INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, MCP/Caring Together 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:
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of first aid cards, Cardio Pulmonary Resuscitation (CPR) certifications, and an interview with the project director, the facility failed to ensure that a sufficient number of staff persons trained in first aid and CPR skills are present during all the project's hours of operation.
The findings include:
On March 21, 2014, March 24, 2014, and March 25, 2014 the facility's first aid cards and CPR certifications were reviewed. The facility's hours of operation are Monday to Friday from 9:00 A.M. to 5:00 P.M. Two staff members, a counselor assistant intern and the child development specialist, have CPR certification. However, the only staff member that has first aid training is the project director. The project director typically only works at the facility Monday, Tuesday, and Wednesday and only works at the facility 20 hours a week. In addition, the counselor assistant intern that has CPR certification only works at the facility 4 hours each day. The facility did not provide sufficient first aid and CPR coverage during the hours of operation.
The findings were confirmed during an interview with the lead counselor and child development specialist on March 25, 2014 at approximately 3:00 P.M.
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Plan of Correction
The child development specialist, who is on site during all hours of operation, has CPR training but not a current First Aid certifcate. CPR certification and first aid training have been scheduled for counselor, employee #2 on May 13, 2014. First aid training will be completed for the early child development specialist no later than May 15, 2014. The Program Medical Director/Interim Program Manager will ensure that all certification is complete by the designated dates and that certifcation will be updated as required. The Program Medical Director/Interim Program Manager will be responsible for making sure that at least one person with CPR certification and first aid training is onsite during all hours of operation. |
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 ensure that each counselor completed at least 25 clock hours of annual training in one of one personnel record reviewed.
The findings include:
On March 25, 2014, one personnel record requiring documentation of 25 clock hours of annual training was reviewed. The facility failed to provide documentation of 25 clock hours of annual training in personnel record # 2.
Employee # 2 is the lead counselor and was hired August 29, 2000. Employee # 2 was required to complete 25 clock hours of annual training hours by June 30, 2013. However, personnel record # 2 only had documentation of 6 clock hours of annual training for the July 1, 2012 to June 30, 2013 training year as of March 25, 2014.
The findings were confirmed during an interview with the lead counselor and child development specialist on March 25, 2014 at approximately 3:00 P.M.
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Plan of Correction
Employee #2 has to date (4/10/2014) completed 30 hours of training and is scheduled for addtional training hours to be completed before 6/30/2014. A new training plan will be developed for all staff in early July, 2014.The Program Medical Director/Interim Program Manager will ensure that all training is compete by the designated dates. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records and an interview with the facility director, the facility failed to maintain a written fire drill record that included documentation of unannounced fire drills at least once a month in one of eleven months reviewed and failed to provide documentation that the facility's alarm is in working order.
The findings include:
Fire drill records were reviewed on March 21, 2014, March 24, 2014, and March 25, 2014. The records were reviewed from the period covering April 2013 to February 2014. The facility did not conduct an unannounced fire drill at least once a month in one of eleven months reviewed, specifically, February 2014.
Also, the facility was granted an approval on May 20, 2008 to the Physical Plant Standards for Nonresidential Facilities, Chapter 705.28 (d) (7), relative to activating a fire alarm or smoke detector during a fire drill. As a result of the approval, the facility was required to provide documentation that their fire alarm is in working order. Documentation that the facility's fire alarm is in working order was not presented for review.
The findings were confirmed during an interview with the lead counselor and child development specialist on March 25, 2014 at approximately 3:00 P.M.
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Plan of Correction
The Program Medical Director/Interim Program Manager will ensure that fire drills are held monthly without exception in the future. The Program Medical Director/Interim Program Manager will obtain facility documentation that the fire alarm is in working order no later than 4/10/2014. Moving forward the Program Medical Director/Interim Program Manager will obtain facility documentation yearly to ensure fire alarms are in working order and conduct monthly fire drills as required. |
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on observations on March 25, 2014, the facility failed to maintain protective caps over each electrical outlet in the facility's childcare area.
The findings include:
A physical plant inspection was conducted on March 25, 2014. It was observed during the inspection from approximately 10:36 A.M. to 10:40 A.M. that there was no protective cap over two of the electrical outlets on the front wall of the childcare area and no protective cap over one of the electrical outlets on the rear wall of the childcare area.
The findings were confirmed during an interview with project director and child development specialist on March 25, 2014 at approximately 10:42 A.M.
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Plan of Correction
All electrical outlets in the childcare area were covered with protective caps on 3/26/2014. The child development specialist will be responsbile to ensure that all outlets are inspected daily and covered with protective caps if any are missing. |
711.91(b)((2)(iii) LICENSURE Fee Schedule
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project that included the familiarization with a fee schedule in ten of ten records reviewed.
On March 25, 2014, ten client records requiring documentation of client orientation to the project that included familiarization with a fee schedule were reviewed. The facility failed to document the familiarization with a fee schedule in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
Client # 1 was admitted November 15, 2013. Client orientation to the project that includes a fee schedule was due upon the client's admission by November 15, 2013. The client orientation to the project was completed on November 15, 2013 but did not include the familiarization with a fee schedule.
Client # 2 was admitted September 9, 2013. Client orientation to the project that includes a fee schedule was due upon the client's admission by September 9, 2013. The client orientation to the project was completed on September 9, 2013 but did not include the familiarization with a fee schedule.
Client # 3 was admitted January 8, 2014. Client orientation to the project that includes a fee schedule was due upon the client's admission by January 8, 2014. The client orientation to the project was completed on January 7, 2014 but did not include the familiarization with a fee schedule.
Client # 4 was admitted February 7, 2014. Client orientation to the project that includes a fee schedule was due upon the client's admission by February 7, 2014. The client orientation to the project was completed on February 6, 2014 but did not include the familiarization with a fee schedule.
Client # 5 was admitted September 20, 2013. Client orientation to the project that includes a fee schedule was due upon the client's admission by September 20, 2013. The client orientation to the project was completed on September 20, 2013 but did not include the familiarization with a fee schedule.
Client # 6 was admitted June 28, 2013. Client orientation to the project that includes a fee schedule was due upon the client's admission by June 28, 2013. The client orientation to the project was completed on June 28, 2013 but did not include the familiarization with a fee schedule.
Client # 7 was admitted June 18, 2013 and discharged October 21, 2013. Client orientation to the project that includes a fee schedule was due upon the client's admission by June 18, 2013. The client orientation to the project was completed on June 18, 2013 but did not include the familiarization with a fee schedule.
Client # 8 was admitted July 18, 2013 and discharged November 22, 2013. Client orientation to the project that includes a fee schedule was due upon the client's admission by July 18, 2013. The client orientation to the project was completed on July 17, 2013 but did not include the familiarization with a fee schedule.
Client # 9 was admitted July 29, 2013 and discharged December 2, 2013. Client orientation to the project that includes a fee schedule was due upon the client's admission by July 29, 2013. The client orientation to the project was completed on July 29, 2013 but did not include the familiarization with a fee schedule.
Client # 10 was admitted September 4, 2013 and discharged November 11, 2013. Client orientation to the project that includes a fee schedule was due upon the client's admission by September 4, 2013. The client orientation to the project was completed on September 4, 2013 but did not include the familiarization with a fee schedule.
The findings were confirmed during an interview with the lead counselor and child development specialist on March 25, 2014 at approximately 3:00 P.M.
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Plan of Correction
The fee schedule is now posted in the Program office in a visable place for all clients to view. In addition, the fee schedule has been added to the program orientation packet that is given to all clients who will sign off that they recieved the material. In addition, clients 1-10 who are still active in the program will be given copies of the fee schedule by 4/25/2014. The early child development specialist will ensure that fee schedules will be give to all current clients and staff who perform intake evaluations will be responsible for ensuring that all new clinets are given the fee schedule. |
711.91(b)(7) LICENSURE Preliminary Treatment Plan
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment and rehabilitation plan in two of ten client records reviewed.
The findings include:
On March 25, 2014, ten client records requiring documentation of a preliminary treatment and rehabilitation plan were reviewed. The facility failed to document a preliminary treatment and rehabilitation plan in client records # 8 and 10.
Client # 8 was admitted July 18, 2013 and discharged November 22, 2013. The preliminary treatment and rehabilitation plan was due August 16, 2013. However, client record # 8 did not include documentation of a preliminary treatment and rehabilitation plan as of March 25, 2014.
Client # 10 was admitted September 4, 2013 and discharged November 11, 2013. The preliminary treatment and rehabilitation plan was due October 12, 2013. However, client record # 10 did not include documentation of a preliminary treatment and rehabilitation plan as of March 25, 2014.
The findings were confirmed during an interview with the lead counselor and child development specialist on March 25, 2014 at approximately 3:00 P.M.
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Plan of Correction
Preliminary treatment plans and rehabilitation plans are expected to be completed on all clients as part of the intake process for all new clients. All other client charts have been reviewed to ensure that preliminary treatment plans and rehabilation plans have been completed. No additional missing preliminary treatment or rehabiliation plans were noted. Preliminary treatment and rehabilitation plans for clients #8 and #10 are unable to be completed because they have been discharged.
The Program Medical Director/Interim Program Manager conducted educational inservice training session for staff and counselor interns on 4/2/2014 and 4/9/2014 on conducting and documenting preliminary treatment plans and rehabiliation plans.
The Program Medical Director/Interim Program Manager will ensure that all clients have a completed preliminary treatment plan and rehabiliation plan completed within one week after a new client enters the program.All preliminary treamnet plans and rehabiliation plans are expected to be presented at the weekly clinet rounds by the appropriate staff who performed the intake. |
711.92(c)(3) LICENSURE Support Service
711.92. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in three of seven client records reviewed.
The findings include:
On March 25, 2013, seven client records requiring documentation of the proposed type of support services on the individual treatment and rehabilitation plans were reviewed. The facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in client records # 5, 6 and 9.
Client # 5 was admitted September 20, 2013 and the individual treatment and rehabilitation plan was completed October 20, 2013. The facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan as of March 25, 2014.
Client # 6 was admitted June 28, 2013 and the individual treatment and rehabilitation plan was completed July 28, 2013. The facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan as of March 25, 2014.
Client # 9 was admitted July 29, 2013 and discharged December 2, 2013. The individual treatment and rehabilitation plan was completed August 29, 2013. The facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan as of March 25, 2014.
The findings were confirmed during an interview with the lead counselor and child development specialist on March 25, 2014 at approximately 3:00 P.M.
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Plan of Correction
Proposed types of support services are expected to be incorporated into and documented in all individual treatment and rehabiliation plans for all clients. This was completed on all current clients by 3/31/2014. In addition, each counselor and counselor intern are expected to complete these plans including documentation of recommended proposed type of support services. Documentation in the client record of the proposed type of support services offerred to graduating clients will now be fully documented in the client chart. These proposed type of support services are also routinely documented in the initial psychiatric evaluation and in the psychiatry progress notes.Moving forward the Program Medical Director/Interim Program Manager will ensure that proposed type of support services are documented on individual treatment and rehabilitation plans for all clients and performed a staff inservice training on 4/2/2014 to discuss the types and the learning of how to document proposed type of support services on individual treatment and rehabilitation plans.
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711.93(a) LICENSURE Complete Client Record
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which include information relative to the client's involvement with the project regarding documentation of an individual treatment and rehabilitation plan in one of eight client records reviewed. Also, based on a review of client records, the facility failed to have a complete client record of an individual which includes information relative to the client's involvement with the project regarding documentation of an aftercare plan that contains the client's future goals with time frames and support services in two of two client records reviewed.
The findings include:
On March 25, 2014, twelve client records requiring documentation of a complete client record were reviewed. The facility failed to document an individual treatment and rehabilitation plan in one of eight records reviewed, specifically, client record # 8. Also, the facility failed to document an aftercare plan that includes the client's future goals with time frames and support services in two of two client records reviewed, specifically, client records # 11 and 12.
Client # 8 was admitted July 18, 2013 and discharged November 22, 2013. The individual treatment and rehabilitation plan was due August 17, 2013. However, client record # 8 did not include documentation of an individual treatment and rehabilitation plan as of March 25, 2014.
Client # 11 was admitted February 22, 2013 and discharged December 20, 2013. The aftercare plan was completed December 17, 2013 but did not include the client's future goals with time frames and support services as of March 25, 2014.
Client # 12 was admitted August 24, 2012 and discharged July 27, 2013. The aftercare plan was completed July 27, 2013 but did not include the client's future goals with time frames and support services as of March 25, 2014.
The findings were confirmed during an interview with the lead counselor and child development specialist on March 25, 2014 at approximately 3:00 P.M.
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Plan of Correction
Counselors and couselor interns will ensure individual treatment plans and rehabilitation plans are to be completed and documented in a timely manner. Counselors and counseling interns will ensure that aftercare plans are documented and that aftercare plans contain the client's future goals with time frames and support services in all client records in a timely manner. All current charts were reviewed by 3/31/2014 to ensure that all time sensitive components of these plans were completed in a timely manner. Charts of all active clients are now fully up to date.
The Program Medical Director/Interim Program Manager held an educational inservice session with all staff on 4/2/2014 and again on 4/9/2014 to review these components of treatment planning and will be resonsible to ensure that those components of treatment are completed and fully documented. Moving forward The Program Medical Director/Interim will ensure on an ongoing basis that individual treatment and rehabilitation plans are documented on time, aftercare plans are documented on time, and that aftercare plans include the client's future goals with time frames and support services, which conselors and conseling interns are to create and document in a timely manner. |