INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 25-26, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mercy Behavioral Health 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 December 23, 2008.
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Plan of Correction
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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on the review of administrative policies and Board of Director's meeting minutes, the facility failed to document that the governing body approved a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
Findings:
Administrative policies and Board meeting minutes were reviewed on November 10, 12 and 13, 2008. The facility did not provide documentation that the governing body had approved a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Plan of Correction
Following the review it was discovered that the Board of Director's approved a compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter on May 17, 2005. This was not made available to the reviewer at the time of the review. Furthermore in light of a new board of directors for the organization the new Board of Directors will approve the compliance plan for this chapter at the next meeting of the board. |
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 the facility's staffing compliance plan and the active patient to counselor caseload list presented by the program director on November 25, 2008, it was determined that the facility failed to comply with the Full Time Equivalency counselor caseload for counseling in outpatient programs which may not exceed 35 active clients.
The findings include:
The number of outpatient hours the counselor worked divided by the number of outpatient clients the counselor had on her caseload exceed the 35:1 limitation on caseload sizes. The counselor had a 39:1 client to counselor caseload.
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Plan of Correction
Hours/Caseload size adjusted to ensure that all project staff do not exceed the 35:1 limitation. Facility Director will monitor this |
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on a review of administrative material and an interview with the project/facility director on November 10, 12 and 13, 2008, the current project/facility director does not meet the requirements for the project director position.
The findings include:
Facility documentation and the interview with the current Project/Facility director demonstrated that the individual currently assigned to the project director position is not officially responsible to the Board of Directors, but must in fact report to the Chief Executive Officer, who is officially responsible to the Board of Directors. The current project organization chart shows that the person currently assigned to the project director position reports to the Chief Executive Officer who in turn reports to the Board of Directors.
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Plan of Correction
CEO will be identified as the Project Director. An exeception request will be submitted for the mandatory HIV/AIDS and TB/STD trainings for the newly appointed Project Director. The Board of Directors will make this appointment at the next scheduled meeting |
709.24(a) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
Based on the review of administrative policies, Board meeting minutes and an interview with the project director, the facility failed to demonstrate that the governing body adopted a written plan for the coordination of client treatment and rehabilitation services.
Findings:
The facility did not provide documentation that the governing body had adopted and implemented a plan for the coordination of client treatment and rehabilitation.
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Plan of Correction
Following the review it was discovered that the Board of Directors had adopted and implemented a written plan for the coordination of client treatment and rehabilitation services on May 17, 2005. This was not made available to the reviewer at the time of the review. Furthermore in light of a new board of directors for the organization the new Board of Directors will adopt and implement a written plan for the coordination of client treatment and rehabilitation at the next meeting of the board. |
709.26(a) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
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Observations
Based on the review of administrative policies, Board meeting minutes and an interview with the project director, the facility failed to demonstrate that the governing body adopted and implemented written project personnel policies and procedures.
Findings:
The facility did not provide documentation that the governing body had adopted and implemented written personnel policies and procedures.
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Plan of Correction
Following the review it was discovered that the Board of Directors adopted and implemented a written project personnel policies and procedures on May 17, 2005. This was not made available to the reviewer at the time of the review. Furthermore in light of a new board of directors for the organization the new Board of Directors will adopt and implement written project personnel policies and proceedures at the next board meeting |
709.26(b) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
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Observations
Based on the review of administrative policies, Board meeting minutes and an interview with the project director, the facility failed to demonstrate that the governing body adopted and implemented written policy for the coordination of personnel management.
Findings:
The facility did not provide documentation that the governing body had adopted and implemented written policies regarding the coordination of personnel management.
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Plan of Correction
Following the review it was discovered that the Board of Directors adopted and implemented a written policy for the coordination of personnel management on May 17, 2005. This was not made available to the reviewer at the time of the review. Furthermore in light of a new board of directors for the organization the new Board of Directors will adopt and implement a written policy for the coordination of personnel management at the next meeting of the board. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of thirteen client records, the facility failed to document a medical history in eight of ten client records.
Findings:
Eleven client records were reviewed on November 25-26, 2008. Ten were reviewed for medical histories. The facility did not document a medical history in records #1, 3, 4, 5, 7, 8, 12 and 13.
There was no documentation that the medical history had been completed in any of the client records.
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Plan of Correction
New redesigned version of the electronic assessement captures the medical history elements. Citations were with the old version of the assessment. Cases #12 and #13 were cited but were not identified by the reviewer during the review or at the exit interview. I am assuming the older version of the assessment is the documentation that is being cited. Facility Director will be responsible for monitoring this. |
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 the review of client records, the facility failed to document a complete psychosocial evaluation in ten of ten client records.
Findings:
Thirteen client records were reviewed on November 25-26, 2008. Ten were required to have psychosocial evaluations. The facility did not document a complete psychosocial evaluation in client records # 1, 2, 3, 4, 5, 6, 7, 8, 12 and 13.
In client records # 1, 2, 3, 4, 5, 6, 7, 8, 12 and 13, the psychosocial evaluation was a repeat of historical information and was not a clinical assessment of the client.
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Plan of Correction
Psychosocial Evaluation standards will be reviewed with Project Staff during a staff inservice which will include hands on practice. The Facility Director will regularly review the style and content of the psychosocial evaluations to ensure that the standard is being met. |