INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection Pennsylvania Counseling Services Carlisle 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 March 8, 2011.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of employee personnel, administrative documentation, and an interview with the Vice President of Quality Improvement, the facility failed to document monthly supervisory sessions for each new supervisor for the first six months of employment.
The findings include:
On January 31, 2011 and February 1, 2011 personnel records were reviewed. The "Staffing Requirements Facility Summary Report" was reviewed. Employee record # 3 was listed as the clinical supervisor with the start date of 5/13/2010. The record did not have any documentation of supervisory notes for the initial six months of employment for employee #3. An interview with the Vice President of Quality Improvement on January 31, 2011 at 12:55 p.m. confirmed that the clinical supervisor did not have documented monthly supervisory meetings with their supervisor for the first six months of employment in that position.
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Plan of Correction
Pennsylvania Counseling Services submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State laws relating to drug and alcohol treatment. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or an admission of past or ongoing violations of applicable regulatory requirements.
The Vice President of Quality Improvement and Director of Quality Improvement will ensure that the clinical supervisor receives monthly supervision with his/her supervisor to discuss his/her duties and performance. The monthly supervision meetings will occur for 6 months starting March 2011 and frequency of meetings thereafter will be based upon the clinical supervisor's skill level. Documentation of these meetings will be kept in the personnel file.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and review of the facility policy and procedure manual on January 31, 2011 and February 1, 2011, the facility failed to document an aftercare plan in one of one client record.
The findings include:
Six client records were reviewed on February 7, 2011. According to facility policy and procedure an aftercare plan is completed prior to discharge for each successfully discharged client. An aftercare plan was required in one client record. The facility did not document an aftercare plan in client record # 5.
In client record # 5, the client was admitted on 6/1/2010 and was successfully discharged on 8/11/2010. There was no documentation of an aftercare plan in this record or a statement that the client refused to participate in aftercare.
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Plan of Correction
The Vice President of Quality Improvement and Director of Quality Improvement will ensure that all staff are re-educated through staff meeting to complete aftercare plans with each client who is successfully discharged. Staff will also be re-educated to clearly document in the record if the client has refused to participate in aftercare planning. The local office administration and Quality Improvement department will monitor ongoing compliance via random record reviews. |