INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 1 - 2, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Freedom Healthcare Services, 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 April 4, 2011.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure that each counselor met the qualifications for the position in one of two personnel records.
The findings include:
On March 1, 2011, six personnel records were reviewed. Two personnel records pertained to counselors and were required to include documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel record # 5.
Employee # 5 was hired as a counselor on January 28, 2010. The personnel record for employee # 5 contained a copy of a Bachelors degree; which did not specify the major. Transcripts were not available for review, at the time of the licensing inspection on March 1 - 2, 2011. It was not possible to determine if employee # 5 meets the qualifications for the position of counselor; since the college major was not documented.
The facility director was interviewed on March 1 - 2, 2011. The facility director confirmed the degree for employee # 5 did not specify the major. The facility director reported that employee # 5 did not have a copy of her college transcripts; but will obtain them as soon as possible.
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Plan of Correction
Employees #5 submitted to receive her official transcripts on 3/31/2011 through her college. The Facility Director will review the transcripts and place them in employee #5's personnel file. Upon hire of any new counselors, the Facility Director will request a copy of their degree and transcripts, which will be kept in their personnel file. The facility Director will conduct quarterly reviews of personnel records to ensure that this information has been obtained and is documented in records. |
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
Based on a review of personnel records and an interview with the facility director, the facility failed to provide documentation of communicable disease training in two of four personnel records, as required by regulation.
The findings include:
Six personnel records were reviewed on March 1, 2011. Four personnel training records were required to include documentation of communicable disease training. Two employees are new and are not yet required to have documentation of communicable disease training. Per regulation, staff persons shall receive a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first 2 years of employment. The facility did not provide documentation of TB/STD training in personnel records # 3 and 4. The facility did not provide documentation of HIV/AIDS training in personnel record # 4.
Employee # 3 is a counselor and was hired September 28, 2009. TB/STD training was due to be completed no later than September 28, 2010. The facility failed to provide documentation of TB/STD training, at the time of the review on March 1 - 2, 2011.
Employee # 4 is a counselor and was hired February 23, 2009. HIV/AIDS and TB/STD training was due to be completed no later than February 23, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training, at the time of the review on March 1 - 2, 2011.
The facility director was interviewed on March 1 - 2, 2011 and confirmed that personnel records # 3 and 4 did not include documentation of the required communicable disease training. The facility director reported these employees have taken the training; but did not have documentation available at the time of the review. Employees # 3 and 4 will submit proof of the communicable disease training as soon as possible.
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Plan of Correction
Employees #3 and #4 were notified 3/3/2011 that they would have to provide proof of their communicable disease training as well as HIV/AIDS training for employee #4. Both employees have taken the required communicable training through last employer. The facility director has given both employees 30 days to provide documentation of these trainings. If these employees cannot provide documentation of this, then they will be scheduled by lead counselor to attend the communicable disease training within 90 days.
The Facility Director has restructured the training process at Freedom by assigning the scheduling of all trainings to be completed by Lead Counselor. All staff will receive HIV/AIDS as well as communicable disease training by the end of 2011. The Facility Director will continue to oversee trainings scheduled by Lead Counselor and will meet with Lead Counselor on a monthly basis to ensure required trainings are being scheduled. |
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.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to document the completion of 12 clock hours of annual training required for facility directors in one of one personnel record.
The findings include:
Six personnel records were reviewed on March 1, 2011. One personnel record pertained to the facility director. One personnel record required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 2.
Employee # 2 has been the facility director since October 21, 2009. The facility training year is from January 2010 through December 2010. Personnel record # 2 included documentation of 10 clock hours of annual training for 2010.
The facility director was interviewed on March 1 - 2, 2011. The facility director confirmed that she had only completed 10 clock hours of annual training for 2010.
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Plan of Correction
The Facility Director will complete required 12 hours of annual training prior to December 2011. The Project Director will monitor personnel files quarterly to make sure training requirements are being met. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative policies and procedures and an interview with the project and facility directors, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24 hour emergency psychiatric coverage.
The findings include:
The administrative policies and procedures were reviewed on March 1, 2011. The facility was unable to provide a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric coverage, as required. The project and facility directors were interviewed on March 1, 2011. Both confirmed they did not have a current written agreement for 24 hour emergency psychiatric coverage. The project director confirmed there was a written agreement that had expired in 2010.
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Plan of Correction
The Project Director will be responsible for finding and obtaining 24 hr emergency psychiatric coverage at one of the local hospitals. The Project Director will obtain a written agreement for psychiatric coverage within 90 days and will monitor agreements annually to ensure that they are valid and up to date. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative materials and an interview with the project director, the project failed to complete an annual audit by fiscal year end, December 31, 2009.
The findings include:
A review of administrative materials was conducted on March 1, 2011. Per regulation, the project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The project's fiscal year is from January through December. The project's audit for January 1, 2009 through December 31, 2009 was not documented, at the time of the review on March 1 - 2, 2011.
On March 1, 2011, the project director was interviewed. The project director confirmed that an annual audit had not been completed for the 2009 fiscal year.
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Plan of Correction
In accordance with the licensing alert posted by the Department on 3/3/11 for financial audits, the Project Director will be submitting for exemption for 2009. If the exception is not granted, the Project Director will ensure the annual audit for 2009 and 2010 is completed no later than June 30, 2011. The Project Director will ensure that this deficiency is not repeated. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to document the results of reference investigations in two of three personnel records, as required.
The findings include:
Six personnel records were reviewed on March 1, 2011. Three personnel records required the results of reference investigations. Per regulation, the personnel records shall include the results of reference investigations. Personnel records # 5 and 6 did not include the results of reference investigations.
Employee # 5 was hired on January 28, 2010. Results of reference investigations were not documented in personnel record # 5, at the time of the review on March 1 - 2, 2011.
Employee # 6 was hired on July 29, 2010. Results of reference investigations were not documented in personnel record # 6, at the time of the review on March 1 - 2, 2011.
The facility director was interviewed on March 1 - 2, 2011. The facility director confirmed there was an attempt to complete reference investigations by conducting criminal background checks on employees # 5 and 6. The facility director reported the facility did not have documentation of the results of these investigations on employees # 5 and 6.
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Plan of Correction
Background checks for employees #5 and #6 will be completed by the Project Director within the next 30 days. Upon hire, all new staff will have criminal background checks submitted by the Project Director within the first week of employment. |
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
Based on a review of client records, qualified service organization agreements and an interview with the facility director, the facility failed to document an informed and voluntary consent or a qualified service organization agreement when releasing blood and urine samples to an outside agency for testing in sixteen of sixteen client records.
The findings include:
Sixteen client records were reviewed on March 1 - 2, 2011. Sixteen client records required documentation of a qualified service organization agreement with the outside agency or an informed and voluntary consent from the client for the disclosure of information contained in the client record. Clients participate in blood and urine testing during the intake process and then urine testing on a minimum of a monthly basis. Client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16 did not include a signed release of information nor was a qualified service organization agreement in place for the outside agency.
The facility director was interviewed on March 2, 2011 and confirmed the facility did not have a qualified service organization agreement with the agencies that conduct blood and urine testing. The facility director also confirmed that informed and voluntary consents had not been completed for clients who were participating in blood and urine testing.
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Plan of Correction
On 3/4/2011, the agencies that conduct blood and urine testing were contacted and notified about the qualified service organization agreement. The Facility Director is still in the process of obtaining the QSOAs through each of the agencies legal departments. This process is expected to be completed within the next 30 days. The Facility Director will be responsible for monitoring the QSOAs on an annual basis to ensure that they remain current. |