INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 7 and 8, 2005 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, 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 May 8, 2008.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records on April 7, 2008, the facility failed to document that the facility director met the qualification for that position.
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Plan of Correction
The previous facility director who meets the required qualifications has been reinstated as director. |
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
Based on a review of training records on April 8, 2008, the facility failed to document complete training plans in five of seven records reviewed, #3, 4, 5, 6 and 7. Individual training plans did not identify specific subject areas.
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Plan of Correction
The program coordinator is responsible for ensuring complete training plans.The plans will be discussed and reviewed as a part of weekly supervision with the coordinator.All training plans will identify and address specific subject areas that are needed. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill record on 4/8/08, the facility failed to document that the fire alarm or smoke detector was set off in nine of the last nine fire drills.
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Plan of Correction
The facility will set off and document that the fire alarm has been set off during each fire drill.This record will be kept in the fire alarm log by the Safety Director.The Program Coordinator will check monthly with the Safety Director to ensure this is happening.The Program Coordinator is responsible for this action. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documents on 4/7/08, the facility failed to document available resources for the 2008 goals and objectives.
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Plan of Correction
The Facility Director will document available resources to meet the yearly goals and objective, which are a part of the Annual plan. This information will be available each year for the annual survey. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documents on April 9, 2008, the facility failed to document that the audit for the 2006/2007 fiscal year was completed within the required time frame. The audit was due December 31, 2007. It was dated March 24, 2008.
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Plan of Correction
Holcomb Behavioral Health System's annual fiscal audit is done at the behest of Chimes,Inc.,our parent company. The Program Director will contact the audit firm and explain the necessity of completing the audit by the end of the calendar year. |
709.28 (c)(1) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records on 4/8/08, the facility failed to obtain an informed and voluntary consent from the client in one of three client records reviewed, #3. The facility failed to document the name of the person, agency or organization to whom disclosure was for on a consent form.
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Plan of Correction
Intake staff and clinicians will be educated by Coordinator in the protocol of the Informed and Voluntary consents, and will be presented with the specific Pa. Code 255.5 for future use. Supervisors/Coordinators will address this issue in weekly supervision and weekly chart reviews. |
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
Based on a review of client records on April 8, 2008, the facility failed to obtain an informed and voluntary consent from the client in two of three client records reviewed, #1 and 3. The specific information to be disclosed on consent to release information forms to probation/parole exceeded that allowed by the limitations imposed at 4 Pa. Code 255.5. Information to be disclosed included client medications, psychiatric evaluations, treatment/aftercare plans and discharge summaries.
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Plan of Correction
Coordinator will educate Intake staff and clinicians regarding the appropriate and limited information permitted in the Pa. Code 255.5; Coordinator will review these Consents on a weekly basis in supervision. |
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 a review of client records on 4/8/08, the facility failed to document a complete psychosocial evaluation in three of three client records reviewed, #1, 2 and 3. The psychosocial evaluations were a repeat of historical data and did not include an assessment of coping mechanisms, problems/needs, assets/strengths, support systems, negative factors or client's attitude toward treatment. Additionally, the evaluations did not include a clinical assessment of how assets/strengths, support systems and negative factors impact the potential for treatment.
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Plan of Correction
The Director of Clinical Services provided training to staff to ensure that all future assessments include a clinical assessment of client's assets,strengths,support systems,and negative factors that may impede treatment. The Program Coordinator will review this issue in weekly supervision and is responsible for this action. |
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 client records on April 8, 2008, the facility failed to document a complete treatment plan in two of two client records reviewed, #2 and 3. Treatment plan goals were not stated in terms of measurable criteria
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Plan of Correction
The Clinical Supervisor provided training on documentation in treatment plans with the emphasis on measurable treatment plan goals.This will be addressed in weekly supervision by the Program Coordinator who is responsible for compliance. |
709.93(a)(5) LICENSURE Client records
709.93. 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:
(5) Progress notes.
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Observations
Based on a review of facility policy and client records on April 8, 2008, the facility failed to document progress notes according to the DAP format required by their policy in three of three client records reviewed, #1, 2 and 3.
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Plan of Correction
Psychologists and clinicians will be educated in the writing of DAP notes by the Clinical Supervisor. In-Service trainings will be offered to improve documentation skills. Coordinators/Supervisors will address appropriate documentation in weekly supervision and in weekly chart reviews.The Program Coordinator is responsible for ensuring that the notes are according to the DAP format.This training has begun and will be ongoing for all treatment staff. |
709.93(a)(11) LICENSURE Client records
709.93. 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 facility policy and client records on April 8, 2008, the facility failed to document follow-up information within seven days in one of one client record reviewed, #3.
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Plan of Correction
The Program Coordinator is responsible for the 7 day followup after discharge or transfer.Training of staff on followup has begun and is ongoing.Documentation of follow-ups will be in all cient charts. |