INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on November 6-8, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Tadiso Inc., 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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704.7(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, the facility failed to ensure that each counselor met the qualifications for the position.
The findings include:
On November 6-8, 2012, sixteen personnel records were reviewed. Nine personnel records were required to have documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel record #14.
Employee # 14 was hired as a counselor on January 31, 2012. Employee # 14 has a Bachelor of Science in Nursing and a Master of Science in Health Science. The Bachelor of Science in Nursing meets the education requirements; however, employee #14 does not have one year of required clinical experience.
An interview with the clinical supervisor took place on November 7, 2012 at which time it was confirmed that employee #14 did not have any additional clinical experience than what was documented on his resume.
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Plan of Correction
Effective immediately, employee #14 will have all clinica documentation signed off by the Director of Social Services. His caseload will be modified to the appropriate level for Counselor Assistant. Staff #14 will continue as Counselor Assistant until they meet the staffing guidelines for Counselor. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection of the bathrooms, the facility failed to ensure that each bathroom was ventilated by an exhaust fan or operable window.
The findings include:
An inspection of the bathroom located near the medical wing on the first floor of the physical plant revealed that there were no windows and the exhaust fan was not functional at the time of the inspection.
This was reviewed with the Project Director who confirmed that the fan was not functioning.
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Plan of Correction
The restroom located near the medical wing on the first floor will have an exhaust fan installed in the ceiling to ventilate the restroom at all times. The Chief Operations Officer will be responsible for ensuring the fan is installed and operable. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in two of five client records.
The findings include:
Twenty-seven client records were reviewed on November 6-8, 2012. Five of the discharged clients reviewed were involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client records # 16 and 18.
Client # 16 was admitted into treatment on January 9, 2012 and was involuntarily terminated from the project on July 22, 2012. There was no documentation of written notification provided to the client as of the on-site inspection which was conducted on November 6-8, 2012.
Client # 18 was admitted into treatment on November 17, 2008 and was involuntarily terminated from the project on August 14, 2012. There was no documentation of written notification provided to the client as of the on-site inspection which was conducted on November 6-8, 2012.
The clinical supervisor was interviewed on November 8, 2012. It was confirmed that clients # 16 and 18 were not provided with written notification of the decision to involuntarily terminate the client's treatment at the project.
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Plan of Correction
All decisions for involuntary termination of patients will be reviewed by the Director of Social Services. All involuntary termination decisions will be conducted through a case conference which will include the Medical Director, Administrator or designee, and the patient. Notification will be made verbally and in writing and will be made part of the patient record. |
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
Based on a review of the client records, the facility failed to provide a personal history that included detail in the areas of family history, legal history, employment/vocational history, education history, military history, recreational history and sexual history in six of fourteen records.
The findings include:
During the inspection conducted November 6-8, 2012, fourteen personal histories were reviewed. All fourteen client records required the documentation of a complete personal history. Six client records did not document personal histories that included all components of a personal history that are comprised of family history, legal history, employment and vocational history, education history, military history, recreational history and sexual history. Client records # 3, 7, 11, 12, 13 and 14 contained an incomplete personal history.
The facility began to utilize a new computer-based record keeping system in June 2012. The computer system includes a "drop down" box for each required component in the personal history. Only current information is entered into the drop down box. There is no historical information entered for the required areas: family, legal, employment/vocational, education, military, recreational and sexual.
An interview with the clinical supervisor took place on November 8, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
The instrument used to document the personal history of patients will be modified to ensure that the history includes detail in the areas of family history, legal history, employment/vocational history, education history, military history, recreational history, and sexual history. The new instrument will be contained in the electronic record for each patient. The Director of Social Services or one of the Social Services Coordinators will be responsible for reviewing each patient history to verify compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. 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, the facility failed to document psychosocial evaluations which included an assessment that provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in seven of fourteen client records.
The findings include:
The psychosocial evaluations were reviewed in fourteen active client records on November 6-8, 2012. The psychosocial evaluations did not include a counselor assessment that provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in client records # 3, 6, 7, 11, 12, 13 and 14.
An interview with the clinical supervisor took place on November 8, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
The new instrument to be utilized by the clinical staff will include the counselor's assessment of the psychosocial evaluation for each patient that provides a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the patient's current situation. This instrument will be contained in the patient record. The Director of Social Services or one of the Social Services Coordinators will be responsible for ensuring that this is completed for all new patients admitted to the program. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in six of fourteen client records.
The findings include:
Fourteen active outpatient client records were reviewed on November 6-8, 2012. All fourteen client records required an individual treatment and rehabilitation plan which included the type and frequency of treatment and rehabilitation services. The individual treatment and rehabilitation plans contained in client records # 3, 4, 7, 12, 13 and 14 did not include the type and frequency of treatment and rehabilitation services.
Client #3 was admitted to treatment on August 10, 2012. There was no individual treatment and rehabilitation plan documented for this client. The type and frequency of treatment and rehabilitation services was not specifically identified on the document.
Client #4 was admitted to treatment on June 13, 2012. The individual treatment and rehabilitation plan was developed on July 6, 2012. There was no frequency of treatment and rehabilitation services documented on the treatment plan.
Client #7 was admitted to treatment on January 26, 2012. The individual treatment and rehabilitation plan was developed on February 22, 2012. There was no type and frequency of treatment and rehabilitation services documented on the treatment plan.
Client #12 was admitted to treatment on September 24, 2012. The individual treatment and rehabilitation plan was developed on October 24, 2012. There was no type and frequency of treatment and rehabilitation services documented on the treatment plan.
Client #13 was admitted to treatment on October 11, 2012. The individual treatment and rehabilitation plan was developed on November 5, 2012. There was no type and frequency of treatment and rehabilitation services documented on the treatment plan.
Client #14 was admitted to treatment on August 7, 2012. There was no individual treatment and rehabilitation plan documented for this client. The type and frequency of treatment and rehabilitation services was not specifically identified on the document.
An interview with the clinical supervisor took place on November 8, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
The type and frequency of services for all patients will be documented and contained in the patient record. This information will be found in the Treatment Plan for each patient under "ongoing care". The Director of Social Services will ensure that this programming is modified. |
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 a review of client records, the facility failed to document treatment plan updates every sixty days in six of eleven client records.
The findings include:
Fourteen active client records were reviewed on November 6-8, 2012. Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. Eleven of the client records reviewed required documentation of a treatment plan update. Treatment and rehabilitation plans were not updated at least every 60 days in client records # 1, 2, 4, 5, 6 and 8.
Client #1 was admitted on May 7, 2012. The comprehensive treatment plan was completed on May 10, 2012. This treatment and rehabilitation plan was due to be reviewed and updated by July 10 and September 10, 2012. The only treatment plan update was completed on September 19, 2012.
Client #2 was admitted on March 22, 2012. The comprehensive treatment plan was completed on April 19, 2012. This treatment and rehabilitation plan was due to be reviewed and updated by June 19, August 19, and October 19, 2012. The treatment plan updates were completed on June 18 and July 12, 2012.
Client #4 was admitted on June 13, 2012. The comprehensive treatment plan was completed on July 6, 2012. This treatment and rehabilitation plan was due to be reviewed and updated by September 6 and November 6, 2012. The only treatment plan update was completed on October 5, 2012.
Client #5 was admitted on May 3, 2012. The comprehensive treatment plan was completed on May 10, 2012. This treatment and rehabilitation plan was due to be reviewed and updated by July 10 and September 10, 2012. There were no treatment plan updates documented in client record #5.
Client #6 was admitted on February 1, 2012. The comprehensive treatment plan was completed on February 8, 2012. This treatment and rehabilitation plan was due to be reviewed and updated by April 8, June 8, August 8 and October 8, 2012. The only treatment plan update was completed on March 30, 2012.
Client #8 was admitted on February 24, 2012. The comprehensive treatment plan was completed on March 6, 2012. This treatment and rehabilitation plan was due to be reviewed and updated by May 6, July 6, September 6 and November 6, 2012. Treatment plan updates were completed on May 4, August 1 and October 3, 2012.
An interview with the clinical supervisor took place on November 8, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
Treatment Plans for all patients will be updated every sixty days based on the patient admit date, and documented in the patient record. The Director of Social Services or one of the Social Services Coordinators will be responsible for ensuring that the treatment plans are completed in a timely manner. All treatment plans completed by counselors will be signed off by the a supervisor and reviewed by the Medical Director. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual which includes information relative to the client's involvement with the project.
The findings include:
Twenty seven client records were reviewed on November 6-8, 2012. The facility started utilizing a new computer-based client record keeping program in June 2012. Since that time, paper records are no longer maintained. Several documents, including client correspondence, are not maintained as part of the client record. The various paper documents are located at multiple places within the facility.
The additional paper documents for the computerized client records were requested and some documentation was provided. The gathering of this information took an extended period of time and it was unclear if the documentation was complete.
An interview with the clinical supervisor took place at multiple times throughout the inspection. It was confirmed that paperwork associated with each client is no longer maintained in a client record and is located at multiple places throughout the facility. The majority of the client record documentation is maintained on the computer.
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Plan of Correction
Eventually, all documentation, including patient correspondence will be maintained in the patient electronic record. Until such time as the electronic record system is capable of maintaining all documents, a paper record for each patient will be maintained which will contain all documents which are not maintained in the electronic record. This will include intake information, referral information,and all medical information from hospitals or other referral sources. The Chief Financial Officer will ensure that all documents related to each patient is maintained appropriately. |
709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
Based on a review of client records, the facility failed to maintain client-related correspondence as part of the client record.
The findings include:
Twenty seven client records were reviewed on November 6-8, 2012. The facility started utilizing a new client record keeping program in June 2012. Since that time, paper records are no longer maintained. Several documents, including client correspondence, are not maintained as part of a client record. The client-related correspondence documents are located at multiple places within the facility.
The additional paper documents for the computerized client records were requested and some documentation was provided. The gathering of this information took an extended period of time and it was unclear if the documentation was complete.
An interview with the clinical supervisor took place at multiple times throughout the inspection. It was confirmed that paperwork associated with each client is no longer maintained in a client record and is located at multiple places throughout the facility. The majority of the client record documentation is maintained on the computer.
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Plan of Correction
Eventually, all documentation, including patient correspondence will be maintained in the patient electronic record. Until such time as the electronic record system is capable of maintaining all documents, a paper record for each patient will be maintained which will contain all documents which are not maintained in the electronic record. This will include intake information, referral information,and all medical information from hospitals or other referral sources. The Chief Financial Officer will ensure that all documents related to each patient is maintained appropriately. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations, as per agency policy in March, June, September and December each year, in eight of ten client records.
The findings include:
Fourteen client records were reviewed on November 6-8, 2012. Case consultations were required to be completed in ten client records. Case consultations were not documented in March, June, September, and December, as per agency policy, in client records #1, 2, 4, 5, 6, 7, 10 and 11.
Client #1 was admitted May 7, 2012. Case consultations were due to be completed in June and September 2012. There were no case consultations documented in client record #1.
Client #2 was admitted March 22, 2012. Case consultations were due to be completed in June and September 2012. There were no case consultations documented in client record #2.
Client #4 was admitted June 13, 2012. A case consultation was due to be completed in September 2012. There were no case consultations documented in client record #4.
Client #5 was admitted May 3, 2012. Case consultations were due to be completed in June and September 2012. There were no case consultations documented in client record #5.
Client #6 was admitted February 1, 2012. Case consultations were due to be completed in March, June and September 2012. There were no case consultations documented in client record #6.
Client #7 was admitted January 26, 2012. Case consultations were due to be completed in March, June and September 2012. There were no case consultations documented in client record #7.
Client #10 was admitted April 17, 2012. Case consultations were due to be completed in June and September 2012. There were no case consultations documented in client record #10.
Client #11 was admitted June 29, 2012. A Case consultation was due to be completed in September 2012. There were no case consultations documented in client record #11.
An interview with the clinical supervisor took place on November 8, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
The policy for Case Consultations will be modified to comply with Pennsylvania regulations. Each patient in treatment less than one year will have a documented case consultation quarterly based the patient's admission date. All patients enrolled in treatment longer than one year will have at least an annual consultation. the Case Consultation will include the patient, the primary counselor, an Administrator or designee, and the medical doctor. The Director of Social Services will be responsible for ensuring that the case consultations are conducted for each patient in a timely manner. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary within seven days of discharge in seven of thirteen client records.
The findings include:
Thirteen discharged outpatient client records were reviewed on November 6-8, 2012. A discharge summary, which is to be completed within seven days of discharge, was required in all thirteen client records. The facility did not document a discharge summary within seven days of discharge in client records # 15, 16, 17, 18, 20, 25 and 27.
Client #15 was admitted to treatment on March 18, 2011 and was discharged on March 25, 2012. A discharge summary was due to be completed by April 1, 2012. The discharge summary was completed on April 3, 2012.
Client #16 was admitted to treatment on January 9, 2012 and was discharged on July 22, 2012. A discharge summary was due to be completed by July 29, 2012. The discharge summary was completed on August 3, 2012.
Client #17 was admitted to treatment on October 19, 2010 and was discharged on September 23, 2012. A discharge summary was due to be completed by September 30, 2012. The discharge summary was completed on November 5, 2012.
Client #18 was admitted to treatment on November 17, 2008 and was discharged on August 14, 2012. A discharge summary was due to be completed by August 21, 2012. The discharge summary was completed on September 18, 2012.
Client #20 was admitted to treatment on November 29, 2010 and was discharged on July 23, 2012. A discharge summary was due to be completed by July 30, 2012. The discharge summary was completed on November 5, 2012.
Client #25 was admitted to treatment on December 20, 2011 and was discharged on June 11, 2012. A discharge summary was due to be completed by June 18, 2012. There was no discharge summary in client record #25.
Client #27 was admitted to treatment on March 14, 2012 and was discharged on May 22, 2012. A discharge summary was due to be completed by May 29, 2012. The discharge summary was completed on May 30, 2012.
An interview with the clinical supervisor took place on November 8, 2012 at which time all of the aforementioned information was confirmed.
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Plan of Correction
A discharge summary will be completed for each patient within seven days of discharge from the program. The documentation will be completed by the primary counselor or one of the supervisors in the Social Services department. The Director of Services will be responsible for ensuring the timeliness of the completion of the discharge summary. |