INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 27 - October 1, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Summit Academy 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 November 3, 2010.
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Plan of Correction
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709.30(2) LICENSURE Client Rights
709.30. Client rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the policy and procedure manual and client intake documentation, and an interview with the project director, the project failed to document a client rights policy indicating the project may not discriminate in the provision of services on the basis of age, race, creed, sex ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, as required by regulation.
The findings include:
The policy and procedure manual was reviewed on September 27, 2010. Per regulation, the project is required to provide a client rights policy which documents the project may not discriminate in the provision of services on the basis of age, race, creed, sex ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. The client's rights were not present in the policy and procedure manual. Furthermore, the clients are required to sign a copy of their rights at intake. The right to non-discrimination was not included on the clients' rights form. The project director was interviewed on September 30, 2010 and confirmed this policy was not in the project's policy and procedure manual.
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Plan of Correction
The statement listed in 709.30(2) is included in The Summit Academy Inpatient Drug/Alcohol Program binder.
The statement listed in 709.30(2) will be typed onto a form which all clients can sign. Current clients will be presented with the form no later than 11/01/10. As of 10/29/10, all new clients will review the form during their orientation to the program.
Clinicians will be trained and instructed to review the form and procure signatures from all clients by 10/29/10 |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a tour of the physical plant and an interview with the clinical supervisor, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times.
Findings include:
A tour of the facility was conducted on September 29, 2010 at 10:40 am. During the tour at approximately 11:24 A.M., Room # 309 was found to have a leaky faucet tied with a sock, which was damp to the touch. Also, at 11:11 A.M. it was observed that Room # 301 had a 4 inch hole in the wall. Additionally, the classroom/group room on the 2nd floor had a displaced ceiling tile, which appeared as if it may fall on the desk directly beneath it.
The clinical supervisor confirmed these findings during the tour of the facility.
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Plan of Correction
The faucet in Room 309 was replaced 09/29/10.
The wall in Room 301 was repaired, patched and painted 09/29/10.
The ceiling tiles in the 2nd floor group room were replaced and secured 09/29/10 |
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 a psychosocial evaluation that included the client's problems/needs that can or cannot be resolved in treatment, assets/strengths that can contribute to the resolution of client's problems, support systems, coping mechanisms, negative factors that might affect client's treatment, client's attitude toward treatment, and counselor's conclusion/impressions regarding client's attitude toward treatment in eight of ten records reviewed.
The findings include:
Ten client records were reviewed on September 9, 2010 for psychosocial evaluations. Nine client records did not include a clinical assessment of the client; and only included client reported historical information.
Client # 1 was admitted on May 17, 2010. The psychosocial evaluation was completed on May 17, 2010 and did not include the client's problem/needs, assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 2 was admitted on June 28, 2010. The psychosocial evaluation was completed on June 28, 2010 and did not include the client's problem/needs, assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 3 was admitted on May 28, 2010. The psychosocial evaluation was completed on May 28, 2010 and did not include the client's assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 4 was admitted on April 8, 2010. The psychosocial evaluation was completed on April 4, 2010 and did not include the client's coping mechanisms and attitude toward treatment.
Client # 5 was admitted on July 28, 2010. The psychosocial evaluation was completed on July 21, 2010 and did not include the client's assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 6 was admitted on January 18, 2010. The psychosocial evaluation was completed on January 16, 2010 and did not include the client's assets/strengths, support systems, coping mechanisms and negative factors.
Client # 7 was admitted on December 18, 2010. The psychosocial evaluation was completed on January 19, 2010 and did not include the client's assets/strengths, support systems, coping mechanisms and negative factors.
Client # 9 was admitted on March 16, 2010. The psychosocial evaluation was completed on March 29, 2010 and did not include the client's assets/strengths, support systems, coping mechanisms and negative factors.
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Plan of Correction
The Clinical Coordinator will review the treatment charts of Clients 1,2,3,4,5,6,7, and 9 with the clinicians, in order to ensure that the missing items are put in place and that these items are reviewed with each client, no later that 11/01/10.
The Clinical Coordinator will provide training to the clinicians no later than 11/15/10, to ensure that psychosocial evaluations always include: problems/needs, assests/strenghts, support systems, coping mechanisms, negative facotrs and attitude toward treatment. |
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.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to document a follow up attempt in one of two client records.
The findings include:
Two client records requiring follow ups were reviewed on September 29, 2010. The facility did not document a follow up in client record # 9.
The facility policy, 709.53a (11) states:
In case of referral to another agency as provided by the probation officer or judge, contact will be made by the Project Director, within seven days by phone and disposition will be documented in the client's file via a program note.
Client # 9 was admitted on March 16, 2010 and discharged on September 2, 2010. A follow up was due on September 9, 2010. No documentation was provided at the time of inspection.
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Plan of Correction
The Project Director reviewed the case of Client #9 09/29/10.
The Project Director will receive emails directly from clinicians and spreadsheets from administrative staff members responsible for intake and discharge, outlining the dates by which such action is required. The Project Director will make contact within seven days by phone and disposition will be documented in the client's file via a program note. The Project Director will meet with administrateive staff by 11/01/10 in order to clarify this procedure. |
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 a review of personnel records, employee credentials, and documentation of supervision notes, the facility failed to document the required period of close supervision for one counselor assistant.
The findings include:
On September 28, 2010, personnel records for ten counselor assistants were reviewed. Of those ten counselor assistants, one employee, #13 had a non-qualifying Bachelor's degree.
Employee #13 was hired on December 18, 2009 and had documentation of direct observation until June 30, 2010. The facility documented only six months of direct observation, and failed to continue six months of close supervision.
An interview with the project director and clinical supervisor confirmed employee #13 only had six months of direct observation on the basis that the degree was qualifying.
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Plan of Correction
Employee # 13 will continue to receive close supervision for the entire six months, beginning 10/04/10 through 04/11/11.
In order to avoid this problem in the future, when uncertain, the Clinical Coordinator will contact DAPL to verify that degrees are qualifying prior to hiring additional clinicians.
The Clinical Coordinator will review records of direct observation and close supervision weekly, in order to ensure its occurrence. |