INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 26-29, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Treatment Services 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 February 26, 2009.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on the review of the agency policy manual, the facility failed to document timeframes in the staff training procedure.
The findings included;
The agency policy and procedure manual was reviewed during the onsite licensing inspection of January 26-29, 2009. The policy and procedure on the staff development program failed to document timeframes for completion of the agency training assessment, plan and evaluation.
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Plan of Correction
The Agency Policy and Proccedure Manual (Employee Training & Professional Development, pg.20)has been changed to reflect the following: The Clinical Director is responsible for development of the Annual Training Plan. The plan will be complete by January 31st of each year.
This change will be ratified at the next scheduled Board Meeting-2/28/09. |
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.
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Observations
Based on the review of the agency client records and agency self reporting on the Staffing Requirements Facility Summary Reports, the facility failed to ensure that client to counselor caseloads did not exceed 35:1 for each counselor.
The findings included:
The Staffing Requirements Facility Summary Report was reviewed on January 26, 2009. The information provided on that form by the facility regarding caseload sizes documents that the caseload for employee # 8 was at 43:1.
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Plan of Correction
The Executive Director and Clinical Director addressed overall caseload ratios (35:1) with all clinical supervisory staff on Feruary 5, 2009; since the caseload in question was that of a supervisor. The Clinical Supervisors will be responsible for making sure all clinical staff don't exceed the 35:1 ratio. The Clinical Director will make sure that all clinical supervisors are within the acceptable range.
This will be checked on a weekly basis and reported in the supervisory meeting held every week. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of the agency personnel and training records, the facility failed to document that all staff had received fire extinguisher training as required..
The findings included :
During the onsite licensing inspection seven employee personnel and training records were reviewed. No documentation was on file in personnel records # 1, 2 and 3 to demonstrate that these employees had received the mandatory fire extinguisher training.
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Plan of Correction
A training is scheduled for all staff Friday February 13, 2009. The building management will instruct staff on the proper use of a fire extinguisher. The Executive Director is responsible for sceduling and documenting the training.
The files reviewed were for long term staff prior to the traing date being added to our Orientation checklist. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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:
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Observations
Based on the review of the client records, the facility failed to document individualized treatment plans in four of five client records.
The findings included:
Nineteen client records were reviewed during the onsite licensing inspection of January 26-29, 2009. Five records were reviewed at the partial hospitalization level of care. Client records # 1, 2, 17 and 18 utilized a generic template for the treatment plan and failed to document individualized goals and objectives for the clients involved.
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Plan of Correction
The Clinical Director shall conduct an in-service for all treatment staff on treatment planning on 2/19/2009. The focus will be on individualized goals and objectives.
There will be more of a focus on this issue during supervisory sessions and quarterly case file reviews. Oversight will be handled by the Clinical Director. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on the review of the client records, the facility failed to document two individual counseling sessions per week for each client in four of five client records.
The findings included:
Nineteen client records were reviewed during the onsite licensing inspection of January 26-29, 2009. Five client records were reviewed for compliance with the partial hospitalization regulations. The records of service and progress notes in client records # 1, 2, 3 and 17 failed to document the provision of two individual counseling sessions per week.
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Plan of Correction
The problem is related to an antiquated billing/CIS system. The 2 individual sessions for partial are not billable so they won't printout.
The Executive Director has already met with the Billing Dept. (2/10/09) and these visits will be recorded separately and blended into the record of service.
The Billing Department Administrator will be responsible for continued oversight of this issue. |
709.82(e)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on the review of the client records and the letter of agreement file, the facility failed to ensure the ability to assist clients in obtaining dental support services.
The findings included :
Nineteen client records were reviewed during the onsite licensing inspection of January 26-29, 2009. Five client records were reviewed for compliance with the partial hospitalization records. Documentation did not appear in any of the records reviewed to support the facility's ability to assist the client in obtaining dental support services. The letter of agreement file was also reviewed and there was no documentation of a signed letter of agreement with a dentist.
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Plan of Correction
The Agency did have an agreement letter on file but it listed the Dentist who have agreed to accept referrals from the Agency. The doctors themselves were listed but did not sign it.
The Executive Director will be responsible for obtaining a signed letter of agreement and will be responsible for all service agreements. |
709.83(a)(8) LICENSURE Client records
709.83. 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) Record of services provided.
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Observations
Based on the review of the client records and interviews with agency billing personnel, the facility failed to document accurate and current records of service in four of five client records.
The findings included:
Nineteen client records were reviewed during the onsite licensing inspection of January 26-29, 2009. Five client records were reviewed for compliance with the partial hospitalization regulations. Client records # 1, 2, 3, and 18 documented group treatment sessions in progress notes which were not documented on the records of services. The records of services were not current or complete.
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Plan of Correction
The Billing Department is behind in their data entry. The Executive Director has already begun interviewing for additional help. A date of hire has been set for 2/20/09, training will start immediately. |
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.
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Observations
Based on the review of the agency policy manual and Corporate By Laws, the facility failed to specify a procedure for the selection of the Project Director.
The findings include:
There was no documentation of the method for selection of a Project Director by the governing body during the on site licensing inspection of January 26-29, 2009.
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Plan of Correction
The By-Laws were changed and approved by the licensing specislist. The change will become official at the Annual Board Meeting when all manual/By-law changes will be voted upon. The meeting originally scheduled for January 28th which was cancelled due to snow and ice will be held on February 25, 2009. It will be the duty of the Executive Director to present all proposed changes at that time. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of the agency's fiscal audit and Corporate By Laws, the facility failed to document the fiscal audit at the end of the fiscal year.
The findings included:
Documentation of the official copy of the fiscal audit was not completed until January 16, 2009. The fiscal year ended on June 30, 2008.
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Plan of Correction
The Agency changed auditors and the new auditor could not get the necessary paper work from the previous auditor in a timely fashion. The Executive Director has already addressed the issue with the auditing company. Our internal goal will be to have the Audit completed by November 30, 2009. The Executive Director will have complete oversight and responsibility for the Audit being completed in a timely fashion. |
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.
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Observations
Based on the review of the agency policy manual, the facility failed to specify a procedure addressing client confidentiality which was compliant with 4. Pa. Code Subsection 255.5.
The findings included the following:
Documentation in the agency policy stated that client records could be released without consent to legal authorities if the client committed a crime against facility staff or on facility grounds. The federal confidentiality law states at 42 CFR subsection 2.12.(c)(5) that the information which may be released in these circumstances "... are directly related to the patient's commission of a crime on the premises of the program or against program personnel ...". Facility policy has incorrectly construed this to permit releases of client records to law enforcement entities. The policy and procedure is in violation of 4 Pa. Code Subsection 255.5.
The HIPAA statement documented in each client record indicated that "... we would like to make you aware that these privacy laws do not require us to agree to your requests in all situations.." regarding limitations on the use of client identifying information. The policy statement as documented is not consistent with 42 CFR Subsection 2.2(b)(1) which states "..the content of any record referred to in subsection (a) of this section may be disclosed in accordance with the prior written consent of the patient with respect to whom such record is maintained...". The confidentiality policy as documented in the manual did not address 4 Pa. Code Subsection 255.5 in its entirety, but focused rather on Subsection 255.5(b) and failed to include a disclaimer regarding the stricter protections provided for at 4 Pa. Code Subsection 255.5 over the HIPAA regulations.
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Plan of Correction
The policy manual will be changed to reflect the attached recommendations. It will be the responsibility of the Executive Director to make the approprite changes to the manual and will present it to the Board of Directors at the 2/25/09 Annual Meeting. The Clinical Director will hold an in-service with all staff on 2/26/09 to update them on the manual changes and the reasons for the change.
A disclaimer has alreday been added to the HIPPA statement stating that we will adhere to all Federal and State confidentiality laws. |
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:
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Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent for each disclosure of client related information in four of sixteen client records.
The findings included :
Nineteen client records were reviewed during the onsite licensing inspection of January 26-29, 2009. The facility released information without the clients written consent in client records # 6, 8, 14 and 18. Information was released without client consent to a county case management unit in client records # 6, 8 and 14. Information was released to a county judge without the client's written consent in client record # 18.
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Plan of Correction
As part of the Feb. 26th in service the Clinical Director will be responsible for re-traing the staff has to informed and voluntary consent for relaese of information. He will focus time on the need for the particular need for the release of information.
This issue will receive attention in the quarterly case file reviews.
The Clinical Director will be responsible for continued oversight. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of the client records, the facility failed to adhere to limitations on disclosure of client identifying information as required at 4 Pa. Code Subsection 255.5 (b) in 7 of 16 client records.
The findings included :
Nineteen client records were reviewed during the onsite licensing inspection of January 26-29, 2009. Sixteen client records were reviewed for compliance with the confidentiality regulations.
The facility disclosed information which included details about the counselors' clinical impressions and client history from client records # 1, 9 and 16 to third party payers and criminal justice entities. This information exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b).
The facility disclosed client identifying information which exceeded the amount and type of information listed on the signed consents to release information in client records # 5, 7 and 17. The client identifying information released included details about the treatment plan goals and details of client struggles with cravings, triggers and references to medication usage. These disclosures were made to funding and criminal justice entities. This information exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b) and exceeded the information the client agreed to release on the consent to release information forms.
The facility failed to document the specific client identifying information that was to be released on a consent to release information form in client record # 18. The section of the consent to release information form that was to contain this information was blank. The incomplete consent to release information form had been signed by the client.
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Plan of Correction
The Clinical Director shall review all confidentiality regulations as part of the in-service performed on February 26, 2009.
There will be an ongoing focus by the Clinical Supervisors and Clinical Director on a weekly basis during supervisory sessions and during quarterly case file reviews. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on the review of the agency policy manual and client records, the facility failed to document physical examinations for each client funded through the Office of Medical Assistance (OMA) funding stream in four of four client records.
The findings included:
Nineteen client records were reviewed during the onsite licensing inspection of January 26-29, 2009. The agency policy manual required that a physical examination be completed for each Medical Assistance eligible client. Client records # 4, 5, 9 and 10 were eligible for medical assistance. There was no documentation of a physical examination in any of the four client records.
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Plan of Correction
It shall be the responsibility of the Executive Director to update the policy manual to reflect that physicals are no longer performed on Medical Assitance clients.
The policy manual update will be approved at the Annual Board Meeting scheduled for 2/25/2009. |
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 the reviewed of the client records, the facility failed to document treatment plan updates which were consistent with the documented treatment plan in five of twelve client records.
The findings included:
Nineteen client records were reviewed during the onsite licensing inspection of January 26-29, 2009. Twelve client records were required to include documentation of treatment plan updates. The treatment plan updates in client records # 5, 8, 9, 14 and 16 were not consistent with the stated goals of the treatment plans in those client records. Treatment plan updates were standardized and did not address the identified needs of the individual clients or access the progress those clients made in relation to the goals of the respective treatment plans.
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Plan of Correction
As part of the 2/26/09 in-service the Clinical Director shall be responsible for traing staff in the area of treatment planning and the need for each plan and update to reflect the particular goals and objectives for each individual client.
The Clinical Director will be responsible for continued oversight of this matter. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow up in accordance with facility policy and procedure in two of four client records.
The findings included:
Nineteen client records were reviewed during the onsite licensing inspection of January 26-29, 2009. Four of the records reviewed during the inspection required documentation of post discharge follow up contacts. Facility policy and procedure require documentation of follow up attempts at 30 and 60 days post discharge. Documentation of attempts to follow up on clients did not appear at 30 and 60 days post discharge in client records # 9 & 11.
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Plan of Correction
The Clinical Director as part of the 2/26/09 in-service shall address the appropriate time frame for follow-up as outlined in the Agency Policy Manual. Thru quarterly case file reviews the Clinical Director will be responsible for continued oversight of this area. |