INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 14- 17, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System at Williamsburg 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 May 15, 2008.
|
Plan of Correction
|
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.
|
Observations
Based on a review of clinical documentation and interviews with administrative personnel the facility failed to consistently place qualified staff in positions involved in provision of therapy services. Individuals providing experiential therapy services do not meet any of the requirements specified in Chapter 704 for the position of counselor . The staff identified included the following personnel: #23, 35, 36, 37 and 38.
|
Plan of Correction
The Regional Director provided training to the Ropes Course staff regarding documentation of the Ropes Course activities as recreational activities with an education/information component. The training was conducted on June 16, 2008. The Ropes Course is a recreational adjunct to the therapeutic services provided at this facility and will be documented as such by the Activities staff. The Activities Coordinator will monitor for ongoing compliance.
The revised Activities forms will be sent electronically to the licensing surveyor for review.
Responsible Parties: Regional Director, Program Manager, and Activities Coordinator.
|
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.
|
Observations
Based on a review of employee training records for 14 staff, the facility failed to ensure that each employee had an individual training plan documented. Employee # 3 did not have training plan documented for the current training year.
|
Plan of Correction
The Regional Director will review individual training plan policy & procedure and complete training plan annually for staff supervised. The Administrative Assistant and Staff Development will monitor to ensure that plans are completed annually. The responsible party for completing the trainings plan is the Regional Director. |
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.
|
Observations
Based on a review of personnel records and agency self reporting on licensing staffing forms on March 14-17, 2008, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics training within the first year of employment for clinical staff and within two years of employment for non-clinical staff. Twenty staff were identified as not completing the required HIV training in the required time frame (11, 12, 15, 16, 17, 18, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33 and 34). Fifteen staff were identified who did not have the required TB/STD training (11 , 12, 13, 17, 19 , 20 , 23, 24, 25, 29, 30, 31, 32, 33, 34). The total sample reviewed was 38 personnel records.
|
Plan of Correction
A staff person has been identified to become a communicable disease trainer utilizing the BDAP approved curriculum and training outline guideline. Training for the trainer will be completed as early as possible with an expected date of completion to be by 7/31/08.
The trainer will then conduct several trainings on grounds until staff has received the required communicable disease trainings. Completion date for staff to be trained is set for September 1, 2008.
Training will then be conducted quarterly by the trainer for all new staff.
Responsible parties for monitoring program of training will be Staff Development and Assistant Administrator.
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on documentation reviewed in agency training files during the onsite inspection held April 14-17, 2008, it was determined that employee # 4 did not have the minimum number of training hours for the last training year. Only 23.5 hours of appropriately documented training was found in the training file. The total sample of counselors was four.
|
Plan of Correction
Program Director/Assistant Program Director will communicate to QI Department on a quarterly basis to ensure all staff meets the training requirements.
Additionally, Program Director will utilize Essential Learning to track training hours.
The responsible party will be Program Director/Assistant Program Director. Effective Date: 5/30/08.
|
705.1 (2) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
|
Observations
Based on the physical plant inspection and conversations with maintenance personnel the facility failed to obtain certificates of occupancy for each of the buildings utilized as part of the D&A services provided on campus. Five shed type buildings were identified which are used either for the provision of counseling services to D&A clients or for administrative/clerical personnel who act in a supportive capacity for the D&A services provided on campus.
|
Plan of Correction
Labor and Industry Certificates of Occupancy are required for five shed type buildings on campus which provide support capacity for D&A services Floor plan drawings will be submitted for inspection by Labor and Industry. Occupancy permits for buildings are expected to be received by October 1, 2008. The responsible party will be the Facility Director. |
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.
|
Observations
Based on a review of client records during the onsite inspection of April 14- 17, 2008, the facility failed to document complete personal histories. In the sample of three client records, all three client records had incomplete personal histories. Client records # 12 and 13 did not address family interrelationships/dynamics. Client records # 12, 13 and 14 did not provide detailed employment histories but addressed only the most recent employment held.
|
Plan of Correction
Re-educate admission's staff to complete all areas of client history, including personal history, at the admission department staff meeting on June 8, 2008. Pre-admission assessment forms are to be completed in their entirety. Audit 10 random charts monthly for 3 months.
Responsible party will be Admission's Coordinator or designee.
|
709.82(a) 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:
|
Observations
Based on a review of client records during the onsite licensing inspection, the facility failed to develop an appropriate treatment plan for each client when the individual moved from one level of care to the next. In three of three client records reviewed at this level of care, the treatment plans were not modified to reflect the change in levels of care, specifically client records # 12, 13 and 14.
|
Plan of Correction
Counselors will be re-educated by the Program Director/Assistant Program Director in order to develop a Partial Treatment Plan for each client that transfers to that level of care. Program Director/Assistant Program Director will complete a monthly audit of 10 charts for six months following the training. The responsible party will be the Program Director/Assistant Program Director. Effective Date: 5/30/08 |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
|
Observations
Based on the review of client records during the onsite licensing inspection of April 14-17, 2008, the facility failed to document that each client at this level of care received the required two individual counseling sessions per week. In two of three client records reviewed ( # 12 and 14), the required individual treatment sessions were not documented weekly.
|
Plan of Correction
Program Director/Assistant Program Director will audit 10 charts on a monthly basis to ensure that the individual sessions are occurring. The responsible party will be the Program Director/Assistant Program Director. Effective Date: 5/20/08. |
709.32(c)(4) 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:
(4) Methods for control and accountability of drugs.
|
Observations
Based on a review of client records the facility failed to document the Medication Administration Records, (MARs), consistently. Four of thirteen client records had gaps in the MAR documentation. (#8, 11, 13 and 14).
|
Plan of Correction
Medication Management Policy # MM09 related to Medication Administration will be reviewed in it's entirety at the next nursing staff meeting on June 8, 2008. Included in the review will be medication administration:
Right Medication, right dose, right route, right time, right patient, and appropriate documentation.
Audit 10 random charts 30 days after staff education at nursing staff meeting on June 8th.
The responsible person for the training and auditing will be the Rehab Nursing Coordinator.
|
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.
|
Observations
Based on a review of client records during the on site licensing inspection of April 14-17, 2008, the facility failed to document complete personal histories. A total of eight client records were reviewed for this level of care. In client records # 1, 2 and 3 no family interrelationships/composition were discussed. In client records # 1, 2, 3 and 9 employment information consisted only of information about the client's most recent job rather than presenting an employment history. In client records #1 and 9 education histories were not included .
|
Plan of Correction
Re-educate nursing staff by electronic communication by May 31, 2008 and at a departmental staff meeting on June 8, 2008 to complete all areas of nursing assessment document, including personal history, family relationships, employment history, and educational history.
Audit 10 random charts 30 days after education at staff meeting is completed.
Responsible party will be Detox Unit Coordinator or designee.
|
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records during the on site licensing inspection of April 14-17, 2008, the facility failed to document complete psychosocial evaluations in each client record. A total of eight client records were reviewed for this level of care. In two client records ( #1 and 9) evaluations were missed. In two other client records ( #2, 3) support systems, coping mechanisms and clinical impressions were missed.
|
Plan of Correction
Re-educate nursing staff by electronic communication by May 31, 2008 and at departmental staff meeting on June 8, 2008 to complete psychosocial evaluations (evaluative summaries) in their entirety, to include support of systems, coping mechanisms, clinical impressions, and overall composite picture of client status.
Audit 10 random charts 30 days after education at staff meeting is completed.
Responsible party will be the Detox Unit Coordinator.
|
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.
|
Observations
Based on a review of client records during the on site licensing inspection of April 14-17, 2008, the facility failed to document complete records of service consistently. A total of eight client records were reviewed for this level of care. Notes written by nursing staff, which addressed groups provided by the nurses, were not documented on the detoxification record of service in client records # 2, 3, 7, 8, 13 and 14.
|
Plan of Correction
Re-educate nursing, counselor and technician staff by electronic communication by May 31, 2008 and at departmental staff meeting on June 8, 2008 to complete the record of service for any group or individual session with each client.
Audit 10 random charts 30 days after education at staff meeting is complete.
Responsible party will be the Detox Unit Coordinator.
|
709.63(a)(8) LICENSURE Follow-up Information
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:
(8) Follow-up information.
|
Observations
Based on a review of client records during the on site licensing inspection of April 14-17, 2008, the facility failed to document follow up for each client. A total of eight records were reviewed for this level of care. Follow up was missed in one of one client records where follow up was due, specifically client record #1.
|
Plan of Correction
The Detox Unit Coordinator will counsel with the Detox Unit Counselor regarding the need for follow-up action and documentation on each detox unit client by May 31, 2008. Monitoring for follow-up documentation will occur for three months.
The responsible party will be the Detox Unit Coordinator.
|
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.
|
Observations
Based on the review of client records during the onsite inspection held April 14-17, 2008, the facility failed to consistently document complete records of service. In the sample of nine client records, seven did not have a complete listing of services provided (#4, 6, 7, 8, 12, 13, 14). Duration of services provided was not included on the records of services in the client records reviewed for the "Ropes" activity which was listed as one of the services provided in each of the client records noted above.
|
Plan of Correction
Program Director/Assistant Program Director will conduct a monthly audit of 10 charts, reviewing the record of service. Duration of services will be monitored as well as a complete listing of services provided. The responsible party will be the Program Director/Assistant Program Director. Effective Date: 5/30/08. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
|
Observations
Based on a review of two client records the facility failed to document follow-up on discharged clients based on agency policy. In one of two client records reviewed, specifically # 7, the follow-up documentation was missing.
|
Plan of Correction
Program Director/Assistant Program Director will conduct a monthly audit of 10 charts to ensure aftercare follow up is completed and in the chart. The responsible party will be the Program Director/Assistant Program Director. Effective Date: 5/30/08. |