INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 2, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services Renaissance 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 March 8, 2011.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on the review of the "Staffing Requirements Facility Summary Report," the facility failed to document all required information.The findings include:The "Staffing Requirements Facility Summary Report" was reviewed on January 31, 2011 and February 1, 2011. The facility listed employee # 2 as the Clinical Supervisor with an original hire date at the Project as 5/17/2010. The date listed for the currrent position was also 5/17/10. Licensing staff interviewed the Quality Improvement personnel regarding the original hire date for the Clinical Supervisor and was inoformed that, for Employeed # 2, 5/17/10 was the correct date for employment at the Project and for the current position. In review of prior staffing forms it was documented that employee # 2 was listed on the "Staffing Requirement Summary Report" signed by the project director and dated 1/5/2009 as having an original hire date with the facility as 9/10/2002. Additionally, employee # 2 was listed on the "Staffing Requirement Summary Report", signed by the project director on 3/3/2008, as having an original hire date with the facility as 9/10/2002. Employee # 2 was listed on the "Staffing Requirement Summary Report" signed by the Vice President of Quality Improvement on 4/5/2007 as having an original hire date with the facility as 9/10/2002. Employee # 2 was listed on the "Staffing Requirement Summary Report" signed by the Vice President of Quality Improvement on 5/3/2006 as having an original hire date with the facility as 9/10/2002. The facility did not provide accurate information on the "Staffing Requirements Summary Report".
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Plan of Correction
The Vice President of Quality Improvement and Director of Quality Improvement will ensure that the Staffing Requirements Facility Summary Report provides all required information and that the original hire date at the facility for employee #2 is revised to reflect the 9/10/02 hire date. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of employee personnel, administrative documentation, and an interview with the Vice President of Quality Improvement, the facility failed to document monthly supervisory sessions for each new supervisor for the first six months of employment.The findings include:On January 31, 2011 and February 1, 2011 personnel records were reviewed. The "Staffing Requirements Facility Summary Reports" was reviewed. Employee record # 2 was listed as the clinical supervisor with the start date of 5/17/2010. The record did not have any documentation of supervisory notes for the initial six months of employment for employee #2. An interview with the Vice President of Quality Improvement on January 31, 2011 at 12:55 p.m. confirmed that the clinical supervisor did not have documented monthly supervisory meetings with their supervisor for the first six months of employment in that position.
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Plan of Correction
Pennsylvania Counseling Services submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State laws relating to drug and alcohol treatment. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or an admission of past or ongoing violations of applicable regulatory requirements.
The Vice President of Quality Improvement and Director of Quality Improvement will ensure that the clinical supervisor receives monthly supervision with his/her supervisor to discuss his/her duties and performance. The monthly supervision meetings will occur for 6 months starting March 2011 and frequency of meetings thereafter will be based upon the clinical supervisor's skill level. Documentation of these meetings will be kept in the personnel file.
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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 a case consultation within the 90 day time frame in three of nine client records.The findings include:Thirteen outpatient client records were reviewed on February 2, 2011. Per agency policy, case consultations will be completed every 90 days. Case consultations were required in nine client records. The facility did not document case consultations within the 90 day time frame in client records # 2, 4, and 11. Additionally, case consultations were not included in client records # 1 and 3 at the time of the licensing specialists record review, however, they were presented at the end of the inspection.Client # 2 was admitted on October 18, 2010. The case consultation was due by January 18, 2011. There was no case consultation documented in the client file at the time of the inspection. Client # 4 was admitted October 25, 2010. The case consultation was due by January 25, 2011. There was no case consultation documented in the client file at the time of the inspection. Client # 11 was admitted April 14, 2010 and discharged on August 13, 2010. The case consultation as due by July 14, 2010. There was no case consultation documented in the client file at the time of the inspection.
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Plan of Correction
The Vice President of Quality Improvement and Director of Quality Improvement will ensure that all staff are re-educated through staff meeting that case consults must be completed for all clients every 90 days. The local office administration will do bi-weekly tracking of completed consults and Vice President of Quality Improvement and Director of Quality Improvement will monitor ongoing compliance via random record reviews. |