INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 23, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Ridgeview Adolescent Behavioral Health Center at Pittsburgh 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.
|
Plan of Correction
|
704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Reports, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Reports for the project's 14 facilities were reviewed on October 15, 2013. The project employed the equivalent of 105.275 full-time counselors, which would require the project to have at least 13 full-time clinical supervisors. The project failed to employ a full-time clinical supervisor for every eight full-time counselors as the project only employed 7 full-time clinical supervisors as of October 15, 2013.
|
Plan of Correction
The Vice President of Clinical Services will ensure that the ratio of Clinical Supervisors for the project is within the defined regulation of 1 fulltime Clinical Supervisor for every 8 fulltime Counselors or Counselor Assistants. The Project will re-evaluate its current system and restructure the project to include the appropriate number of Clinical Supervisors. Human Resource Coordinators will identify the number of Clinical Supervisors, Counselors, and Counselor Assistants within the system on a quarterly basis. Vice President of Clinical Services will be responsible to review staffing hours quarterly to ensure that ratio is maintained. Program Directors will notify the Vice President of Clinical Services should any changes in the ratio per site occur during the quarter. Restructuring of the Clinical Supervisor ratio will begin December 1, 2013. Clinical Supervisor ratio will be in 100% compliance by January 1, 2014. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of employee records, the facility failed to document the completion of 12 clock hours of annual training required for project directors in one of one employee records.
The findings include:
The facility training year runs from July 1 through June 30.
Nine employee records were reviewed on October 23, 2013. One employee record pertained to the project director and required the documentation of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in employee record # 1.
Employee # 1 has been the project director since July 1, 1999. The facility failed to document 12 clock hours of annual training for employee # 1 for the July 2012 - June 2013 training year as the record only contained documentation of 10.5 hours of training.
This is repeat citation from the 2012 licensing inspection.
|
Plan of Correction
Project Manager will complete 12 hours of training annually. Project Manager will ensure needed documentation of completed trainings is presented to Human Resources to be recorded in personnel file. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance. |
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.
|
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 one of one client record.
The findings include:
Twelve client records were reviewed on October 23, 2013. Six of the client records reviewed were for discharged clients. One of the discharged clients was 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 record # 5.
Client # 5 was admitted on July 10, 2013 and involuntarily terminated from the project on August 14, 2013. The facility failed to provide documentation that client # 5 received written notification of the project's decision to involuntarily terminate the client's treatment at the project.
The Facility Director and Clinical Supervisor were interviewed on October 23, 2013 and confirmed the findings.
|
Plan of Correction
Beginning immediately, all clients involuntarily terminated from the program will be provided notification, in writing, the reasons for involuntary termination. This notification will be filed in the client's chart upon discharge. Full compliance will be monitored by Clinical Supervisor during monthly chart audits and will be achieved by January 1, 2014. |
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.
|
Observations
Based on the review of client records, the facility failed to document that the treatment and rehabilitation plans were reviewed and updated at least every 60 days in one of three client records.
The findings include:
Twelve client records were reviewed on October 23, 2013. Five client records were reviewed as outpatient client records. Three outpatient client records required treatment and rehabilitation plan updates. The facility failed to document treatment and rehabilitation plan updates in client record # 8.
Client # 8 was admitted on January 21, 2013. The treatment and rehabilitation plan was completed on February 12, 2013. Treatment and rehabilitation plan updates were due on or about April 12, June 12, August 12 and October 12, 2013. The facility failed to provide documentation to confirm that the treatment plan updates were completed.
The Facility Director and Clinical Supervisor were interviewed on October 23, 2013 and confirmed the findings.
|
Plan of Correction
Beginning immediately, all outpatient clients will recieve and review a documentated treatment update every 60 days. Clinical Supervisor will montior compliance through monthly chart audits. 100% ompliance will be achieved by January 1, 2014. |
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:
|
Observations
Based on a review of client records, the facility failed to document case consultation notes in two of two client records.
The findings include:
Twelve client records were reviewed on October 23, 2013. Five client records were reviewed as outpatient client records. Two outpatient client records required case consultation notes. The facility failed to document case consultation notes in client records # 8 and 9.
Client # 8 was admitted to outpatient treatment on January 21, 2013. Case consultation notes were to be completed by June 30 and September 30, 2013. There was no documentation provided that the case consultations had been completed.
Client # 9 was admitted to outpatient treatment on June 12, 2013. A case consultation note was to be completed by September 30, 2013. There was no documentation provided that the case consultation had been completed.
The Facility Director and Clinical Supervisor were interviewed on October 23, 2013 and confirmed the findings.
|
Plan of Correction
Effective immediately, all outpatient client records will contain case consultation notes every 60 days. The Clinical Supervisor will monitor compliance through monthly chart audits and 100% compliance will be achieved by January 1, 2014. |