to continue training graduate level students in substance abuse counseling. The formal request will be submitted by Jan.31, 2014.In the event that the exception is not granted employee#4 will become a "counselor assistant." the facility director will be responsible for making sure that this occurs.The facility director will also be responsible for determining that all potential hirees for the counselor position meet the requirements for that job. |
711.91(b)(2)(i) LICENSURE Project Policies orientation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project that includes project policies in two of seven client records reviewed. On December 18, 2013, seven client records requiring documentation of client orientation to the project that includes project policies were reviewed. The facility did not document project policies in two of seven records reviewed, specifically, client records # 7 and 9.Client # 7 was admitted November 26, 2013. Client orientation to the project that includes project policies was due upon the client's admission by November 26, 2013. However, client record # 7 did not include documentation of client orientation to the project that included project policies as of December 18, 2013.Client # 9 was admitted November 18, 2013. Client orientation to the project that includes project policies was due upon the client's admission by November 18, 2013. However, client record # 9 did not include documentation of client orientation to the project that included project policies as of December 18, 2013. The findings were presented to the facility director and clinical supervisors on December 18, 2013 at approximately 3:30 P.M.
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Plan of Correction
It is the responsibility of the clinical staff to ensure that all new admissions are oriented to the facility and its policies. This is accomplished via a "Handbook for Patients" which details program policies and includes an orientation to hours of operation, fee schedules, and services available. In addition patient rights and grievance procedures are detailed in the handbook. The counselor will review pogram policies with patients 7 and 9 and by signature/date (patient and counselor) will document that this has occurred.The facility director will assure that this is done, and will be responsible for reviewing all new patient records on an ongoing basis.. |
711.91(b)(2)(ii) LICENSURE Hours of Operation - Orientation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project that includes hours of operation in two of seven client records reviewed. On December 18, 2013, seven client records requiring documentation of client orientation to the project that includes hours of operation were reviewed. The facility did not document project policies in two of seven records reviewed, specifically, client records # 7 and 9.Client # 7 was admitted November 26, 2013. Client orientation to the project that includes hours of operation was due upon the client's admission by November 26, 2013. However, client record # 7 did not include documentation of client orientation to the project that included hours of operation as of December 18, 2013.Client # 9 was admitted November 18, 2013. Client orientation to the project that includes hours of operation was due upon the client's admission by November 18, 2013. However, client record # 9 did not include documentation of client orientation to the project that included hours of operation as of December 18, 2013. The findings were presented to the facility director and clinical supervisors on December 18, 2013 at approximately 3:30 P.M.
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Plan of Correction
It is the responsibility of the clinical staff to ensure that all new admissions are oriented to the facility and its policies. This is accomplished via a "Handbook for Patients" which details program policies and includes an orientation to hours of operation, fee schedules, and services available. In addition patient rights and grievance procedures are detailed in the handbook. The counselor will review program polices that includes hours of operation with patients # 7 and 9 and by signature/date (patient and counselor) will document that this has occurred. The facility director will assure that this is done, and will be responsible for reviewing all new patient records on an ongoing basis to ensure compliance.
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711.91(b)((2)(iii) LICENSURE Fee Schedule
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project that includes a fee schedule in two of seven client records reviewed. On December 18, 2013, seven client records requiring documentation of client orientation to the project that includes a fee schedule were reviewed. The facility did not document project policies in two of seven records reviewed, specifically, client records # 7 and 9.Client # 7 was admitted November 26, 2013. Client orientation to the project that includes a fee schedule was due upon the client's admission by November 26, 2013. However, client record # 7 did not include documentation of client orientation to the project that included a fee schedule as of December 18, 2013.Client # 9 was admitted November 18, 2013. Client orientation to the project that includes a fee schedule was due upon the client's admission by November 18, 2013. However, client record # 9 did not include documentation of client orientation to the project that included a fee schedule as of December 18, 2013. The findings were presented to the facility director and clinical supervisors on December 18, 2013 at approximately 3:30 P.M.
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Plan of Correction
It is the responsibility of the clinical staff to ensure that all new admissions are oriented to the facility and its policies. This is accomplished via a "Handbook for Patients" which details program policies and includes an orientation to hours of operation, fee schedules, and services available. In addition patient rights and grievance procedures are detailed in the handbook. The counselor will review program polices that includes a fee schedule with patients # 7 and 9 and by signature/date (patient and counselor) will document that this has occurred. The facility director will assure that this is done, and will be responsible for reviewing all new patient records on an ongoing basis to ensure compliance. |
711.91(b)(2)(iv) LICENSURE Services Provided - Orientation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project that includes services provided in two of seven records reviewed. On December 18, 2013, seven client records requiring documentation of client orientation to the project that includes services provided were reviewed. The facility did not document project policies in two of seven records reviewed, specifically, client records # 7 and 9.Client # 7 was admitted November 26, 2013. Client orientation to the project that includes services provided was due upon the client's admission by November 26, 2013. However, client record # 7 did not include documentation of client orientation to the project that included services provided as of December 18, 2013.Client # 9 was admitted November 18, 2013. Client orientation to the project that includes services provided was due upon the client's admission by November 18, 2013. However, client record # 9 did not include documentation of client orientation to the project that included services provided as of December 18, 2013. The findings were presented to the facility director and clinical supervisors on December 18, 2013 at approximately 3:30 P.M.
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Plan of Correction
It is the responsibility of the clinical staff to ensure that all new admissions are oriented to the facility and its policies. This is accomplished via a "Handbook for Patients" which details program policies and includes an orientation to hours of operation, fee schedules, and services available. In addition patient rights and grievance procedures are detailed in the handbook. The counselor will review program polices that includes services provided with patients # 7 and 9 and by signature/date (patient and counselor) will document that this has occurred. The facility director will assure that this is done, and will be responsible for reviewing all new patient records on an ongoing basis to ensure compliance. |
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, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in three of four client records reviewed. The findings include:On December 18, 2013, four client records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in three of four records reviewed, specifically, client records # 1, 2, and 9.Client # 1 was admitted October 3, 2013. The individual treatment and rehabilitation plan was completed October 22, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 18, 2013.Client # 2 was admitted October 24, 2013. The individual treatment and rehabilitation plan was completed November 21, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 18, 2013.Client # 9 was admitted November 18, 2013. The individual treatment and rehabilitation plan was completed December 13, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 18, 2013. The findings were presented to the facility director and clinical supervisors on December 18, 2013 at approximately 3:30 P.M.
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Plan of Correction
Several of the charts reviewed did not document proposed support services in the treatment and rehabilitation plans. Recognizing the significance of support services in the recovery process, it is important that treatment plans indicate that the counselor has discussed support services with the patient. The facility director will discuss support services with the counselor who will be responsible for amending support services on the treatment plans for records #1,2,9. The facility director will make sure that this documentation has been completed. It will be the responsibility of the Facility Director to ensure ongoing compliance via chart review conducted during supervision. |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information that included verification or documentation that a copy of the client consent was offered to a client in two of seven client records reviewed The findings include:On December 18, 2013, seven client records requiring documentation of an informed and voluntary consent for the disclosure of information were reviewed. The facility did not obtain an informed and voluntary consent from the client for the disclosure of information that included verification or documentation that a copy of the client consent was offered to a client in two of seven records reviewed, specifically, client records # 1 and 5. Client record # 1 contained consents to release information to one of the client ' s doctors, primary care physician, an agency, and a government agency dated 10/3/13; however, the facility could not provide verification or documentation that a copy of the consent was offered to client # 1. Additionally, the facility was unable to provide documentation that the client was informed of his or her right to receive a copy of the consent to release information either through a policy statement posted in the facility, documentation in an orientation packet, or any other documentation in client record # 1.Client record # 5 contained consents to release information to the client ' s primary care physician, an agency, and a government agency dated 11/5/13; however, the facility could not provide verification or documentation that a copy of the consent was offered to client # 5. Additionally, the facility was unable to provide documentation that the client was informed of his or her right to receive a copy of the consent to release information either through a policy statement posted in the facility, documentation in an orientation packet, or any other documentation in client record # 5. The findings were presented to the facility director and clinical supervisors on December 18, 2013 at approximately 3:30 P.M.
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Plan of Correction
It is the responsibility of the facility director and clinical supervisors to ensure that clinical/counseling staff offer a copy of all signed consent forms to the client. To ensure compliance with the standard, the facility director and clinical supervisor will 1) review program policies regarding completion of release of information consent forms with clinical personnel and 2) during weekly supervision, review clinical records to ensure appropriate execution. Clients #1 and 5 will be offered a copy of all consents to release information by their counselor by 1/31/14. At the same time it will be documentd in the record that copies of the consents were offered. During record review the facility director will ensure that this has occurred. |