INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26 - 27, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Addiction Medicine and Health Advocates, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 a review of personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position in one of two personnel record.
The findings include:
Thirteen personnel records were reviewed on July 25, 2012. Two personnel record reviewed pertained to clinical supervisors. These personnel record required the documentation of monthly meetings between the clinical supervisor and their supervisor for the first six months of employment in that position. The facility failed to document monthly supervision meetings for six months in personnel record # 3.
Employee # 3 was hired by the project on June 19, 2006 and was promoted to the position of clinical supervisor on January 1, 2012. Monthly supervision meetings were required to take place during the first six month in the new position. A review of personnel record # 3 revealed that there were only four months of supervision documented for the months of January, February, March and April 2012. There was not documentation of supervision for the months of May and June 2012.
An interview with the clinical coordinator took place on July 26, 2012 at which time it was confirmed that there was no documentation of monthly supervision meetings for the following months May and June 2012.
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Plan of Correction
The Clinical Coordinator will schedule and conduct monthly supervision sessions with the clinical supervisor for a period of two months commencing immediately after acceptance of this plan of correction. The project director will ensure that all future hired and or promoted supervisors are supervised monthly for a minimum of six consecutive months . Documented evidence of the supervision will be reviewed by the director and placed in the respective personnel file. The director will be responsible for making sure this does not recur. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document an overall plan for addressing training needs, as required by regulation.
The findings include:
The policy and procedure manual was reviewed on July 25, 2012. Per agency policy, a training plan will be completed after the summary of staff training needs in December of each year. The regulation requires that an overall plan to address training needs to be completed as a component of a staff development program. The facility failed to document the completion of an overall training plan for training year 2013.
An interview with the clinical coordinator on July 26, 2012 confirmed the findings.
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Plan of Correction
The Clinical Coordinator will oversee and monitor the development of an Overall Training Plan for the year 2012, and all subsequent years, at the completion of the Summary of Staff Training Needs. The plan will include all mandatory training for agency staff irrespective of discipline or employment category. The Staff Development Coordinator will be responsible for developing the plan. The overall plan will be completed within two weeks of the acceptance of this plan of correction. |
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
Based on a review of personnel records and a review of the facilities policy and procedures manual, the facility failed to document a mechanism to collect feedback on completed training in six of thirteen records.
The findings include:
Thirteen personnel records were reviewed on July 25-26, 2012. During the review of the personnel records, the training certificates and feedback forms were reviewed for the training year 2011, #1, 2, 3, 4, 5, 12 and 11. Per the facility's policy, feedback forms are to be submitted after every training. The following personnel records did not document feedback forms in their record, #1, 2, 3, 4, 5 and 11. An interview with the clinical coordinator on July 26, 2012 confirmed the findings.
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Plan of Correction
The Clinical Coordinator will oversee and monitor the development of a procedure whereby each training certificate is accompanied by a training feedback form. The Staff Development Coordinator will be responsible for developing and implementing adherence to the training feedback submission plan. This plan will be completed within 30 days of the acceptance of of this plan of correction. |
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
Based on a review of employee training records, the facility failed to assure that each employee received a written individual training plan.
The findings include:
Thirteen employee records were reviewed on July 25-26, 2012. During the review of the the facility's training binder it was identified that every employee had the same identical training plan. The training plans for every employee consisted of HIV/AIDS, TB/STD's, Co-Occurring Disorders, Recovery Model, Mgmt. on Non-complaint patients, Case Management, Cultural Awareness, Verbal/Non-verbal de-escalation, Fire/Disaster/Incidents/Infection, Corporate Compliance, Adult CPR and Pharmacology of Methadone/Suicide Assessment training. The individual training plans were not specific to each employee's training needs.
An interview with the clinical coordinator on July 26, 2012 confirmed the findings.
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Plan of Correction
The Clinical Coordinator will oversee and monitor the development of an individualized training plan for each staff person. The plan will include those trainings outlined in the Overall Training Plan plus those specific trainings outlined in each staff person's Individual Annual Training Needs Assessment in accordance with each staff person's job category and/or discipline. The Staff Development Coordinator will be responsible for the completion of each individualized training plan. Staff individualized treatment plans will be completed within 30 days of the acceptance of this plan of correction. To ensure complete compliance and that it does not recur, all training plans will be individualized/specific to each employees's training needs and presented to the performance improvement committee for approval and compliance. The persons responsible for making sure this does not recur are the staff development coordinator and clinical coordinator. |
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 the staffing requirements facility summary report, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff in eight of thirteen employeed records.
The findings include:
Thirteen personnel records were reviewed on July 25-26, 2012. The staffing requirements facility summary report was reviewed on July 25, 2012. There was no documentation of TB/STD or HIV/AIDS training in eight employee records, 10, 14, 15, 16, 17, 18, 19 and 20. Employees #10, 14, 15, 16, 17 and 18 were required to have HIV/AIDS and TB/STD training within the one year of employment. The remaining employees were required to have HIV/AIDS and TB/STD training within two years of employment, #19 and 20.
Employee #10 was hired January 1, 2010 and was required to have HIV/AIDS & TB/STD training by January 1, 2011. There was no documentation of TB/STD training in the employee's record as of July 26, 2012.
Employee #14 was hired June 20, 2011 and was required to have HIV/AIDS & TB/STD training by June 20, 2012. There was no documentation of TB/STD training in the employee's record as of July 26, 2012.
Employee #15 was hired June 13, 2011 and was required to have HIV/AIDS & TB/STD training by June 13, 2012. There was no documentation of TB/STD training in the employee's record as of July 26, 2012.
Employee #16 was hired June 13, 2011 and was required to have HIV/AIDS & TB/STD training by June 13, 2012. There was no documentation of TB/STD training in the employee's record as of July 26, 2012.
Employee #17 was hired October 21, 2008 and was required to have HIV/AIDS & TB/STD training by October 21, 2009. There was no documentation of TB/STD training in the employee's record as of July 26, 2012.
Employee #18 was hired June 19, 2006 and was required to have HIV/AIDS & TB/STD training by June 19, 2007. There was no documentation of HIV/AIDS training in the employee's record as of July 26, 2012.
Employee #19 was hired December 1, 2007 and was required to have HIV/AIDS & TB/STD training by December 1, 2009. There was no documentation of TB/STD training in the employee's record as of July 26, 2012.
Employee #20 was hired January 2, 2008 and was required to have HIV/AIDS & TB/STD training by January 2, 2010. There was no documentation of HIV/AIDS training in the employee's record as of July 26, 2012.
An interview with the clinical coordinator on July 26, 2012 confirmed the findings.
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Plan of Correction
The Clinical Coordinator will oversee and monitor the training of staff to ensure that each staff person has the required 6 hours of HIV training and 4 hours of TB/STD training. The Nursing supervisor will have the responsibility of providing staff with the requried HIV and TB/STD training. The training will be completed within 30 days of the acceptance of this plan of correction. |
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 documentation it was determined that the facility failed to provide a have a sufficient number of staff persons certified in first aid training in order that at least one person trained in first aid training is onsite during the project's hours of operation.
The findings include:
The personnel records were reviewed on July 26, 2012. During the review of the personnel records it was revealed that the facility had sufficient coverage regarding CPR, but did not provide sufficient coverage for first aid.
At this present time the facility does not have sufficient number of staff trained in first aid for coverage during the project's hours of operation.
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Plan of Correction
The Clinical Coordinator will oversee and monitor the training of sufficient staff to ensure that there are sufficient First Aid trained staff present during the project's hours of operation. At all times during operation their will be sufficient staff with First Aid Training. The Staff Development Coordinator will be responsible for scheduleing the required trainings. The trainings will be completed within 30 days of the acceptance of this plan of correction. |
704.11(f)(1) LICENSURE Counselor's Trng Req
704.11. Staff development program.
(f) Training requirements for counselors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
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Observations
Based on a review of employee records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of eight personnel records reviewed.
The findings included:
Thirteen personnel records were reviewed on July 26, 2012. Eight personnel record was required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 4.
Employee # 4 was hired on August 17, 2009. The facility training year is from January through December. The training year for January 2011 to December 2011 was reviewed. Employee # 4 only completed 18 hours of annual training in 2011.
An interview with the clinical coordinator on July 26, 2012 confirmed the findings.
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Plan of Correction
The Clinical Coordinator will oversee and monitor the scheduling and completion of required staff trainings to ensure that each staff person completes the required number of training hours. The Staff Development Coordinator will be responsible for scheduling staff for trainings and follow-up to ensure that sufficient trainings have been completed to meet the required hours and that certificates with accompanying feedback forms have been turned in. A running total of training hours will be kept. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate the staff male and female bathroom by an exhaust fan or window.
The findings include:
A physical plant inspection was conducted with the project director and clinical coordinator on July 26, 2011 from 1:30 pm to 1:50 pm. Per regulation, the nonresidential facility shall ventilate bathrooms by exhaust fan or window. The facility has five restrooms designated for staff and client use. The bathrooms are located throughout the facility. Two restrooms, designated for staff use did not have working exhaust fans or windows for ventilation.
An interview with the project director and clinical coordinator on July 27, 2012 confirmed the findings.
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Plan of Correction
The Program Director has contracted with the building electrician to replace the fan motors. The motors have been ordered and received and will be installed within the next 2 weeks. To ensure this does not recur, the facility bathrooms will continue to be inspected monthly by a safety committee member to make sure all fans are working properly. If a fan is not working properly, it will be immediately reported to the clinical coordinator or director for action. The director will be responsible to make sure this does not recur. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment in four of thirteen personnel records.
The findings include:
Thirteen personnel records were reviewed on July 25-26, 2012. Four personnel records were required to document fire extinguisher training. The facility failed to document the completion of fire extinguisher training within upon staff employment in personnel record #6, 7, 8 and 9.
Employee # 6 was hired on April 23, 2012. The training was documented as completed on June 14, 2012, which is later than the seven days required.
Employee # 7 was hired on May 21, 2012. The training was documented as completed on June 11, 2012.
Employee # 8 was hired on June 4, 2012. The training was documented as completed on June 12, 2012.
Employee # 9 was hired on February 27, 2012. The training was documented on March 8, 2012.
An interview with the clinical coordinator on July 26, 2012 confirmed the findings.
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Plan of Correction
The Clinical Coordinator will oversee and monitor the training of all newly hired staff in the proper use of fire extinquishers within the first 7 days of employment. The head of the Safety Committee will be responsible for training newly hired staff in the proper use of fire extinguishers within the first 7 days of hire. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff training during emergencies within seven days of staff employment, in four of thirteen personnel records.
The findings include:
Thirteen personnel records were reviewed on July 25-26, 2012. Four personnel records were required to document emergency training. The facility failed to document the completion of emergency training upon hire #6, 7, 8 and 9.
Employee # 6 was hired on April 23, 2012. The training was documented as completed on June 14, 2012.
Employee # 7 was hired on May 21, 2012. The training was documented on June 11, 2012.
Employee # 8 was hired on June 4, 2012. The training was documented on June 12, 2012.
Employee # 9 was hired on February 27, 2012. The training was documented on March 8, 2012.
An interview with the clinical coordinator on July 26, 2012 confirmed the findings.
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Plan of Correction
The Clinical Coordinator will oversee and monitor the training of all newly hired staff in proper emergency procedures within the first 7 days of hire. The head of the safety committee will be responsible for training staff in proper emergency procedures within the first 7 days of hire. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record, the facility failed to document alternate exit routes to be used during fire drills.
The findings include:
A review of the fire drill record was conducted on July 25, 2012. The fire drills conducted from August 2011 - June 2012 were reviewed. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. For the months of August 2011, September 2011, October 2011, December 2011, January 2011, February 2011, March 2011, April 2011, May 2011 and June 2011 the only exit documented was (A). The only change in the exits was in November 2011 which documented (A,B, and C) exits used.
An interview with the project director was conducted on July 26, 2012 and confirmed the findings.
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Plan of Correction
The Clinical Coordinator will oversee and monitor the use and proper documentation of alternate exits to be used during fire drills. The head of the safety committee will be responsible for seeing to it that all alternate exits are used during fire drills and that said use is properly documented. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills are conducted during different times of the day.
The findings include:
The fire drill record was reviewed on July 26, 2012. There were eleven fire drills conducted on the morning shift. There were no fire drills conducted during the afternoon hours. The following months were reviewed August 2011, September 2011, October 2011, November 2011, December 2011, January 2012, February 2012, March 2012, April 2012, May 2012 and June 2012. The facility's hours are Monday through Friday 7am to 4:30 pm, Saturday 6:30 am to 12 pm.
An interview with the project director on July 26, 2012 confirmed the findings.
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Plan of Correction
The Clinical Coordinator will oversee and monitor the scheduling of fire drills to ensure that they are conducted on different days of the week and at different times of the day, including both mornings and afternoons. The head of the safety committee will be responsible for scheduling and conducting fire drills so that they meet the necessary regulatory requirements. |
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, the facility failed to ensure that the facility obtained an informed and voluntary consent form in six of eight client records.
The findings include:
Ten client records were reviewed on July 26, 2012. Eight of the ten were reviewed for consent to release forms, #1, 2, 3, 4, 5, 6, 7 and 8. Of the eight, six were determined to be out of compliance, #1, 2, 5, 6, 7 and 8.
Client #1 was admitted on January 4, 2012 and there was documentation of a consent to release form for the insurance company that did not document information regarding what was being released.
Client #2 was admitted on February 23, 2012 and there was documentation of a consent to release form for the insurance company that did not document information regarding what was being released.
Client #5 was admitted on March 2, 2012 and there was documentation of consent to release forms for the insurance company, probation/parole and emergency contact person that did not document what was being released.
Client #6 was admitted on January 25, 2012 and there was documentation of a consent to release form for the insurance company that did not document what was being released. Also, there was a consent to release form for the client's physician that marked that the facility can release only the clients enrollment date and dosage. There was a letter that went out on March 14, 2012 to the client's physician that gave more identifying information of the client then was allowed.
Client #7 was admitted on January 24, 2012 and there was documentation of a consent to release form for the insurance company that did not document what was being released. Also, the consent to release form for the clients PCP on January 24, 2012 did not document if the client was offered a copy or not.
Client #8 was admitted on January 12, 2012 and there was documentation of a consent to release form for the insurance company that did not document what was being released.
An interview with the clinical coordinator on July 26, 2012 confirmed the findings.
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Plan of Correction
The Clinical Coordinator will conduct a staff training on the proper completion of the Consent to Release Confidential Information form. The trianing will be completed within 30 days of the acceptance of this plan of correction. To ensure that releases obtained are voluntary, informed and specific, each supervisor will review this area during clinical supervision. Additionally, a random review of consents will be conducted by the quality record reviewer on a monthy basis. The clinical coordinator will be responsible for making sure it does not recur. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in seven of eight client records.
The findings include:
Ten client records were reviewed on July 26, 2012. A psychosocial evaluation was required in eight client records, #1, 2, 3, 4, 5, 6, 7 and 8. An interview with the clinical coordinator on July 26, 2012 confirmed the findings.
The psychosocial evaluations in client records #1, 2, 3, 4, 5 and 6 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6 and 7 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #4, 5 and 8 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #1, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5 and 6 did not include an evaluation of the counselor conclusions/impressions of the client.
Also, in client records #1, 2, 3, 4, 5 and 7 had identical counselor conclusions/impressions.
Client records #1, 2, 3 and 7 had identical counselor conclusions/impressions which stated that "it is recommended that the patient be maintained on a therapeutic dose of methadone 7x/wee, submit to random urinalysis monthly, and be followed in individual psychotherapy on a 3-4x/month basis utilizing conginitive, behavioral, supportive, and reality-base therapeutic techniques. Patient will be encouraged to seek out recovery-based supports, actively participate in therapy, and secure steady housing and employment."
Client records #4 and 5 had identical counselor conclusions/impressions which stated that " it is recommended that the patient be maintained on a therapeutic dose of methadone, 7days/week, submit to random urine analysis on a bi-weekly basis and participate in individual counseling weekly as well as group therapy 3 x weekly utilizing motivational interviewing, solution focused therapy, cognitive behavioral therapy and 12 step facilitation. Patient will be encouraged to develop a sober network for on-going support."
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Plan of Correction
The Clinical Coordinator will schedule and conduct a staff training on the proper completion and individualization of the psychosocial evaluation, with special emphasis on the areas noted as being deficient, i.e. assets/strengths, support systems, coping mechanisms, and negative factors that inhibit treatment. The training will be completed within 30 days of the acceptance of this plan of correction.
The clinical supervisors will also monitor/review the proper completion of the psychosocial evaluation for each of his/her surpervisee's during supervision. The reviews by the supervisors will focus on the areas identified as not meeting the standard. The clinical coordinator will be responsible for this deficiency not recurring. |
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.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates in four of seven client records.
The findings include:
Ten client records were reviewed on July 26, 2012. Seven of the ten client records were reviewed for treatment plans, #1, 2, 3, 4, 5, 7 and 8. Treatment plan updates failed to show the client's progress as it related to the goals identified in the individualized treatment and rehabilitation plan, #1, 2, 4 and 8.
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Plan of Correction
The Clinical Coordinator will schedule and conduct a clinical staff training on the proper completion of the Progress To Date With Treatment Goals section of the treatment plan update. The training will be conducted within 30 days of the acceptance of this plan of correction.
To ensure this does not recur, the clinical supervisors will review treatment plan updates for complete comliance with the standard during supervision. Addionally, a random sample of treatment plan updates will be reviewed on a monthly basis by the quality record reviewer for compliance and reported to the quality improvement committee for action during its monthly meeting.
The clinical coordinator will be responsible to make sure this does not recur. |