INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19, 2010 through July 22, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Addiction Medicine And Health Advocates, 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 August 17, 2010.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, staffing requirements facility summary report and a staff interview, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Sixteen personnel records were reviewed on July 20, 2010 and the staffing requirements facility summary report was reviewed on July 19, 2010 and July 20, 2010. There was no documentation of HIV/AIDS and TB/STD training in nine employee records. Of the nine, six staff were required to have HIV/AIDS and TB/STD training within the first year of employment and the other three staff were required to have HIV/AIDS and TB/STD training within the first two years of employment.
Employee #4 was hired February 1, 2008 and was required to have HIV/AIDS & TB/STD training by February 1, 2009. There was no documentation of TB/STD training in the employee's record as of July 20, 2010.
Employee #6 was hired October 14, 2008 and was required to have HIV/AIDS & TB/STD training by October 14, 2009. There was no documentation of TB/STD training documented in the staffing requirement's facility summary report, dated July 20, 2010.
Employee #8 was hired March 2, 2009 and was required to have HIV/AIDS & TB/STD training by March 2, 2010. There was no documentation of TB/STD training documented in the staffing requirement's facility summary report dated, July 20, 2010.
Employee #7 was hired October 21, 2008 and was required to have HIV/AIDS & TB/STD training by October 21, 2009. There was no documentation of HIV/AIDS training documented in the staffing requirement's facility summary report, dated July 20, 2010.
Employee #10 was hired June 29, 2009 and was required to have HIV/AIDS & TB/STD training by June 29, 2010. There was no documentation of TB/STD training documented in the staffing requirements facility summary report, dated July 20, 2010.
Employee #11 was hired April 27, 2009 and was required to have HIV/AIDS & TB/STD training by April 27, 2010. There was no documentation of HIV/AIDS & TB/STD training documented in the staffing requirements facility summary report, dated July 20, 2010.
Employee #13 was hired April 1, 1986 and was required to have HIV/AIDS & TB/STD training by April 1, 1988. There was no documentation of TB/STD training documented in the staffing requirements facility summary report dated July 20, 2010.
Employee #15 was hired January 2, 2008 and was required to have HIV/AIDS & TB/STD training by January 2, 2010. There was no documentation of HIV/AIDS training documented in the staffing requirements facility summary report, dated July 20, 2010.
Employee #16 was hired December 1, 2007 and was required to have HIV/AIDS & TB/STD training by December 1, 2009. There was no documentation of TB/STD training documented in the staffing requirements facility summary report, dated July 20, 2010.
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Plan of Correction
We have identified qualified staff people who are able to train others using the state state approved HIV/AIDS and TB/STD curriculum. The Staff Development Coordinator is responsible for managing all trainings and has begun scheduling the staff people who have not had these required trainings. As new people are hired we will ensure that they have these required trainings during the designated time frames. The Clinical Coordinator and Staff Development Coordinator will be responsible for ensuring the corrective plan of action is implemented. |
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 and an interview with the facility director, the facility failed to ensure and document that counselors completed at least 25 hours of training for the 2009 training year in three of nine personnel records where due.
The findings include:
Sixteen personnel records were reviewed on July 20, 2010. Nine employee records represented the counselors who were required to have obtained 25 hours of training for the 2009 training year based on the hire dates.
Employee #5 was hired 4/21/08 and was required to have obtained 25 training hours for the 2009 training year. Employee #5 only had 20.5 hours of training for training year 2009.
Employee #9 was hired 4/27/09 and was required to have obtained 25 training hours for the 2009 training year. Employee #9 only had 22 hours of training for training year 2009.
Employee #11 was hired 4/27/09 and was required to have obtained 25 training hours for the 2009 training year. Employee #11 only had 14.5 hours of training for training year 2009.
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Plan of Correction
AMHA's Staff Development Coordinator has streamlined his procedure for tracking and monitoring each staff person's attendance at the required number of trainings. He will keep a running list for each staff person and as the training year progresses, will schedule those who are not at the required 25 hours for additional trainings. We will also identify new training resources to increase the number of available trainings for our staff. Staff will also be made aware of the need for training hours during ongoing supervision sessions as a means of monitoring this process. |
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 fire drill record, the facility failed to document that the fire alarm/smoke detector system was operational.
The findings include:
The fire drill logs were reviewed on July 19, 2010. Per regulation, facilities shall set off a fire alarm or smoke detector during each fire drill. In reviewing the fire drill documentation, the facility was verbally announcing the fire drills for the months of September 2009, October 2009, November 2009, December 2009, January 2010, February 2010, March 2010, April 2010, May 2010 and June 2010.
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Plan of Correction
AMHA has received written approval from The Department for this address allowing for alternative methods for notifying staff and patients of fire drills other than using the actual fire alarm. The written approval will be on file for future inspections. The Executive Director secured this approval and will maintain it for future reference. |
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 the audit for July 1,2008 through June 30, 2009, the project failed to complete a financial audit by the end of the project's fiscal year.
The findings include:
A review of the annual audit was conducted on July 19, 2010. The project's audit for July 1, 2008 through June 30, 2009 was due to be completed no later than December 30, 2009. The project's audit was not completed until January 21, 2010.
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Plan of Correction
The Exective Director has initiated the process for completing the audit by formally engaging the CPA/Accounting Firm immediately following the end of the fiscal year. The accountants have been made aware of the licensing requirement to have the audit completed within the required timeframe of no later than December 30th. The Exectuive Director will monitor the process to completion within the timeframe required. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records and the facility's policy and procedure manual, the facility failed to document drug and alcohol histories in six of thirteen client records.
The findings include:
Thirteen client records were reviewed on July 21, 2010 and July 22, 2010. Drug and alcohol histories were required in thirteen of thirteen client records. Client records # 1, 5, 7 and 12 did not have documentation of histories in the records reviewed. Per the facility's policy and procedure, drug and alcohol histories are to be documented within 21 days of the client's admission date.
Client record #1 was admitted on 3/30/10 and their drug and alcohol history was to be documented by 4/19/10.
Client record #5 was admitted on 4/29/10 and their drug and alcohol history was to be documented by 5/19/10.
Client record #7 was admitted on 4/7/10 and their drug and alcohol history was to be documented by 4/27/10.
Client record #12 was admitted on 12/8/09 and discharged on 2/12/10 and their drug and alcohol history was to be documented by 12/28/09.
Additionally client records #6 and 11 histories were documented later than the completion date specified by facility policy.
Client #6 was admitted on 3/17/10 and their drug and alcohol history was not documented until 4/22/10. The drug and alcohol history was to be completed by 4/6/10.
Client #11 was admitted on 11/24/09 and discharged 3/29/10. Their drug and alcohol history was not documented until 1/20/10. The drug and alcohol history was to be completed by 12/13/09.
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Plan of Correction
AMHA will have each counselor submit completed new patient paperwork which includes the biopsychosocial history and biopsychosocial evaluation to their immediate supervisor for review within 21 days of admission. The biopsychosocial history and evaluation contain the patient's drug and alcohol history. Staff will also be sent a reminder if the 21 day deadline is approaching and they have yet to submit the necessary paperwork. The two clinical supervisors will be responsible for monitoring this process. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records and the facility's policy and procedure manual, the facility failed to document personal histories in six of thirteen client records.
The findings include:
Thirteen client records were reviewed on July 21, 2010 and July 22, 2010. Personal histories were required in thirteen of thirteen client records. Client records 1, 5, 7 and 12 did not have documentation of personal histories. Per the facility's policy and procedure, personal histories are to be documented within 21 days of the client's admission date.
Client # 1 was admitted on 3/30/10 and their personal history was to be documented by 4/19/10.
Client # 5 was admitted on 4/29/10 and their personal history was to be documented by 5/19/10.
Client # 7 was admitted on 4/7/10 and their personal history was to be documented by 4/27/10.
Client #12 was admitted on 12/8/09 and discharged on 2/12/10 and their personal history was to be documented by 12/28/09.
Additionally client records # 6 and 11 histories were documented late.
Client record # 6 was admitted on 3/17/10 and their personal history was not documented until 4/22/10. Personal history documentation was to be completed by 4/6/10.
Client record #11 was admitted on 11/24/09 and discharge date 3/29/10. Their personal history was not documented until 2/31/10. Personal history documentation was to be completed by 1/20/10.
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Plan of Correction
AMHA addresses personal histories as part of the intake paperwork. This paperwork is found in the intake/admission section of the chart rather than the biopsychosocial history section. The required elements of the personal history will be included in the personal history section of the chart within the intake section and the biopsychosocial within the required timeframe for the completion of the biopsychosocial. The Clinical Coordinator will be responsible for implementation,completion, and ongoing monitoring. |
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, the facility failed to document all elements of a psychosocial evaluation in thirteen of thirteen client records.
The finding included:
Thirteen records were reviewed on July 21, 2010 through July 22, 2010. Psychosocial evaluations were required in thirteen records reviewed.
Client records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 13 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment.
Also, a review of client record documentation revealed that psychosocial evaluations were completed before the personal histories were finished in client records # 6, 11 and 13.
Client record #6 evaluation was completed on 3/31/10; the personal histories were completed on 4/22/10.
In client record #11, the client's psychosocial evaluation was completed on 12/14/09 and their personal history was completed on 12/21/09.
In client record #13, the client's psychosocial evaluation was completed on 3/11/10 and their personal history completed on 4/7/10.
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Plan of Correction
In a staff meeting held on 7/29/10 to review the outcome of the licensing inspection, we discussed the sequence of paperwork to be completed for new patients. Specifically, that evaluations should be done only have completion of the biopsychosocial history. The clinical Coordinator will also provide counselors with an updated template for the biopsychosocial evaluation which includes all necessary elements. It was emphasized during the meeting that the evaluations, in addition to providing historical information regarding the patient, should be more evaluative in nature and contain more clinical insight. The histories will be reviewed as part of our new procedure to have all new patient paperwork reviewed by the counselor's direct supervisor within the 21 day timeframe. |