INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 23-26, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on February 15, 2007.
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Plan of Correction
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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
The staffing compliance plan was not approved by the Pinnacle governing body. This statement must be approved by the governing body and documented via meeting minutes or governing body sign off.
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Plan of Correction
Board meeting will address this issue on 4/24/07 |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
The counselor assistant (employee record #2) did not have an approved degree and needed to be supervised at the direct observation level. She has been supervised at the close supervision level since employed from August, 2006 to November, 2006. In order to complete the required supervision period this employee will need 3 months of direct observation and an additional 5 months of close supervision, which is to include at least one hour of direct observation per week. This supervision will need to be clearly documented. See the Licensing Alert of April,2002.
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Plan of Correction
The clinical supervisor or another counselor will provide direct observation for the next three months. A weekly supervision note will be completed focusing on skill development and specific case consultation. After satisfying this requirement, the counselor assistant will be closly supervised by the clinical supervisor for an additional five months with at least one hour weekly of direct observation. |
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
The staff to client ratio was 38:1. Some individual caseloads were 36:1.
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Plan of Correction
Ratio will be corrected by addressing counselor assistant issue as noted in 704.9(c) licensure deficiency. Other than the discrepancy related to the counselor assistant, ratios were within department guidelines. |
704.12(b) & (c) & (d) LICENSURE Counselor Asst/Exceptions
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(b) Counselor assistants. Counselor assistants may be included in determining FTE ratios when the counselor assistant is eligible for a caseload.
(c) Exemption for transitional living. Specific client/staff ratios are not required for transitional living facilities.
(d) Exceptions. A project director may submit to the Department a written petition requesting an exception to the client/staff and client/counselor ratios in this section. The petition shall describe how the characteristics of the program and its client mix support the request for the exception and shall be approved by the governing body. Granting the petition shall be at the discretion of the Department. Long-term residential facilities and halfway houses which include a client's participation in schooling or employment as part of a treatment day are examples when requests for exceptions will be considered.
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Observations
The counselor assistant hours could not be counted because she did not receive the proper supervision.
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Plan of Correction
Ratio will be corrected by addressing counselor assistant issue as noted in 704.9(c) licensure deficiency. |
705.28 (b) (2) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(2) Place the smoke detector in a common area or hallway. All detection devices shall be interconnected.
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Observations
Smoke detectors are not interconnected. Facilities occupying multiple floors must have the detection devices installed so that all devices sound an alarm when one device is activated.
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Plan of Correction
Security company is installing interconnected smoke detectors on the second floor EI. Facility Director will be responsible for compliance by 3/1/2007 |
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
Fire extinguisher training was not documented for each staff person within seven days of hire (employee records # 5 & 13).
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Plan of Correction
Supervisory staff have been reminded of this requirement, and a tickler system is established to monitor compliance as part of employment packet and will be monitored by HR staff. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Emergency procedure training was not documented for each staff person within seven days of hire (employee records # 5 & 13).
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Plan of Correction
Supervisory staff have been reminded of this requirement, and a tickler system is established to monitor compliance as part of employment packet
Human Resourses staff will monitor for compliance. |
709.22(b) LICENSURE Governing Body
709.22. Governing body.
(b) If a project is publicly funded, not more than one staff member of the project may sit on the governing body at a designated time.
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Observations
No documentation was on file to verify who sits on the governing body for Pinnacle Treatment Centers. Documentation must be available to demonstrate compliance with this regulation.
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Plan of Correction
Board meeting will address this issue on 4/24/07 |
709.22(c)(2) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(2) Qualifications for membership.
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Observations
No documentation was presented to specify qualifications for membership on the Pinnacle Treatment Centers Board of Directors. At least two qualifications for board membership should be specified.
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Plan of Correction
Board meeting will address this issue on 4/24/07 |
709.22(c)(3) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(3) Criteria for continued membership.
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Observations
No criteria for continuing membership on the Pinnacle Board of Directors were specified. Examples of such criteria would include but not be limited to: regular attendance at Board meetings; acting in the best interests of the corporation; no criminal activity, etcetera.
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Plan of Correction
Board meeting will address this issue on 4/24/07 |
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
No method for selection of the Project Director was specified in the materials presented. The method of selection must be clearly identified.
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Plan of Correction
Board meeting will address this issue on 4/24/07 |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
The manual did not include approval by the Pinnacle governing body. The manual was not complete in regard to identifying the relationship of Pinnacle Treatment Center to Alliance Medical.
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Plan of Correction
Board meeting will address this issue on 4/24/07 |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
No documentation was presented to verify that the Project Director and the the Pinnacle Board collaborated in formulating goals and objectives, written reports of project operations and a performance report on meeting goals and objectives.
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Plan of Correction
Board meeting will address this issue on 4/24/07 |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
No goals and objective were documented for the current fiscal year (Jan- Dec., 2007). Goals and objectives should be formulated and approved prior to the beginning of each fiscal year.
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Plan of Correction
The board that was in place for '06 has been disbanded |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
No performance report summarizing progress toward meeting goals and objectives for 2006 was presented at the time of the inspection.
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Plan of Correction
The board that was in place for '06 has been disbanded. Goals for 2007 will be approved via the board meeting. |
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
Specific information disclosed, (GAF scores), to funding entities exceeded the limitations imposed at 4 Pa. subsection 255.5(b).
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Plan of Correction
The Facility Director will develop a specific release of information limited to 255.5. The Medical Director as part of his diagnosis will provide the GAF score that will be communicated to the funders. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
No inspection was documented for the last quarter of 2006.
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Plan of Correction
Report was misplaced. The Medical Director will be responsible for future compliance. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories should collect as much personal information about a client as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated. Personal histories in files reviewed lacked detail on family of origin, current family constellation and employment history.
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Plan of Correction
The Facility Director and Clinical Supervisor will provide training in further development of the personal histories. Ongoing training and compliance will be monitored by the clinical supervisor. |