INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 2008- January 29, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, POWER 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 29, 2008.
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Plan of Correction
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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 review of client records throughout the project employee # 16 does not meet counselor qualifications. This employee was providing treatment services throughout the project without verification that his/her credentials were consistent with the regulations.
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Plan of Correction
The Expressive Arts Therapist, who does group one afternoon a week meets the qualifications for a Counselor. She has a Bachelor's Degree from an accredited college with a major in psychology. She has worked in a licensed D &A program for more than five years prior to coming to coming to POWER. She holds a Master's Degree in Music Therapy. This therapist will update her resume and said resume will be forwarded to Licensing. The Associate/Clinical Director has verified her that credentials are consistent with the regulations. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on review of personnel records the facility failed to document individual training plans for all staff. Employee's # 8, 9, 11, and 12 did not have current individual training plans in their personnel records at the time of the review.
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Plan of Correction
When POWER acquired Zoar's programs, the first priority was to continue to deliver treatment and support services to clients in the Partial Hospitalization Program without disruption.
While direct line staff continued to deliver services and focus on client needs, the administration and management of POWER focused on establishing new policies, procedures, systems and processes; and helping the staff become familiar with our standards and expectations. A merger presents enormous challenges as the staff experiences and adjusts to changes.
When POWER acquired the Partial Hospitalization Program, just six months prior to the on-site inspection, our goal was to bring the former Zoar program in line with POWER's standards and integrate this program site and new level of care into our continuum. Naturally, integrating the new program meant bringing it in line with all of our goals and timelines.
POWER conducts its agency-wide Employee Training Survey and Individualized Training Plans in May, which then drives the Annual Training Plan for the new fiscal year. Our plan was to survey the new Partial Hospitalization Program staff and develop their Individualized Training Plans with the rest of the agency, which helps to fully integrate the program and unifies the overall staff development planning and implementation.
With just six months since Zoar's dissolution and a new Manager being hired in August of 2007, time would be needed to observe the new staff and assess their training needs. And, when the merger occurred, POWER was already halfway into its current training year (FY 08)so the Partial Hospitalization Program staff were incorporated into this plan, which had a focus on MI and MET through a contract with Western Psychiatric Institute & Clinic.
POWER has a long history of compliance with this particular standard and takes very seriously the staff development requirements. In fact, POWER exceeds the expectations of the regulations with regard to training and professional development.
While we believe there should have been confidence that the staff from the Partial Hospitalization Program would have developed their Individualized Training Plans with their immediate supervisor per POWER's annual timeline, since the reviewer's comments, Individual Training Plans for employees number 8, 9, 11 and 12 were completed on January 28 and have been filed in their respective personnel records. This plan will serve for FY 09 as well and will not be repeated on our May 2008 schedule with the rest of the agency.The Executive Assistant will monitor the Personnel Files for timely completion of the Individual Training Plan for all staff, on an annual basis. She will advise the Associate/Clinical Director of any training plans that were not completed.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on review of the fire drill log the facility failed to complete fire drills monthly. At the time of the inspection the facility had not completed May, June and July for 2007.
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Plan of Correction
POWER had no control over the Partial Hospitalization Program prior to July 1, 2007 as it was a program of Zoar New Day, which was dissolved on June 30, 2007. POWER acquired the Partial Hospitalization Program as a result of the merger on July 1 and hired a new Program Manager who began working for POWER in August of 2007. The new Manager immediately began conducting fire drills and since August, 2007 has ensured that random fire drills occur each month. The Partial Hospitalization Program Manger will continue to implement the policy and a fire drill will be conducted monthly. The Associate/Clinical Director will review the Fire Drill Log on a quarterly basis to monitor compliance.
This citation has been corrected and will continue to be monitored. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records on January 25, 2008, the facility failed to document a complete personal history in three out of three client records reviewed, #1, 2 and 3. Family histories failed to include historical and personal data in client records #1 and 3. Legal histories were incomplete in client records # 1 and 2. Employment and education histories were incomplete in client records # 1, 2, and 3. Recreational and sexual histories histories were incomplete in client records # 1,2, and 3.
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Plan of Correction
A full day, mandatory training on Clinical Documentation has been developed and is scheduled on March 15, 2008 for all clinical staff. This training will focus on documenting all facets of the client's personal history, which includes but not limited to family, legal, employment, education, recreational and sexual histories.
The Program Manger will review two bio psychosocial assessments a week for completeness. This review will take place during weekly supervision with all Counselors/Therapists. The Associate/Clinical Director will randomly review one client record from each program on a quarterly basis.
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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, on January 25, 2008 the facility failed to document a complete psychosocial evaluation in three out of three client records, # 1, 2 and 3. Psychosocial evaluations did not include a clinical assessment of the client's problems/needs, assets/strengths, support systems, and coping mechanisms. Negative factors was missing in client record # 3.
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Plan of Correction
A full day mandatory training on Clinical Documentation has been developed and is scheduled on March 15, 2008 for all clinical staff. In additional to completely documenting the bio-psychosocial assessment, the training will devote three hours on developing the bio psychosocial evaluation (narrative). Specific attention will be focused on the clinical assessment/impression of the clients' strengths, assets, support systems, needs/problems and coping mechanisms.
During the above stated supervision with Counselors//Therapists, the Program Manager will review all the bio psychosocial evaluations for completeness. The Associate /Clinical Director will randomly review one client record from each Program on a quarterly basis.
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709.82(a)(1) 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:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a a review of client records on January 25, 2008, the facility failed to document short and long term goals for treatment, in three out of three client records reviewed, specifically client records # 1, 2 and 3. The individual treatment and rehabilitation plan documented in the client records revealed objectives/tasks to meet goals that were not measurable or specific to each clients' issues and/or needs.
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Plan of Correction
The above stated training will address long- and short-term goals on the Treatment Plan. On February 15, 2008, the Outpatient clinical staff(Partial and IOP) received a one hour consultation on Strengths Based Treatment Planning by POWER's Medical Director. The staff's treatment plans were reviewed with emphasis on the long term goals and the short term goals which are measurable and specific to the client's identified needs. The Program Managers will approve all Treatment Plans in weekly supervision. The Associate/Clinical Director will randomly review the clinical records on a quarterly basis. |
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 a review of client records on January 25, 2008, the facility failed to document an accurate record of service. In two out of three client records reviewed # 2 and 3, the record of service documented clients attending group services and individuals at the same time. In client record #2 on 9/14/07 the client attended an individual session and a group session at the same time frame. In client record # 3, on 1/17/08, the client attended group session and an individual session at the same time frame.
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Plan of Correction
POWER's Group Progress Form has been revised and all clinical staff will be provided training on documenting the clinical impressions/assessment of each client during the group process. This training will take place on March 15, 2008. The above stated monitoring with occur with respect to the Program Manager and Associate/Clinical Director. |
709.83(a)(9) 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:
(9) Progress notes.
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Observations
Based on a review of client records on January 24, 2008 , the facility failed to document complete group progress notes in three out of three client records reviewed, # 1, 2, and 3. In client record # 1 progress notes failed to document data, assessment and plan on 8/28, 8/29, 9/11 and 9/6/07. In client record # 2 progress notes failed to document data, assessment, and plan on 9/10, 9/13, 8/23 and 8/31/07. In client record # 3 progress notes failed to document data, assessment and plan on 1/17, 1/13, 1/23/08 and 12/31/07, 12/08/07, and 12/11/07. Group progress notes listed above contained incomplete assessments, failing to include the counselor's analysis of and conclusions regarding the client during the group process.
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Plan of Correction
On March 15th, 2008, an all day training on Clinical Documentation was held, with added emphasis on Group Process Notes. Effective immediately, all clinical staff will ensure all notes follow the DAP format. Staff will individualize the assessment portion of the note. Staff will also provide more detail on the plan portion of the note. The Partial Program Managers will review notes on a weekly basis during supervision for two months. She will then randomly review notes on a monthly basis. The Associate/Clinical Director will randomly review the clients chart on a quarterly basis. |
709.83(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records on January 25, 2008 the facility failed to document follow up information. In client records # 1 and 2, two out of two client records reviewed, follow up was not documented.
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Plan of Correction
Effective immediately, in all instances, when a client is discharged from one of POWER's programs and referred to another agency or program, the POWER staff will contact the receiving agency/program to determine if the client followed through with the appointment. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on review of personal records, the facility failed to include job descriptions for all staff. Employee's #9 and 10 did not have job description in their personnel files at the time of the review.
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Plan of Correction
Job descriptions for employees #9 and #19 are in the Personnel Files as of 1/23/08. |