INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25 - 27, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health-HA, Inc., 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 July 28, 2008.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on review of personnel records on June 25-26, 2008, employee # 5 does not meet counselor qualifications. The facility failed to document that the necessary experience was obtained by the employee prior to that person's promotion to counselor.
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Plan of Correction
Corrections will be made and documented expericence for employee #5 to meet the counselor qualifications. Program Director will be responsible. |
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 review of personnel records on June 25-26, 2008, supervision of the counselor assistant was not documented in accordance with the standards for counselor assistant at the bachelor's degree level. Documentation of direct observation for employee # 5 covered only two months, while three months of direct observation was required.
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Plan of Correction
The Clinical Supervisor will review the
regulation 704.9 with the lead counselor in the supervison of a counselor assistant. The Clinical Supervisor will be responsible. |
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 client census information and caseload distribution documentation on June 25 - 26, 2008, the facility failed to comply with the stipulations of the 2004 exception granted by the Division for reduced counseling clients on extended caseloads. Two counselors had extended caseloads where more than 50% of the caseload was made up of reduced counseling clients.
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Plan of Correction
There has been a memo sent to the program licensure in regards to this non-compliance explaining our special circumstances for the caseloads in question. With results of the response to the memo the Program Director will be responisle to either maintain what we are doing to accomidate our special circumstances or change to follow the exception as written. |
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 review of the policy and procedure manual on June 16-17, 2008, the facility policy and procedure on the annual report states that the report will be completed within 90 days of the end of the reporting year. The annual report was not made available to the public until May 22, 2008, more than 140 days after the end of the reporting year.
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Plan of Correction
The policy will be reviewed/amended as needed. The Program Director and policy advisor from Discovery House Home Office will be responsible. |
709.22(e)(2) 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:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the annual report on June 18, 2008, the financial statement of income and expenses was not documented as a part of the annual report.
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Plan of Correction
The policy willl be reviewed/amended as needed. The Program Director and policy advisor from Discovery House Home Office will be responisble. |
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 review of the policy and procedure manual on June 16-17, 2008, the facility failed to provide a complete manual at the time of the inspection.
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Plan of Correction
Policies will be reviewed and amended/changes/purged as needed. The Program Director and policy advisor from DH Home Office will be responsible. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on review of personnel records on June 25, 2008, the facility failed to document reference checks in four personnel records.
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Plan of Correction
All new hires will have reference checks done upon hire. Program Director will be responsible. |
709.28(a)(1) 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:
(1) Confidentiality of client identity and records.
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Observations
Based on review of the policy and procedure manual on June 16-17, 2008, the facility policy and procedure on client confidentiality relating to state regulation at 4 Pa. Code subsection 255.5 was not consistent with state law at 71 P.S. Subsection 1690.108 (b) which requires written client consent prior to the release of client identifying information. The facility policy and procedure currently allows for release to criminal justice entities "with or without" client consent.
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Plan of Correction
The policy will be reviewed/amended as needed. The Director and policy advisor from Discovery House Home Office will be responsible. |
709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
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Observations
Based on review of the policy and procedure manual on June 16-17, 2008, the facility failed to document a policy consistent with the regulation. The regulation specifically states that the project director may temporarily remove portions of the records prior to the inspection by the client. Facility policy allows for the "Medical Director, Nurse Practitioner, Physician Assistant or other appropriately credentialed designees as allowed by law..." to make the decision to temporarily remove portions of the records prior to the inspection by the client.
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Plan of Correction
The policy will be reviewed/amended a needed. The Program Director and policy advisor from Discovery House Home Office will be responsible. |
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 review of client records on June 26 - 27, 2008, the facility failed to document complete psychosocial evaluations. Assets/strengths were incomplete in eight out of eight client records. Support systems were incomplete in client records #1, 3, 7 and 8. Coping mechanism were incomplete in client records #1, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
Clinical Staff will have in-service done by the clinical supervisor on the psychosocial evaluations of Assets/strengths and coping mechanism. Clinical Supervisor will be responsible. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of eight client records on June 26, 2008, the facility failed to document measurable criteria for the goals and objectives on the treatment plan and failed to document goals and objectives consistent with the clinicians's assessment documented in the psychosocial evaluation in eight out of eight client records reviewed.
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Plan of Correction
The Clinical Supervisor will conduct an in-service training on treatment plans and teaching documentation of measurable goals and objectives. Making sure the treatment plans is something the patient will be able to use and goals are attainable by the assessment of the clinician as stated in the psychosocial. The clinical supervisor will be responsible. |