INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 19, 2010 through January 21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Roxbury 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 February 16, 2010.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the review of personnel records and an interview with the clinical supervisor, the facility failed to document supervision notes in one of one personnel record.
The findings include:
Eight personnel records were review on January 19, 2010. Documentation of clinical supervision was required in one record, employee #8. Employee #8 was hired on 1/19/09 as counselor aide and promoted to counselor assistant on 7/5/09. A review of the supervision documentation for employee # 8 revealed only one clinical supervision document, dated 9/13/09.
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Plan of Correction
Counselor Assistant will be supervised per the Close Supervision process beginning Feb 1, 2010, through August 1, 2010. This will involve direct oversight from Clinical Supervisor during Counselor Assistant's counseling activities and documented supervision sessions (at least bi-weekly). Should the Counselor Assistant's educational or credentialing status change, Roxbury's Director of Human Resources will notify the Dept of Health as such.
Human Resources will maintain criteria for deliniating staff as Counselor or Counselor Assistant. When a staff person is classified as Counselor Assistant, all necessary supervision steps and documentation requirements will be forwarded to Clinical Supervisor. HR will maintain a checklist to assure all requirements are met. This list will be checked and updated monthly until such time the staff person meets the requirements for re-classification to Counselor. Checklist will be developed in HR by 3/1/2010. |
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, the facility failed to ensure that all staff are trained for 6 hours in HIV/AIDS and at least 4 hours in TB/STD training in the required amount of time in one of four records reviewed.
Findings:
Eight personnel records were reviewed on January 19, 2010. HIV/AIDS and TB/STD training was required in eight records while compliance in achieving the training within one year of hire was reviewed and required in four employee records. Employee # 4 was hired October 6, 2008 and was required to have HIV/AIDS & TB/STD training by October 6, 2009. As of January 21, 2010, employee # 4 had not received the required training.
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Plan of Correction
Identified employee attended the Department approved 6 hours in HIV/AIDS and at 4 hours in TB/STD trainings on January 26-27 at Roxbury Treatment Center. To assure ongoing compliance, Director of Human Resources will maintain training records for all Roxbury employees and provide both employees and Supervisors regular updates of employee training requirements as well as scheduled trainings, both internal and external. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document psychosocial evaluations in four of five short-term detoxification records reviewed.
The finding includes:
Thirteen records were reviewed on January 20, 2009. Of these records, five were were reviewed for content and compliance with short term, non hospitalized detoxification regulations. Four of the five records did not contain a completed psychosocial evaluation, records # 1, 3, 4, and 5.
Client record #1 failed to include documentation of a clinical evaluation that provided an assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client record #3 failed to include documentation of a clinical evaluation that provided an assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client record #4 failed to include documentation of a clinical evaluation that provided an assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client record #5 failed to include documentation of a clinical evaluation that provided an assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
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Plan of Correction
Director of Social Work will facilitate a training on February 24, 2010 for all Clinical and Social Services staff on psycho-social interviewing and documentation; focusing on proper documentation of each client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment from the staff's perspective. Director of Social Work and Clinical Supervisor will audit medical records regularly to monitor for compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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 document complete psychosocial evaluations in four of four outpatient records reviewed.
The finding includes:
Thirteen records were reviewed on January 20, 2009. Of these records, four were were
in outpatient treatment and were reviewed for psychosocial evaluation content. The facility failed to document a complete psychosocial evaluation in four client records, # 6, 7, 8 and 9.
Client record #6 failed to include documentation of a clinical evaluation that provided an assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client record #7 failed to include documentation of a clinical evaluation that provided an assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client record #8 failed to include documentation of a clinical evaluation that provided an assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client record #9 failed to include documentation of a clinical evaluation that provided an assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
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Plan of Correction
The Director of OP Services will facilitate training on 2/26/10 with pertinent clinical staff on psycho-social interviewing and documentation. This training will educate staff on the importance of completing the psychosocial evaluation from the clinician's perspective, with emphasis on covering all the recommended points in each composite picture, as the records do not sufficiently demonstrate their clinical assessment of the client.
Random chart reviews will be performed to monitor ongoing completeness of psychosocial evaluations. Any identified deficiencies will be addressed through supervision and additional training as necessary.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
Based on the review of client records and an interview with the clinical supervisor, the facility failed to individualize treatment plans in two of four outpatient records reviewed.
The findings include:
Thirteen records were reviewed on January 21, 2010. Of these records, four were reviewed for outpatient content and compliance. Two of the four client records, # 6 and 7 were identical, with only the client names changed or inserted into each plan. An interview with clinical supervisor on January 21, 2010 confirmed that the treatment plans were identical.
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Plan of Correction
Performance Improvement Plans have been initiated and placed in HR files as of 2/22/10 with those clinicians whose Treatment Care Plans were not individualized. Director of OP Services will begin co-signing treatment care plans done by identified staff with planned re-evaluation of job performance within 60 days. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records and a interview with the facility director, the facility failed to ensure that counseling services were provided according to each client's individual treatment and rehabilitation plan in five of six inpatient rehabilitation records reviewed.
The findings include:
Thirteen client records were reviewed on January 21, 2010. Of these client records, five were reviewed for inpatient treatment content. The five inpatient rehabilitation records did not include documentation of group therapy notes in client records #10, 11, 13, 14 and 15.
Client record #10 provided documentation of one group note, written on 1/16/2010. Client # 10's treatment plans for 12/30/2009, 1/6/2010 and 1/13/2010 documented that theclient was to attend seven groups a week.
Client record #11 provided documentation for two groups, dated 1/6/2010 and 1/12/2010. The client's treatment plan for 1/1/2010 included documentation that the client was to attend seven groups a week and the treatment plan dated1/10/2010 included documentation that the client was to attend 10 groups each week.
Client record #13 included documentation of three groups, dated 12/8/2009, 12/14/2009, and 12/15/2009. Client # 13's treatment plan for 12/7/2009 included documentatio that the client was to attend seven groups each week and the treatment plan dated 12/15/2009 included documentation that the client would attend 10 groups each week.
Client record #14 included documentation of two groups, dated 11/19/2009 and 11/24/2009. Client # 14's treatment plan for 11/18/09 included documentation that the client was to attend 10 groups each week.
Client record #15 included documentation of one group, dated 10/12/2009. Client # 15's treatment plan for 10/1/09 included documentation that the client was to attend seven groups each week.
In an interview with the facility director on January 22, 2010, the facility director offered an explanation that they did not realize they had to write a progress note for every therapeutic contact.
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Plan of Correction
Roxbury provides counseling services according to each client's individual treatment and rehabilitation plan. This is evidenced in or Records of Service and Patient Daily Schedule. However, progress notes have not consistently been written for every therapeutic contact. On 2/24/10, Project Director will facilitate a training with Clinical staff to educate on proper documentation practices. Treatment Care Plans will be altered on 2/28/10 to reflect types of groups to be attended by each patient to clarify which groups would be "therapy" vs. "psycho-educational" and therefore which would require a progress not to be written. Ongoing chart audits by Director of Clinical Services beginning 3/1/10 will assure compliance with this standard. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on the review of client records and interview with the clinical supervisor, the facility failed to individualize case consultations in two of four outpatient records reviewed.
The findings include:
Thirteen client records were reviewed on January 21, 2010. Of these records, four were reviewed for content of outpatient treatment and compliance. Case consults for client #6 and 7 were identical, their respective names were asserted into the treatment plans. In the course of a staff interview, the clinical supervisor concurred that the case consultations for clients # 6 and 7 were identical.
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Plan of Correction
Performance Improvement Plans have been initiated and placed in HR files as of 2/22/10 with those clinicians whose Case Consultations were not individualized. Re-evaluation of job performance will occur within 60 days. Director of OP Services will conduct a training for all OP staff on 2/22/10 to educate staff on proper completion of Case Consult forms. Random chart audits will begin 2/23/10 to assure compliance with these standards. |