INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9, 2009 through July 10, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, NTP Consultants, Llc 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 August 5, 2009.
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Plan of Correction
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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 a review of fire drill records, as well as a staff interview, the facility failed to conduct unannounced fire drills at least once a month in five of twelve months.
The findings include:
Fire drill records were reviewed from July 2008 through June 2009. Documentation of a fire drill was missing for July 2008, August 2008, October 2008, December 2008 and February 2009.
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Plan of Correction
Facility Director will ensure monthly fire drills and document each accordingly. Director will ensure that the drills are not missed by planning and documenting the week that the unannounced drill will occur. This process started as of July 20, 2009. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records on July 9, 2009 and July 10, 2009, the facility failed to document proposed support services specific to each client in the individual treatment and rehabilitation plan in five of eight client records.
The findings include:
Eight client records were reviewed on July 9, 2009 through July 10, 2009. Eight client records were required to have individualized support services documented on the individual treatment and rehabilitation plan. Support services listed in client records #1, 2, 3, 4 and 6 listed only probation.
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Plan of Correction
Facility Director facilitated meeting with clinicians to discuss and formulate appropriate proposed support services for our client population, and then discussed and documented the importance of stating these available support systems on the individualized treatment plans. Director reviewed current treatment plans to ensure the proposed support services are identified in the plan, and will continue follow up with monthly review of charts and treatment plans. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records and staff interview on July 9, 2009 and July 10, 2009, the facility failed to document follow-up information in four of four client records.
The findings include:
Eight client records were reviewed on July 9, 2009 through July 10, 2009. Four client records were required to have documented follow-up information. Follow-up was not documented in client records #5, 6, 7 and 8. The project/facility director also informed the licensing specialist that the facility had not been performing follow-up.
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Plan of Correction
Facility Director has assessed current follow-up form and letter, which will be mailed out by primary counselor three months after discharge. This will then be documented on the Record of Service, which is located in front of chart, the date the letter and form was mailed. This process will be evaluated and reinforced through case consult and staff meetings, as well as monthly chart reviews of open and closed files. This process started and implemented as of July 20, 2009. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of administrative materials and client records on July 9, 2009 and July 10, 2009, the facility failed to document evidence that a physician was reviewing and signing treatment plans and treatment plan updates in two of two client records.
The findings include:
Eight client records were reviewed on July 9, 2009 through July 10, 2009. Two client records were required to have a physician review and sign off on treatment plans and treatment plan updates. There was no documentation that a physician reviewed and signed off on the treatment plans and treatment plan updates in client records #2 and 3. The project/facility director also informed the licensing specialist that they do not have a physician performing these duties.
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Plan of Correction
Facility Director has assumed this deficiency as pending DOH licensure response from letter Director sent on July 15, 2009 concerning this deficiency, and confirmed receipt by DOH licensure staff on July 17, 2009. In the event that my letter of exception is denied our agency will recruit a physician who is able and willing to meet with agency clinicians on site monthly to review and sign our MA client treatment plans and case consults. We would make an attempt to accomplish this by September 10, 2009. Once instructed by DOH that my request for exception is denied, then the agency will not admit MA funded clients. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of administrative materials, personnel records and staff interview on July 9, 2009 and July 10, 2009, the facility failed to ensure a sufficient number of staff are trained in CPR and first aid.
The findings include:
Three staff work at this facility full-time. Staff person #1 was trained in CPR, but not in first aid. Staff person #2 has neither CPR nor first aid training. Staff person #3 has first aid training, but no CPR. Based on these findings, if staff person #1 is on vacation or out sick, there was no one at the facility trained in CPR. If staff person #2 is on vacation or out sick, there was no one at the facility trained in first aid.
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Plan of Correction
All staff, 1, 2, and 3 will attend CPR and first Aid training by August 31, 2009. Facility Director will review CPR and First Aide status of each staff during yearly training plan developments. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records and administrative materials, as well as a staff interview, the facility failed to ensure that all clinical staff received the required number of training hours annually in one of one personnel record.
The findings include:
Three personnel records were reviewed on July 9, 2009 through July 10, 2009. One personnel record was required to have 25 hours of training completed on or before June 30, 2009. Documentation provided showed personnel record #2 only had six hours of documented annual training.
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Plan of Correction
Staff number 2 has a training plan for this year, 2009, that will go beyond the 25 hours of the training standards. This plan was created by Facility Director and staff number 2. All training plans are reviewed and reinforced quarterly by Facility Director to ensure compliance with training requirements. Facility Director will also ensure that certificates of completion of trainings are available for review by Director to ensure that the trainings are appropriate satisfaction towards job descriptions. |