INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5-6, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conemaugh Valley Memorial Hospital 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 5, 2010.
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Plan of Correction
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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.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in two of five personnel records reviewed.
The findings include:
Six personnel records were reviewed on January 5, 2010. Five personnel records represented counselors. Two personnel records are required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training for employees # 3 and # 4.
Employee # 3 was hired on August 1, 2006. The facility training year is from July 1 through June 30. The training year for July 1, 2008 to June 30, 2009 was reviewed. Employee # 3 only completed 18 clock hours of annual training in 2008-2009.
Employee # 4 was hired on November 25, 2003. The facility training year is from July 1 through June 30. The training year for July 1, 2008 to June 30, 2009 was reviewed. Employee # 4 only completed 14 clock hours of annual training in 2008-2009.
The director confirmed on January 5, 2010 that the two counselors did not have the 25 clock hours of training for the 2008-2009 training year.
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Plan of Correction
All counselors are required to receive 25 clock hours of training each year. This requirement is identified in the job description, the annual performance evaluation and in the completion of the individual needs assessment annually.
Will review the requirement and each of the above documents with all staff at the next scheduled staff meeting.
Annual performance evaluations for the counselors idenitified will reflect unacceptable performance in the area of education and development. A plan for compliancce in the coming year will be developed for each counselor.
The Program Director will make clear in the developed action plans that CAC requirements do not supercede BDAP requirements for 25 hours each year. |
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on a physical plant tour on January 6, 2010, the facility failed to provide smoke detectors within the facility.
The findings include:
Based on a physical plant tour conducted with the facility director, the facility did not have smoke detectors. The maintenance staff from the hospital was consulted and after an onsite visit, confirmed there is not a smoke detector in the facility. Both the maintenance staff and the director confirmed on January 6, 2010 that there is not a smoke detector in the facility.
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Plan of Correction
Facilities Engineering notified to install integrated smoke detector within 2 weeks. Date of expected completion: 02/10/2010 |
711.81(b)(6) LICENSURE Psychosocial Evaluation
711.81. 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 a psychosocial evaluation in two of the three client records.
The findings include:
Ten client records were reviewed on January 5-6, 2010. Three of the ten records were from the partial hospitalization activity. Three of the three records were required to include documentation of a psychosocial evaluation. The facility policy states that a psychosocial evaluation is due by the fifth treatment session.
Client record #1 did include documentation of a psychosocial evaluation.
Client record #2 - The client was admitted on July 31, 2009, and was discharged on November 5, 2009. The psychosocial evaluation was due by the fifth treatment session which was August 13, 2009. The psychosocial evaluation was not documented for this client as of January 6, 2010.
Client record #3 - The client was admitted on September 10, 2009, and was discharged on October 7, 2009. The psychosocial evaluation was due by the fifth treatment session which was September 17, 2009. The psychosocial evaluation was not documented for this client as of January 6, 2010.
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Plan of Correction
Policy for completion of psychosocial evaluation will be reviewed with all staff at next staff meeting.
From this point forward clients requiring partial hospitalization will not be placed in group setting until psychosocial assessment is completed.
Individual counselor whose charts did not reflect appropriate completion of the psychosocial evaluation will be counseled and direct supervision will be provided by the Program Director for a period of 3 months.
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711.82(c) LICENSURE Individualized Tx Plan
711.82. Treatment and rehabilitation services.
(c) 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 a review of client records, the facility failed to provide an individual treatment plan in three of the three client records.
The findings include:
Ten client records were reviewed on January 5-6, 2010. Three of the ten client records were from the partial hospitalization activity. Three of the three records were required to include documentation of an individual treatment plan. The facility policy states that an individual treatment plan is due by the fifth treatment session.
Client record #1 - The client was admitted on December 21, 2010. An individual treatment plan was due by the fifth treatment session which was December 30, 2009. An individual treatment plan was not documented for this client as of January 6, 2010.
Client record #2 - The client was admitted on July 31, 2009, and was discharged on November 5, 2009. An individual treatment plan was due by the fifth treatment session which was August 13, 2009. An individual treatment plan was not documented for this client as of January 6, 2010.
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Client record #3 - The client was admitted on September 10, 2009, and was discharged on October 7, 2009. An individual treatment plan was due by the fifth treatment session which was September 17, 2009. An individual treatment plan was not documented for this client as of January 6, 2010.
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Plan of Correction
Treatment planning policy and procedure will be reviewed with all staff at the next staff meeting (scheduled Thursday 1/21/2010).
Individual counselor responsible for 2 of 3 clients will be counseled and place under clinical supervision by program director for 3 months.
Program Director to assume all clinical supervision responsibilities from this date on. |