INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 2, 2011 through July 3, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, NTP Consultants, LLC 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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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to document an updated compliance plan.
The findings include:
The policy and procedure book was reviewed on August 2, 2011. The compliance plan is to be updated annually The last update was dated June 30, 2010. The facility's fiscal year is July 1 through June 30 of each year. A discussion on July 2, 2011 with the owner confirmed that the last update of the compliance plan was June 30, 2010.
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Plan of Correction
Plan of Correction:
Project Director met with Board of Directors August 17, 2011 to review DOH site visit and to discuss NTP policies that are out of date or required to bring NTP Consultants LLC in compliance with facility policies and procedures.
Project Director reviewed plan with Board, to do complete review, revise out of date, and implement new policies as identified during DOH site inspection Aug 2-3, 2011. The full review and completion of updates of NTP policies manual will be complete by 9/8/2011 by the Facility Director.
Compliance plan will be reviwed and updated again prior to 9/8/2012 by the Facility Director. |
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 and an interview with the project director/facility director, the facility documented an overall plan for addressing training needs, as required by regulation, but did not indicate a completion date.
The findings include:
On August 2, 2011 the policy and procedure manual was reviewed. Per the agency policy and procedure manual, a training plan will be completed at the end of the training year, June 30. The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. The facility documented an overall training plan for the July 1, 2011 - June 30, 2012, but the plan was not signed and did not indicate a completion date.
This was discussed with the project director/facility director on August 2, 2011. The project director/facility director confirmed that a plan for addressing training needs of staff was not dated, and therefore it was not able to be determined that the plan was completed per the facility policy and procedure.
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Plan of Correction
Overall staff training plans for July 1, 2011-June 12, 2012 have been signed and dated by Facility Director. All training plans will conitune to be developed, signed, dated and reveiwed by the facility Director. Overall training plans will be done with individual training plans yearly, by the Facility Director, which will have an agency focus and direction. Completion dates for the objectives will be included in this plan. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the staffing requirements and the facility summary report form completed by the facility on August 2, 2011 and an interview with the project director/facility director on August 2, 2011, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings included:
Based on the number of hours the employee worked at this facility, and the number of clients on the counselors' caseload, all employees who provided counseling exceeded the maximum ratio of 35:1. The project director/facility director represented as employee # 1 had a caseload of 40:1. The counselor represented as employee # 2 had a caseload of 35:1.
On August 2, 2011, the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed the project director/facility director and a counselor having clients on a caseload. The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based on the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40), and the total number of clients assigned to the following employees on August 2, 2011, 28 to employee #1 and 13 to employee #2, #1 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by the facility's standard workweek.
The number of hours per week devoted by Employee # 1 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 28 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 1 had 28 active clients on August 2, 2011.
Employee # 1 (28/40 = 0.7 FTE 28 clients/0.7 FTE = 40:1 caseload)
During an interview, the project director/facility director confirmed that they had exceeded the allowable maximum caseload of 35:1 for employees #1.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the June 2, 2010 through June 3, 2010 licensing inspection. The facility's plan of correction submitted on July 29, 2010 and approved on August 9, 2010 stated the following:
"Director corrected form on June 2, 2010.
To avoid this error in the future the Director will have form completed and ready for the auditors when they arrive. Director will also train all other staff on how to complete the form and appropriately define staff to client ratios to all staff.
The Director and Lead Counselor will regularly check ratios to make sure we are maintaining our staff to client ratios."
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Plan of Correction
The Project Director has reviewed the staffing/ client caseload computation and has corrected the staffing form to represent the staff client caseload ratio for the dates of 8/2/2011 and 8/3/2011.
The revised client staff form will be addede to the Project Director's manual.
Staffing client ratios will be reviewed with staff monthly. The staff client ratios will also be presented to the Governing Board monthly.
Project Director is responsible for ensuring that staff client ratios are maintained at all times.
The Project Director and NTP Consultant Business Manager are reviewing NTP Consultants LLC's treatment services and projected need for additional clinical staff. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant tour on August 2, 2011 at around 2:50 pm, the project director/facility director's office included 2 heaters that was not permanently mounted or installed.
The findings include:
The director's office included 2 heaters that were not permanently mounted or installed. An interview with the project director/facility director on August 2, 2011 confirmed that there were heaters in her office.
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Plan of Correction
Portable heaters were removed from the building. Prohibited use of any portable heating device was discussed at staff meeting held Aug 18, 2011.
Facility Director will ensure this does not reoccur by doing monthly walk throughs of every area of the building. |
705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to have a procedure in place for emergencies.
The findings included:
The facility's policy and procedures were reviewed on August 2, 2011. The policy and procedure for emergencies only covered if an emergency occurred within the facility such as fires, bomb threats, etc. The policy and procedure didn't include the emergency procedures for staff and clients if the emergency occurred outside of the facility such as a tornado, nuclear emergency, etc. An interview with the owner on August 2, 2011 confirmed the findings.
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Plan of Correction
Project Director has implemented policies and procedires for emergencies that occur outside the facility, such as tornadoes, nuclear emergency. This policy and procedure is to maximize the safety of both clients and staff. Policy has been reviewed with NTP staff and is in effect as of 8/22/2011. Policy will be reviewed by Facility Director yearly to ensure up to date proceedures are in place. |
709.22(d)(3) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(3) Describing the project's organizational structure.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to describe the project's organizational structure.
The findings include:
The policy and procedure manual was reviewed on August 2, 2011. The facility did not have an updated organizational structure in the policy and procedure book. An interview with the project director/facility director on August 2, 2011 confirmed the findings.
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Plan of Correction
The current NTP Consultants LLC Organization structure has been added to the NTP Policies Manual as of 8/18/2011. The organizational structure will also become part of a new Program Director's manual. Inclusion of this in the Program Directors manual will ensure that the organization structure is updated with any change of staff. An changes to the organizational structure will be updated within 7 days of staff change and updated organizational structure will be place in the NTP Policies manual as well as the Program Directors Manual. The organizational structure will be modified/ updated with the 1) hiring of new staff, 2) change in staff position, or 3) if a staff member leaves employment at NTP. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to make the annual report available to the public within the time period stated in the project's policy manual.
The findings included:
The facility's policy and procedures were reviewed on August 2, 2011. The annual report for fiscal year July 1, 2009 - June 30, 2010 was not made available for review during the onsite licensing inspection. An interview with the owner on August 2, 2011 confirmed that the annual report was not documented for fiscal year ending June 30, 2010.
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Plan of Correction
On August 17. 2011, the Project Director reviewed regulation 709.22 with NTP Consultants LLC Governing Board.
The NTP Policy related to the Governing Board is being updated to specifically address the responsibilities for public notification of 1) activities and accomplishments, 2) Financial Statement of income and expenses, and 3) Statement diclosing the names of officers, directors , and principle shareholders if applicable. This notification will be published via local newspaper.The policy relating to the Governing Board's responsibilities will be revised no later than 9/8/2011.
It has been agreed upon that publication of notification will be reviewed during the May Governing Board meeting each year. This notice will be published by the governing board no later than June 1 of each year.
This public notification will include
1) activities and accomplishments, 2) Financial Statement of income and expenses, and 3) Statement diclosing the names of officers, directors , and principle shareholders if applicable as required under 709.22.
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to document the project director's dated signature indicating an annual update of the written manual delineating project polices and procedures.
The findings include:
The facility's policies and procedures were reviewed on August 2, 2011. The project director failed to document the annual update of the written project policies and procedures, as required by regulation.
An interview with the owner on August 2, 2011 confirmed the findings.
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Plan of Correction
Project Director met with Board of Directors August 17, 2011 to review DOH site visit and to discuss NTP policies that are out of date or required to bring NTP Consultants LLC in compliance with facility policies and procedures.
Project Director reviewed plan with Board, to do complete review, revise out of date, and implement new policies as identified during DOH site inspection Aug 2-3, 2011. The full review and completion of updates of NTP policies manual will be complete by 9/8/2011.
Annual Review
Project Director's manual identifies the NTP Policy manual review and update as an annual responsibility. Project Director will review and update the NTP Policies Manual no later than June 1.
Project Director will review the NTP policies manual with NTP Board of Directors during annual June Board meeting and will complete updates to manual no later than June 30.
Board will be be asked to sign each policy annually as documentation that the policies and procedures manual have been reviewed and approved.
Project Director will also document review of any modified, updated, or new policies with all staff.
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709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on the review of the facility's policy and procedure manual, the project failed to demonstrate that the project director assisted the governing body in formulating facility
policy and procedures.
The findings include:
The facility's policies and procedures were reviewed on August 2, 2011. The project director failed to document the annual update of the written project's policies and procedures, as required by regulation.
An interview with the owner on August 2, 2011 confirmed the findings.
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Plan of Correction
Project Director met with Board of Directors August 17, 2011 to review DOH site visit and to discuss NTP policies that are out of date or required to bring NTP Consultants LLC in compliance with facility policies and procedures.
Project Director reviewed plan with Board, to do complete review, revise out of date, and implement new policies as identified during DOH site inspection Aug 2-3, 2011. The full review and completion of updates of NTP policies manual will be complete by 9/8/2011.
Annual Review
Project Director's manual identifies the NTP Policy manual review and update as an annual responsibility. Project Director will review and update the NTP Policies Manual no later than June 1.
Project Director will review the NTP policies manual with NTP Board of Directors during annual June Board meeting and will complete updates to manual no later than June 30.
Project Director will also document review of any modified, updated, or new policies with all staff. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documentation and interviews, it was determined the project failed to develop goals and objectives for the fiscal year of July 1, 2011 to June 30, 2012.
The findings were:
A review of administrative documents on August 2, 2011 indicated that the annual goals and objectives for the fiscal year of July 1, 2011 to June 30, 2012 did not include the time frames with available resources..
An interview with the owner on August 2, 2011 confirmed that the annual goals and objectives for the fiscal year of July 1, 2011 to June 30, 2012 failed to include those components.
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Plan of Correction
Program Director and Board of Directors met for monthly Board of Directors meeting. Board Members approved annual goals and objectives and signed on Auigust 17, 2011.
Program Director willaithe goals and objectives with timeframes and resources to achieve goals for September 2011 Board Meeting on September 20, 2011.
Program Director will maintain and review updates of goals and objectives with Board Members monthly. Program Diirector and Board members discussion will be acknowledged by Board members signature and date.
Annual goals and objectives have been included in the Program Director's mannual under monthly and annual responsibilities.
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709.24(a) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
Based on the review of the facility's policy and procedure manual, the project failed to demonstrate that the project director assisted the governing body in formulating
a written plan for coordination of client treatment and rehabilitation services..
The findings include:
The facility's policies and procedures were reviewed on August 2, 2011. The project director failed to document the annual update of the project's written policies and procedures, as required by regulation.
An interview with the owner on August 2, 2011 confirmed the findings.
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Plan of Correction
Project Director met with Board of Directors August 17, 2011 to review DOH site visit and to discuss NTP policies that are out of date or required to bring NTP Consultants LLC in compliance with facility policies and procedures.
Project Director reviewed plan with Board, to do complete review, revise out of date, and implement new policies as identified during DOH site inspection Aug 2-3, 2011. The full review and completion of updates of NTP policies manual will be complete by 9/8/2011.
The Board of Directors will be asekd to sign off on all NTP Manual policies and procedures.
Annual Review
Project Director's manual identifies the NTP Policy manual review and update as an annual responsibility. Project Director will review and update the NTP Policies Manual no later than June 1.
Project Director will review the NTP policies manual with NTP Board of Directors during annual June Board meeting and will complete updates to manual no later than June 30.
Project Director will also document review of any modified, updated, or new policies with all staff.
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709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to maintain updated letters of agreement.
The findings include:
The facility's policy and procedures were reviewed on August 2, 2011, revealing that there was no current arrangement with a licensed hospital or physician to provide 24 hour coverage. There was no current letter of agreements in place. The letters of agreement expired in 2009 and has not been updated.. An interview with the owner confirmed the findings.
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Plan of Correction
NTP Consultants is in the process og obtaining an updated letter of agreement with the licensed hosital facility that would be the referral resource for 24 hour coverage. This letter of agreement will also become part of the new Program Director's manual and will be identified as an annual responsibility of the Program Director to acquire an updated agreement.
NTP Consultants LLC will have an updated agreement with licensed hospital facility no later than October 1, 2011. |
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 letters of agreement and an interview with the staff, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The findings include:
The letters of agreement were reviewed on August 2, 2011. The current letter of agreement did not document that they had 24 hours medical and or psychiatric coverage.
The staff was interviewed on August 2, 2011 confirmed the findings.
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Plan of Correction
NTP Consultants is in the process og obtaining an updated letter of agreement with the licensed hosital facility that would be the referral resource for 24 hour coverage. This letter of agreement will also become part of the new Program Director's manual and will be identified as an annual responsibility of the Program Director to acquire an updated agreement.
NTP Consultants LLC will have an updated agreement with licensed hospital facility no later than October 1, 2011. The updated agreement with licensed hospital will state that the facility has 24 hour medical and psychiatric coverage. |
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 owner during the onsite inspection on August 2, 2011, the annual audit for the fiscal year reviewed was not completed.
The findings include:
During the onsite licensing inspection, conducted from August 2, 2011 through August 3, 2011, the fiscal documentation was reviewed. The certified public accountant's dated and signed comments at the beginning of the fiscal document indicated that the document was not an audit. The letter from the accountant stated "... we have not audited or reviewed the accompanying financial statements and accordingly do not express an opinion or any other form of assurance.."
The documentation presented failed to meet the requirement for the annual financial audit.
The owner was interviewed on August 2, 2011 regarding the documentation and content of the annual audit and confirmed that this was the only fiscal document available for review.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the June 2, 2010 through June 3, 2010 licensing inspection. The facility's plan of correction submitted on July 29, 2010 and approved on August 19, 2010 stated the following:
"NTP Consultants is requesting an exception to these requirements as noted by the Division of Drug and Alcohol Program Licensing Alert 4-97 (Requests for Exceptions to Regulations, Part V., Drug and Alcohol Activities, Chapter 701). Application is in process.
If the exception request is rejected, Owner will work with accountant to develop an audit plan for the company. Owner will begin working with accountant on September 1, 2010 to determine exact fiscal documents that are acceptable for audits. The audits will then take place by June of that fiscal year- auditing the previous fiscal year's financial records. The Owner will be responsible for all actions related to the financial records and auditing.
To make sure this error does not happen in the future, the Owner will make sure all financial documents are received from the accountant by June 30 of each fiscal year- for the previous fiscal year's financial's."
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Plan of Correction
NTP Consultants LLC made an exemption annual audit exemption request based on the small size of the facility and the limited income revenue of the facility. NTP Consultant's Business manager received a letter from Pa DOH dated August 15, 2011. Pa DOH has granted an exemption of for the annual audit.
This exemption has been granted for the fiscal year 2011 and forward, so long as the following conditions are met: 1) the ownership remains the same and 2) the total revenues do not exceed the revenue limit noted by Pa DOH. This exception is again limited to the current ownership and the annual audit requirement exemption would be voided with change of ownership.
The annual audit exemption for 2010 was not made retroactive. |
709.26(a) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
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Observations
Based on the review of the facility's policy and procedure manual, the project failed to demonstrate that the project director assisted the governing body in formulating
policies and procedures.
The findings include:
The facility's policies and procedures were reviewed on August 2, 2011. The project director failed to document the annual update of the project's policies and procedures, as required by regulation.
An interview with the owner on August 2, 2011 confirmed the findings.
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Plan of Correction
Project Director met with Board of Directors August 17, 2011 to review DOH site visit and to discuss NTP policies that are out of date or required to bring NTP Consultants LLC in compliance with facility policies and procedures.
Project Director reviewed plan with Board, to do complete review, revise out of date, and implement new policies as identified during DOH site inspection Aug 2-3, 2011. The full review and completion of updates of NTP policies manual will be complete by 9/8/2011.
Annual Review
Project Director's manual identifies the NTP Policy manual review and update as an annual responsibility. Project Director will review and update the NTP Policies Manual no later than June 1.
Project Director will review the NTP policies manual with NTP Board of Directors during annual June Board meeting and will complete updates to manual no later than June 30.
Board will be be asked to sign each policy annually as documentation that the policies and procedures manual have been reviewed and approved.
Project Director will also document review of any modified, updated, or new policies with all staff.
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709.26(b) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
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Observations
Based on the review of the facility's policy and procedure manual, the project failed to demonstrate that the project director assisted the governing body in formulating
a written policy to implement and coordinate personnel management.
The findings include:
The policies and procedure book was reviewed on August 2, 2011. The project director failed to document the annual update of the project's policies and procedures, as required by regulation.
An interview with the owner on August 2, 2011 confirmed the findings.
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Plan of Correction
Project Director met with Board of Directors August 17, 2011 to review DOH site visit and to discuss NTP policies that are out of date or required to bring NTP Consultants LLC in compliance with facility policies and procedures. This review will include personnel management policies.
Board of Directors will be asked to approve and sign revised personnel policies.
Project Director reviewed plan with Board, to do complete review, revise out of date, and implement new policies as identified during DOH site inspection Aug 2-3, 2011. The full review and completion of updates of NTP policies manual will be complete by 9/8/2011. |
709.26(b)(4) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(4) The implementation of Federal, State and local statutes concerning fair employment practices.
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Observations
Based on a review of administrative documentation it was determined that the facility failed to demonstrate the implementation of fair employment practices.
The findings included
The policy and procedure book was reviewed on August 2, 2011. The policy and procedure book was last updated on July 9, 2009 and the EEO grid that was documented was outdated and did not fairly represent the current staff members. An interview with the owner on August 2, 2011 confirmed that the EEO grid had not been updated.
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Plan of Correction
NTP Consultants LLC Project Director updated the EEO Grid as of 8/9/2011. The EEO grid will added to the Project Director's manual for updates of the EEO grid due to any personnel/ staff change and to align NTP current personnel policies into compliance with fair employment practices.
NTP Policies and Procedures manual as well as Project Directors manual policy reflect the Project Director's responsibility for updates of the EEO grid.
NTP Consultants LLC Policies manual and the Project Director's manual contains the the EEO grid update based on current staff as of 8/9/2011. Facility Director will update grid as staff changes occur within the agency.
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on the review of personnel records and the facility's policy and procedure manual, the facility failed to document performance evaluations in three of five records reviewed.
The findings include:
Five personnel records were reviewed on August 2, 2011. Three of the five were required to have a performance evaluation in records reviewed, #1, 2 and 5. Per the facility's policy and procedure manual a performance evaluation will be done on all staff after their 90 day probation period then done annually in December. An interview with the project director/facility director on August 2, 2011 confirmed the following findings.
Employee #1 was hired January 3, 2011 and their performance evaluation was to be documented by April 3, 2011. As of the date of the inspection there was no documentation of employee #1's performance evaluation.
Employee #2 was hired March 3, 2011 and their performance evaluation was to be documented by June 3, 2011. As of the date of the inspection there was no documentation of employee #2's performance evaluation.
Employee #3 was hired December 20, 2010 and their performance evaluation was to be documented by March 20, 2011. As of the date of the inspection there was no documentation of employee #3's performance evaluation.
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Plan of Correction
NTP Consultants LLC policy and procedure manual is under full review by Project Director. NTP Consultants employs 2 full time staff and 2 part time staff. Performance evaluations will be completed with all 4 NTP staff by 9/10/2011.
Personnel Performance evaluations will be conducted by the Facility Director 90 days after an employee has started at the agency and then annually there after. Evaluation will be discussed and signed by the Director and staff at the time of evaluation. |
709.28(a)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(2) Staff access to client records.
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Observations
Based on a review of the agency policy manual, the facility failed to document a policy and procedure that specified how staff may access client records.
The findings include:
The policy and procedure manual was reviewed on August 2, 2011. The policy did not document the method of access to client records. An interview with the owner on August 2, 2011 confirmed the findings.
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Plan of Correction
Project Director met with governing board on August 17, 2011. The NTP Consultants LLC Confidentiality policy was identified as apolicy that require revision to address how staff accesses client records.
Project Director will complete a full review of all the policies and procedures in teh current NTP Consultants manual. The projected completion date for all revised policies, including the Confidentiality policy, is 9/8/2011.
Project Director is responsible for ensuring that NTP staff maintains compliance with this and all policies of NTP Conusltants manual. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records and an interview with the project director/facility director, the facility failed to document a medical history in eight of eight client records.
The findings include:
Eight client records were reviewed on August 3, 2011. All client records were required to have documentation of a medical history, #1, 2, 3, 4, 5, 6, 7 and 8. Per facility policy, the medical history is completed by the second session and will include the client and their family medical history with symptoms/illnesses. The facility failed to provide documentation of a medical history in client record # 1, 2, 3, 4, 5, 6, 7 and 8.
Client # 1 was admitted on April 24, 2011 and the client's medical history was completed on April 24, 2011. The medical history did not include the family medical history or symptoms/illness.
Client # 2 was admitted on April 14, 2011 and the client's medical history was completed on April 14, 2011. The medical history did not include the family medical history or symptoms/illness.
Client # 3 was admitted on May 4, 2011 and the client's medical history was completed on May 4, 2011. The medical history did not include the family medical history or symptoms/illness.
Client # 4 was admitted on March 23, 2011 and the client's medical history was completed on March 23, 2011. The medical history did not include the family medical history or symptoms/illness.
Client # 5 was admitted on January 3, 2011 and the client's medical history was completed on January 3, 2011. The medical history did not include the family medical history or symptoms/illness.
Client # 6 was admitted on January 10, 2011 and the client's medical history was completed on January 10, 2011. The medical history did not include the family medical history or symptoms/illness.
Client # 7 was admitted on February 18, 2011 and the client's medical history was completed on February 18, 2011. The medical history did not include the family medical history or symptoms/illness.
Client # 8 was admitted on January 3, 2011 and the client's medical history was completed on January 3, 2011. The medical history did not include the family medical history or symptoms/illness.
A discussion on August 3, 2011 the project director/facility director confirmed the findings.
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Plan of Correction
The Project Director has reviewed documentation of family medical history requirement with all NTP staff as of August 18,2011.
Project Director is reviewing the current NTP documentation and is developing a revised psychosocial document that includes family medical history in addition to client medical history information.
The revised psychosocial will be completed by 9/9/2011. Staff will start using this form on 9/12/2011.
Project director will conduct monthly client chart audits to ensure that the psychosocial documentation demonstrates a thorough assessment of client. The Project Director will be responsible for ensuring that staff are trained in the use of this clinical document. |
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 and an interview with the project director/facility director, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor conclusions and or impressions of the client in eight of eight client records.
The findings include:
Eight client records were reviewed on August 3, 2011. A psychosocial evaluation was required in eight of those records, #1, 2, 3, 4, 5, 6, 7 and 8. An interview with the project director/facility director on August 3, 2011 confirmed the findings.
Client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include a documented evaluation of the client's assets/strengths and how they would impact treatment.
Client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include a documented evaluation of the client's support systems and how they would relate to treatment.
Client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include a documented evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
Client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include a documented evaluation of the client's negative factors and how they would impact treatment.
Client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include a documented evaluation of the clients response to treatment and how it would effect their treatment.
Client records #2, 3, 4, 5, 6, 7 and 8 did not include a documented evaluation of the counselor's conclusion and impression of the client.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the June 2, 2010 through June 3, 2010 licensing inspection. The facility's plan of correction submitted on July 29, 2010 and approved on August 2, 2010 stated the following:
"On June 4, 2010 Director and Counselors implemented a Chart auditing form that allows us to use this checklist to avoid overlooking errors such as this. Director will conduct monthly audits of charts to ensure all assessments and psychosocial forms are completed, in detail, and up to date."
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Plan of Correction
The Project Director has the requirement of the psychosocial evaluation requirements of client assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor conclusions and or impressions of the client. This clinical documentation was reviewed with all NTP staff as of August 18,2011.
Project Director is reviewing the current NTP documentation and is developing a revised psychosocial document that includes assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor conclusions and or impressions of the client.
The revised psychosocial will be completed by 9/9/2011. Staff will start using this form on 9/12/2011.
Project director will conduct monthly client chart audits to ensure that the psychosocial documentation demonstrates a thorough assessment of client. The Project Director will be responsible for ensuring that staff are trained in the use of this clinical document.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services on six of eight client records reviewed.
The findings include:
Eight client records were reviewed on August 3, 2011. Eight client records were reviewed for documentation of proposed support services on the client's treatment plan. Client records # 1, 2, 4, 6, 7 and 8 had no documentation of proposed support services on the comprehensive treatment plan. An interview with the project director/facility director on August 3, 2011 confirmed the findings.
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Plan of Correction
Project Director met with NTP staff to review the need to document proposed support services on client's treatment plan. Potential support services/ resources were discussed with staff.
Project Director will conduct monthly audits of client charts to ensure that clinicians are addressing support systems that client may utilize to positively impact their treatment goal.
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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 one of two client records.
The findings include:
Eight client records were reviewed on August 3, 2011. Per agency policy, case consultations shall be completed every 90 days. Case consultations were required in two client records. The facility did not document a case consultations within the 90 day time frame in client record # 2.
Client # 2 was admitted on April 14, 2011. The case consultations were due by July 14, 2011. As of August 3, 2011 there was no documentation of a case consultation in record #2. An interview with the project director/facility director confirmed the findings.
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Plan of Correction
Facility Director has implemented a structured schedule as to when case consult meetings will be held among staff members and Director, which is ever other week. At these meetings the cases that are due for their 90 day review will be discussed and reviews will be done. (progress will be discussed with clients seperate from the case consult meeting as appropriate). The Case Consult will be documented and filed in the chart. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and an interview with the project director/facility director, the facility failed to document an aftercare plan in four of four client record.
The findings include:
Eight client records were reviewed on August 3, 2011. Per the facility policy, the counselor and client will complete an aftercare plan prior to discharge. An aftercare plan was required in four client records, #5, 6, 7 and 8. The facility did not document an aftercare plan in client records #6 and 7.
In client record # 6, the client was admitted on January 10, 2011 and was discharged on February 17, 2011. There was no documentation of an aftercare plan.
In client record # 8, the client was admitted on January 3, 2011 and was discharged on March 17, 2011. There was no documentation of an aftercare plan.
Also, client records #5 and 7 failed to document goals with time frames in aftercare plans reviewed.
In client record # 5, the client was admitted on January 3, 2011 and was discharged on April 5, 2011. There was no documentation of an aftercare plan.
In client record # 7, the client was admitted on February 18, 2011 and was discharged on April 18, 2011. There was no documentation of an aftercare plan.
This was discussed and confirmed with the project director/facility director on August 3, 2011.
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Plan of Correction
Project Director met with clinical staff to review aftercare plan documentation.
Project Director will revise aftercare plan format and develop an aftercare plan document that will be in compliance with requirements of this document to be an after treatment plan of action that will support client's needs.
The revised aftercare plan will be completed no later than 9/15 and will be in use by clinical staff as of 9/19/2011.
Project Director will conduct random audits on discharged client files to ensure compliance with the use and appropriate documentation of client aftercare. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary within one week of discharge in three of four client records.
The findings include:
Eight client records were reviewed on August 3, 2011. Per agency policy, discharge summaries are due within one week of discharge. Discharge summaries were required in four client records. The facility did not document a discharge summary within one week of discharge in client records #5, 6 and 7.
Client # 5 was admitted on January 3, 2011 and was discharged on April 5, 2011. The discharge summary was due by April 12, 2011. The discharge summary was not documented as of August 3, 2011.
Client # 6 was admitted on January 10, 2011 and was discharged on February 17, 2011. The discharge summary was due by February 24, 2011. The discharge summary was documented and dated May 5, 2011.
Client # 7 was admitted on February 18, 2011 and was discharged on April 22, 2011. The discharge summary was due by April 29, 2011. The discharge summary was documented and dated May 5, 2011.
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Plan of Correction
Project Director has reviewed discharge summary requirement staff.
Discharge summary of each discharged client will be completed within 7 days of diacharge date.
Client discharges will be discussed in monthly staff meetings.
Project Director will do monthly audits of discharged client records to ensure compliance with the completion of the diacharge summary. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up attempts in three of four required records.
The findings include:
Eight client records were reviewed on August 3, 2011. Four of the eight client records were required to document follow-up attempts. Follow up was not documented in three of the four required client records. Per the facility's policy and procedures, follow-ups will be conducted 3 months after discharge if not being referred. An interview with the project director/facility director on August 3, 2011 confirmed the findings.
Client # 5 was admitted on January 3, 2011 and discharged on April 5, 2011. The follow up attempt was due on July 5, 2011
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Client # 7 was admitted on February 18, 2011 and discharged on April 22, 2011. The follow up attempt was due on July 22, 2011.
Client # 8 was admitted on January 3, 2011 and discharged on March 17, 2011. The follow up attempt was due on June 17, 2011.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the June 2, 2010 through June 3, 2010 licensing inspection. The facility's plan of correction submitted on July 29, 2010 and approved on August 2, 2010 stated the following:
"On June 10, 2010 a follow-up plan was implemented by Director and Lead Counselor. A designated staff member will begin making follow-up contact with clients within 3 months of the client ' s discharge date. NTP had been doing follow-ups since January, 2010 but there was not a specific format in place. As of June 10, 2010, there is a specific format to follow. Director will be auditing charts monthly to make sure correct follow-up procedures are being followed."
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Plan of Correction
Prior to Pa DOH site review, a process for follow ups was implemented.
Follow-ups will be conducetd according to NTP Consultants LLC policy for 3 month follow up via mail.
NTP staff will provide administrative staff with client discharge files. Administrative staff will mail follow up packet to clients.
Client follow ups will be initiaited on all May 2011 through August 2011 clients.
Project Director will be responsible for review and status of client follow up process with NTP Administrattive staff. Project Director will review all client follow up packets received back from clients.
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of the client records, the facility failed to provide a physician signature on treatment plans and treatment plan updates in two of four client records.
The findings include:
Eight client records were reviewed on August 3, 2011. Of the eight client records reviewed four were medical assistance clients who are required to have a physician signature on all treatment plans and treatment plan updates, #3, 4, 5 and 6. This documentation was missing in records # 3 and 4.
Client record #3 - The client was admitted to treatment on May 4, 2011. The treatments plan and treatment plan update was completed on May 17, 2011 and June 29, 2011. The physician signature was missing on both the treatment plan and treatment plan update.
Client record #4 - The client was admitted to treatment on March 23, 2011. The treatments plan and treatment plan update was completed on May 17, 2011 and July 25, 2011. The physician signature was missing on both the treatment plan and treatment plan update.
An interview with the project director/facility director on August 3, 2011 confirmed the findings.
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Plan of Correction
Facility Director will be responsible for ensuring that the contracted physician reviews the treatment plan and treatment updates by reviewing with staff the proceedure by which plans and updates get signed by the Doctor. Staff were reminded that plans and updates need to be given to the Facility Director to ensure that the Physician can review and sign the documentation within 10 days of creating the treatment plan or update. Facility Director will remind staff of this proceedure at meetings and Administrative Assistant will track when treatment plans and updates are due, as to be able to ask staff for these materials for the physician to sign.
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