INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7 through 9, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on September 12, 2006.
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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
Employee # 13 does not meet the educational requirements for the position of a counselor.
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Plan of Correction
1. The project was not in compliance with the standard because the interpretation of the employee's educational qualifications by the project's management team was not consistent with the standard.
2. The project is in full compliance with this standard as of 09/01/2006.
The employee's status has been changed to Counselor Assistant.
3. The person responsible for maintaining compliance with this standard is Kevin Williams, Director of Support Services. Kevin is responsible for Human Resource Management. |
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
The policies and procedures did not identify the personnel responsible nor the timeframe for the completion of the required components.
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Plan of Correction
1. The project was not in compliance with this standard because the 'Competency Assessment Program' Policy and Procedure (Policy Number 02.03) did not specifically identify the personnel responsible for the completion of the required components.
2. The 'Competency Assessment Program' Policy and Procedure has been revised
(revision date: 08/09/2006)to specifically identify the personnel responsible for the completion of the required components.
3. Please see above.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The individual training plan for new hires was not completed within 30 days of the employee's hire date.
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Plan of Correction
1. The project was not in compliance with this standard because the 'Competency Assessment Program' Policy and Procedure (Policy Number 02.03) did not specifically outline in its procedure that the employee will receive an individual training plan within the first 30 days of employment.
2. The 'Competency Assessment Program' Policy and Procedure has been revised
(revision date: 08/09/2006) to specifically include as part of the procedure the employee evaluation that will be completed within 30 days of employment.
3. Please see above.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Three client bathrooms did not have an operable exhaust fan or window, specifically the client bathroom between bedrooms # 201 and 202, client bathroom for bedroom # 128, and the client/staff bathroom on the first floor of the male residential building.
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Plan of Correction
1. The rooms/areas included in Observation #63 did not have operable exhaust fans.
2. These fans will be installed by 09/30/2006.
3. The person responsible for achieving and maintaining this standard is Kevin Williams, Director of Support Services. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
709.14 (a) (2) Restriction on license. Change in authorized maximum capacity.
The licensed capacity of the residential treatment program is 69. The number of beds counted during the licensing inspection was 82.
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Plan of Correction
1. The project was not in compliance with the standard as a result of a misinterpretation of the standard.
Additional beds were utilized for increased flexibility with patient care.
2. The project was in full compliance with this standard as of 09/05/2006.
3. The project submitted a formal request for an increase in bed capacity from 69 to 83. This request was approved on 09/05/2006 in a letter submitted to Dr. Michael Salazar, CEO/Managing Director. |
709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The consents to release information to the client's funding source allowed for the release of information identified as "aftercare plans" which exceeds that allowed by 4 Pa. Code 255.5.
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Plan of Correction
1. The project was not in compliance because the information allowed to be released exceeded that allowed by 4 Pa. Code 255.5.
2. The project's standard release of information has been revised. The section referencing 'aftercare plans' has been changed to 'aftercare appointmnet'. Date of revision was 08/09/2006.
3. The person responsible for achieving and maintaining compliance with this standard is Emi Lawson, Director of Admissions and Utilization Management. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Documentation on the medication administration record was not consistently completed as per the facility's policies and procedures.
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Plan of Correction
1. The project was not in compliance with this standard because the medication administration record was not consistently completed as per the project's policies and procedures.
2. The project will be in full compliance with this standard by 9/30/2006.
3. A nursing in-service will be held for all nursing personnel to review this policy and procedure. The project's nurse manager will audit monthly to ensure compliance.
The persons responsible for achieving and maintaining compliance to this standard are Kathleen Houston, Director of Patient Affairs, and Ellen Norman, Nurse Manager. |
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
The psychosocial evaluations did not assess the client's assets/strengths, support systems, and negative factors that may inhibit treatment in three of eight client records reviewed, # 3, 7 and 10.
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Plan of Correction
1. The project was not in compliance with this standard because the psychosocial evaluations failed to assess the client's assets/strengths, support systems, and negative factors that may inhibit treatment.
2. The project will be in full compliance with this standard by 09/30/2006.
3. A clinical staff in-service will be held to retrain the staff on proper and comprehensive completion of psychosocial evaluations. David Dorschu, Director of Clinical Services, is the person responsible for achieving and maintaining compliance with this standard. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
The proposed type of support services were not documented in eight of nine records reviewed, #2, 3, 4, 5, 6, 7, 8 and 9.
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Plan of Correction
1. The project was not in compliance with this standard because support services were not listed for certain treatment care plans.
2. The project will be in compliance with this standard by 09/30/2006.
3. An in-service will be held for all clinical staff to retrain on the proper and comprehensive completion of treatment care plans. David Dorschu, Director of Clinical Services, is the person responsible for compliance with this standard. |