INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 11, 12, 13 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 May 16, 2007.
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Plan of Correction
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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
Documentation of counselor assistant supervision did not address the required weekly observation of a counseling session by the Clinical Supervisor or supervising counselor. Weekly direct observation must be documented for the first six months of employment for Counselor assistants qualified at the Bachelor's level.
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Plan of Correction
704.9(c) The Counselor Assistant has been directly supervised weekly in group and individual sessions. However, this was not documented. The Clinical Supervisor will begin to document immediately and continue to do so for six months. The Program Director and HR Assistant will monitor for compliance. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Staff did not consistently utilize the mechanism according to program policy to provide feedback for the training attended.
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Plan of Correction
704.11(a)(3) The Human Resource Assistant sent a notice via e-mail to all Program Directors and Supervisor, informing of the regulation/policy requiring the collection of feedback on all completed trainings. The HR Department is ensuring compliance with this standard by monitoring all submitted training certificates and not issuing credit for the training until the evaluation is completed and submitted to HR. The HR Director is responsible for the overall organizational compliance with this standard. |
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
Individual training plans did not have the required content in employee records reviewed. The individual training plan should identify the subject areas and potential resources for training which meet the requirements for the employee's position and which relate to the employee's skill level and interest. This applies to clinical as well as nonclinical employees.
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Plan of Correction
704.11(b) (1) The Program Director has advised all Supervisors via memo of the need for all required and more complete content on annual training plans. The Western Region HR Assistant will monitor for compliance by submitting all Training Plans. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Documentation of mandatory communicable disease training was incomplete or missing in employee records # 5, 8, 17 and 18 in the sample reviewed.
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Plan of Correction
704.11(c)(1) (Employee #8 has verification of required trainings) The Program Director will work directly with the Human Resources Department to ensure that all employees, including contracted medical staff, are scheduled for and attend all required or requested trainings. The Assistant Director of Nursing will so inform our contracted medical staff as they have not previously fallen into this category. Those employees who do not comply will not be scheduled until they are complete. The HR Department is responsible for monitoring compliance and informing the Program Director of needed trainings via the Training Log.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
One space heater was located in a staff office. Space heaters may not be utilized or stored in the facility.
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Plan of Correction
705.8(2) All staff received a memo from the Program Director to remove and/or not bring to the facility, any heating devices. The maintenance staff will monitor for compliance in doing facility walk-throughs monthly. |
705.10 (b) (1) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
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Observations
Documentation on file indicated that the fire alarm system was not working between September, 2006 and December, 2007.
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Plan of Correction
705.10(b)(1) Eighteen (18) phone calls were made in a very timely fashion to our Fire Panel provider; and there were four (4) visits to the site by the Borough Fire Department at our request, all in a concerted effort to replace or repair the panel that was damaged by lightning as quickly as possible. Ultimately, the Maintenance Supervisor was forced to change providers to ensure proper and prompt response to any future malfunctions and the new fire panel was installed at 501 South Avenue 12/27/06. The Maintenance Supervisor will monitor for compliance based on a contract with the new provider to respond and repair the system within 48 hours.
Comp. 12/27/06
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705.10 (b) (3) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(3) Repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm is found to be inoperative.
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Observations
Documentation made available at the time of the inspection did not support that the inoperable smoke detector and fire alarm problem was repaired within 48 hours.
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Plan of Correction
705.10(b)(1) Eighteen (18) phone calls were made in a very timely fashion to our Fire Panel provider; and there were four (4) visits to the site by the Borough Fire Department at our request, all in a concerted effort to replace or repair the panel that was damaged by lightning as quickly as possible. Ultimately, the Maintenance Supervisor was forced to change providers to ensure proper and prompt response to any future malfunctions and the new fire panel was installed at 501 South Avenue 12/27/06. The Maintenance Supervisor will monitor for compliance based on a contract with the new provider to respond and repair the system within 48 hours.
Comp. 12/27/06
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705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Fire alarms and smoke detectors were inoperable between 9/06 and 12/06.
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Plan of Correction
705.10(b)(1) Eighteen (18) phone calls were made in a very timely fashion to our Fire Panel provider; and there were four (4) visits to the site by the Borough Fire Department at our request, all in a concerted effort to replace or repair the panel that was damaged by lightning as quickly as possible. Ultimately, the Maintenance Supervisor was forced to change providers to ensure proper and prompt response to any future malfunctions and the new fire panel was installed at 501 South Avenue 12/27/06. The Maintenance Supervisor will monitor for compliance based on a contract with the new provider to respond and repair the system within 48 hours.
Comp. 12/27/06
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709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. 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 lacked details in the areas required by the interpretive guidelines. Personal histories should be collected in as much detail as possible. Histories were incomplete in files #1, 2, 3, and 4.
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Plan of Correction
709.81(b)(3)(iii) The Clinical Supervisor and the Assistant Director of Nursing will train both the medical staff and the clinical staff in the necessity to complete and/or add detail to every question in the personal history, the Nursing Assessment, and to review the Self-Assessment Workbook. The Clinical Supervisor and the Assistant Director of Nursing will monitor via revised chart monitors. |
709.82(a)(1) LICENSURE Treatment and rehabilitation services
709.82. 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:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Short and long term goals were not clearly identified . Goals did not consistently contain realistic, measurable criteria. These issues were noted in files # 1, 2, and 4.
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Plan of Correction
709.82(a)(1) New and complete Treatment Plans are developed with the required notations for long- and short-term goals that had inadvertently been omitted. The Clinical Supervisor and/or Program Director will conduct training on completion with the clinical staff and monitor for compliance. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Treatment plan updates did not consistently address whether or not the stated goals of the treatment plan were met, the need for plan modifications or progress on the stated goals and objectives of the treatment plan. These issues were noted in client records #3 and 4.
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Plan of Correction
709.82(b) The Clinical Supervisor and/or the Program Director will address via training and/or memo to the clinical staff how to more full and consistently address treatment plan goals in the Treatment Plan Updates. The Clinical Supervisor and/or Program Director will monitor compliance through use of the revised chart monitor and individual supervision. |
709.83(a)(9) LICENSURE Client records
709.83. 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) Progress notes.
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Observations
Progress notes did not consistently address the stated goals of the treatment plan. Group notes did not address group content and dynamics in sufficient detail. Problems with progress notes were observed in the client records reviewed.
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Plan of Correction
709.83(a)(9) The Clinical Supervisor and/or Program Director will address via training and/or memo to the clinical staff how to document on the revised Group and Individual notes the treatment goals addressed in each session, as well as noting group dynamics and other details on group notes. New forms will be submitted to the Forms committee for approval and use to begin upon approval. Compliance will be monitored by the Clinical Supervisor and/or Program Director by use of the revised chart monitor and in individual supervision. |
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 at the main administrative office and the manuals at the various locations reviewed were not consistent with regard to policies and procedures. The general organization of the manual made the review difficult and increased the potential for misunderstanding the intent of various procedures.
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Plan of Correction
709.23(a) The Master Policy Manual will be reviewed by the Policy Coordinator and Chief Operating Operators from each division (Adult Residential, Adolescent Residential, and Outpatient). The purpose of this review is to 1) ensure consistency of policies across the organization, and 2) to re-organize the Master Manual, separating out Drug and Alcohol Program policies from DPW-licensed Program policies, ensuring ease of access to the policies, and diminishing the potential for misunderstanding of the intent of the policies/procedures. The Policy Coordinator will be responsible for ensuring that the Table of Contents accurately reflects the content of the manual. The CEO/Project Director will be responsible for ensuring timely completion of this project. |
709.28(c) 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:
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Observations
The HIPAA Notice of Privacy Practices form has errors in sections III L. and O.; IV. F; V. A and C.; VI E and H and VII. The "Authority to Represent" form used for MA is a general consent to release information. General consents to release information do not meet the requirements of applicable confidentiality laws.
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Plan of Correction
709.28(c) The Notices of Privacy Practices document was revised April 4, 2007, by the Medical Records Corporate Coordinator, as per recommendations of the Department of Health staff during licensing visit. The Adult Residential Services COO will submit the revised document to the Department of Health for review and approval by April 13, 2007. Approval is still pending and implementation is targeted to begin immediately upon approval. |
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
Content noted in the PCPC continued stay documents contained details related to the client's treatment which exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b).
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Plan of Correction
709.28(c)(2) The Clinical Supervisor will address in clinical meeting, and the Assistant Directory of Nursing will address in a staff meeting, and by memo the need to have PCPCs not exceed confidentiality requirements (limited to the 5 areas), and will monitor compliance via the revised chart monitor and individual supervision. |
709.32(c)(6) 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:
(6) Inventories.
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Observations
Documentation did not support that all prescription stock medications were being inventoried. Inventories are not required for over the counter medicines but all prescription stock medications must be inventoried in accordance with this regulation.
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Plan of Correction
709.32(c)(6) The prescription medication kept in stock will be inventoried every shift using the same tracking system used for our stock narcotics. These stock medications will be counted every shift change by the nursing staff. This will be monitored for compliance by the Assistant Director of Nursing by checking the inventory binder weekly. |
709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories did not address the areas required in sufficient detail in client records # 1, 3, 4 and 10.
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Plan of Correction
709.62.(c)(3)(iii) The Clinical Supervisor and the Assistant Director of Nursing will train both the medical staff and the clinical staff in the necessity to complete and/or add detail to every question in the personal history, the Nursing Assessment, and to review the Self-Assessment Workbook. The Clinical Supervisor and the Assistant Director of Nursing will monitor via revised chart monitors. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
The information provided was not detailed. The required areas specified in the interpretive guideline must be addressed in client records # 1, 3, 4, and 10.
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Plan of Correction
709.62(c)(6) The Assistant Director of Nursing has changed the Nursing Assessment evaluation to note areas needed, and will conduct training on its use. This form will be sent to the Forms Committee for approval. Compliance will be monitored by the Assistant Director of Nursing through use of the medical chart monitor. |
709.63(a)(3) LICENSURE Progress notes
709.63. 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:
(3) Progress notes.
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Observations
Progress notes did not document any effort at counseling the clients in client records # 3 and 4. Content was related only to nursing activities.
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Plan of Correction
709.63(a)(3) The Assistant Director of Nursing and Program Director or Clinical Supervisor will conduct training with the medical staff on completion of progress notes on detoxification clients that include emotional and behavioral content along with medical content. Compliance will be monitored by the Assistant Director of Nursing through weekly chart reviews. |
709.63(a)(5) LICENSURE Record of Services
709.63. 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:
(5) Record of services provided.
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Observations
Records of services provided were missing in client records # 3 and 4.
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Plan of Correction
709.63(a)(5) Historically, Records of Service have been filed upon discharge from the Detox program. The Assistant Director of Nursing will direct her staff to maintain the Record of Service in all open charts and will monitor weekly for compliance. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Drug and alcohol histories were incomplete in client records # 1, 3, 4, 10, 12, 13, 14, 15, 16, 17. A history documenting the substances most frequently abused, the length and patterns of use, and prior treatment episodes must be formulated. Information collected should include the client's perception of their effect on his/her social, physical and mental state. It is recommended that any substance abuse history within the family, or that of significant others be noted.
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Plan of Correction
709.51(b)(3)(ii) The Program Director, Clinical Supervisor and Assistant Director of Nursing have revised the drug and alcohol history to more fully document patterns of use. In a scheduled medical staff meeting, the Program Director, Clinical Director and/or the
Assistant Director of Nursing will train the nursing staff how to use the corrected form which has always included social, physician and mental state issues, but was not being properly utilized. Compliance will monitored by the Assistant Director of Nursing through chart checks on each nurse's admissions.
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709.51(b)(3)(iii) LICENSURE Personal History
709.51. 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 were incomplete in client records # 5, 10 , 12, 13, 14, 15 and 17. Histories should be collected in as much detail as possible.
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Plan of Correction
709.51(b)(3)(iii) The Clinical Supervisor and the Assistant Director of Nursing will train both the medical staff and the clinical staff in the necessity to complete and/or add detail to every question in the personal history, the Nursing Assessment, and to review the Self-Assessment Workbook. The Clinical Supervisor and the Assistant Director of Nursing will monitor via revised chart monitors. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Physical exams did not consistently contain vital signs. This was observed in client records # 2, 11, 12 13 and 15.
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Plan of Correction
709.51(b)(5) The Assistant Director of Nursing will instruct our physicians to consistently document vital signs when completing a History and Physical. The Assistant Director of Nursing will monitor compliance through chart reviews weekly. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations did not contain complete information as required by the interpretive guideline in client records # 2, 3, 4, 8 and 15. Clinical impressions were not detailed, support systems, attitude toward treatment and coping mechanisms were frequently missing or incomplete.
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Plan of Correction
709.51(b)(6) The Clinical Supervisor will address with the clinical staff in staff meeting and via memo the necessity of detailed evaluations and full sentences in completing support systems, attitude toward treatment and coping mechanisms. The Clinical Supervisor will monitor for compliance through the use of the revised chart monitor. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Content on treatment plan updates did not consistently address progress on the stated goals of the treatment plan or the need for modifications in client records # 7, 8, 10 and 12.
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Plan of Correction
709.52(b) The Clinical Supervisor and/or the Program Director will address via training and/or memo to the clinical staff how to more full and consistently address treatment plan goals in the Treatment Plan Updates. The Clinical Supervisor and/or Program Director will monitor compliance through use of the revised chart monitor and individual supervision. |
709.53(a)(2) LICENSURE Medication records
709.53. 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:
(2) Medication records.
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Observations
Medication records were incomplete. Client records # 2, 11, 12 and 13 contained documentation where signatures were missing from the Medication Administration Records and no explanations were documented.
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Plan of Correction
709.53(a)(2) The nursing staff has been directed by the Assistant Director of Nursing to document on the Medication Records at the end of their shift that clients have not come at a specific medication time. Prior to noting that the client has not come for medications, the nursing staff has been directed to seek out any and all clients who fit this category and attempt to medicate them. The Assistant Director of Nursing will monitor open charts weekly for compliance. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
Records of services provided were not accurate and/or were missing required components in client records # 2, 3, 4, 5, 12, 13, 14 and 17. This should be a chronological listing (separate from progress notes) of the various specific services provided to the individual client. This listing should also include the date, the provider(s), and the duration of the service.
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Plan of Correction
709.53(a)(3) The Clinical Supervisor has revised the Record of Service to more accurately portray the services provided, the length of service, and the service provider. The Clinical and Tech staffs will be trained in completion of the form and compliance will be monitored by the Clinical Supervisor via revised chart monitor. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Progress notes were not related to the stated goals of the treatment plan in client records reviewed. Group notes lacked detail and had generic content. Group notes did not give a good sense of what occurred in groups. These issues were noted in client records #2, 5, 7, 10, 11, 12, 13 ,14, 15 and 16.
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Plan of Correction
709.53(a)(5) The Clinical Supervisor and/or Program Director will address via training and/or memo to the clinical staff how to document on the revised Group and Individual notes the treatment goals addressed in each session, as well as noting group dynamics and other details on group notes. Compliance will be monitored by the Clinical Supervisor and/or Program Director by use of the revised chart monitor and in individual supervision. |