INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 15, 2008 and September 16, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Philadelphia Health Management Corporation/Chances 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 October 20, 2008.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records on September 15, 2008 and a conversation with the facility director on September 16, 2008, the facility failed to document that the project director met the qualifications for the position.
Finding:
The facility failed to document any of the qualifications required for project director for personnel record #1.
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Plan of Correction
The Human Resources department obtained verification of Project Director's higher education degree from the National Student Clearing House on 9/17/08. The verification form has been placed in the Project Director's personnel file.
All new hires will bring in original diploma and school transcript by their start date for Program Director to review degree and major. Program director will sign off that original documents were verified, and will send copies to PHMC's Human Resources department to file in their personel record. The Human Resources department will conduct quarterly audits of all employee records to ensure that documentation is properly filed, and will inform Program Director if anything is missing. |
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 a review of personnel records on 9/15/08, the facility failed to document a complete individual training plan for ten of ten personnel records reviewed.
Findings:
The facility did not include time frames and potential resources on the individual training plans for personnel records # 2, 3, 4, 5, 6, 7, 8, 9 and 10. Additionally, the facility did not document an individual training plan for personnel record #1.
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Plan of Correction
Facility Director will meet with each employee annually, by the 15th of January, to complete an individual training plan for the upcoming calendar year. In addition, Facility Director will have new hires complete a training plan on their first day of employment.
In developing the Individual Training Plans with staff, the Facility Director will clearly indicate on form the potential resources and time frames for obtaining the trainings. |
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 a physical plant inspection on September 15, 2008 and September 16, 2008, the facility failed to maintain the confidentiality of client's identities.
Findings:
The client sign-in sheet in the lobby of the facility documented first and last names of the clients in a manner that made the list visible to clients and visitors to the facility.
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Plan of Correction
On 10/24/08, Program Director will instruct clients to sign in with first name and last initial only when entering the facility, and a sign will also be posted by the sign-in sheet indicating this policy. In addition, the Administrative Assistant will verify compliance daily, when collecting the completed sheets. She will inform the Clinical Director immediately if any of the clients are writing their full name, so that the Clinical Director can review the procedure and it's purpose with the client.
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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 eight client records on September 16, 2008, the facility failed to document the frequency of treatment and rehabilitation services on the treatment plan in four of eight client records where required.
Findings:
The facility did not document the frequency of treatment services in client records # 1, 2, 3 and 4.
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Plan of Correction
A Treatment Plan training to be conducted by the Program Director has been scheduled for 10/27/2008. During the training, the Program Director will review the form, and indicate where the frequency of services needs to be indicated. Treatment plans will be reviewed weekly during the clinical team meetings, and Clinical Director will ensure that frequency of services is indicated prior to signing any plans. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of eight client records on September 16, 2008, the facility failed to document that counseling services were provided according to the individual treatment and rehabilitation plan in four of eight client records where required.
Findings:
The facility did not document that counseling services were provided according to the individual treatment plan in client records #1, 2, 3 and 4.
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Plan of Correction
In order to ensure that services are provided according to the client's individual treatment plan, therapists will need to indicate the frequency of services to be provided to the client. A Treatment Plan training to be conducted by the Program Director has therefore been scheduled for 10/27/2008. During the training, the Program Director will review the form, and indicate where the frequency of services needs to be indicated. Treatment plans will be reviewed weekly during the clinical team meetings, and Clinical Director will ensure that frequncey of services is indicated prior to signing any plans. |