INITIAL COMMENTS
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This is a report of the on-site licensure renewal inspection conducted on August 14 through 15, 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 11, 2006.
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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
The Project Director does not meet the requirements of the position based on his Bachelor's Degree in Accounting. Also, he does not have direct service experience.
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Plan of Correction
On 8/10/06, the Governing Body of White Deer Run, Inc appointed an Acting Project Director/Acting Executive Director, during the interim in which a permanent Project Director/Executive Director is identified. |
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
Individual training plans for all staff reviewed were incomplete. The individual plans failed to list the training, the time frames within which the training would be obtained and the resources that would be utilized.
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Plan of Correction
The "Individual Training Plan" will be modified for use and distributed in November 2006 for the 2007 training calendar year. The modification will include a checklist of potential trainings to be offered in the upcoming year. The QI/Staff Development Department will also note on the checklist the proposed resource for training (for example, Ethics-BDAP Trainer), and the proposed time frame in which the training will be offered (for example, Summer 2007). The "Individual Training Plan" will then provide documentation of:
1. Training needs assessment
2. Identified resources in which to meet training needs
3. Proposed timeframes in which to meet those training needs
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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
One counselor, employee # 6, has a client to counselor caseload of 40/1.
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Plan of Correction
Campus Director and Clinical Supervisor meet with Outpatient staff once weekly. Clinical Supervisor will check census daily in qualifacts to ensure 35-1 ratio is met. |
709.32(c)(6) 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:
(6) Inventories.
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Observations
Several bulk, prescription medications which are routinely prescribed by the physician through the mechanism of standing orders, were not inventoried.
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Plan of Correction
A documentation procedure to record emergency medication inventory reviews is being developed. This will include a form to record open containers, unopened containers, replacement containers and expiration dates. The monthly inventory review will be conducted by night shift nurse and reviewed by Nursing Coordinator or designee.
Sept 30
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709.62(c)(3)(ii) LICENSURE D & A History
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
In 4 out of 4 client records reviewed, specifically #1, 7, 9 and 10, the drug and alcohol history was missing lengths and patterns attributing to the client's progression of use. In addition, the client's perception of use was unclear in that it simply listed areas of the client's life, i.e. legal, financial and/or social.
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Plan of Correction
The WDR/CFBH forms committee has been notified of this deficiency. The forms committee is scheduled to meet on 8/30/2006 at which time corrections will be made to the Drug and Alcohol History. The corrections will then be reviewed by the Senior Leadership and Quality Improvement Committees on 9/13/2006 and either modify or approve for implementation. Revised forms will be distributed for use no later than 9/15/2006. Clinical supervisor to inservice staff by 9/21/2006 regarding completion of Drug and Alcohol History. Monthly chart audits to be completed by clinical supervisor-2 charts/counselor for 6 months. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
In 4 out of 4 client records reviewed, specifically #1, 7, 9 and 10, the summary contained in the nursing assessment was more historical than evaluative and did not address the required areas.
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Plan of Correction
At Nurses Meeting on September 12, 2006, nursing staff will be retrained on completing an Evaluative Summary. Evaluative Summaries will be reviewed on weekly basis for 4 months by Nursing Coordinator and when needed individual training will be held with nurses who are having difficulty. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. 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
In 4 out of 4 client records reviewed, specifically #1, 8, 10 and 12, the drug and alcohol history was missing lengths and patterns attributing to the client's progression of use. In addition, the client's perception of use was unclear in that it simply listed areas of the client's life, i.e. legal, financial and/or social.
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Plan of Correction
The WDR/CFBH forms committee has been notified of this deficiency. The forms committee is scheduled to meet on 8/30/2006 at which time corrections will be made to the Drug and Alcohol History. The corrections will then be reviewed by the Senior Leadership and Quality Improvement Committees on 9/13/2006 and either modify or approve for implementation. Revised forms will be distributed for use no later than 9/15/2006. Clinical supervisor to inservice staff by 9/21/2006 regarding completion of Drug and Alcohol History. Monthly chart audits to be completed by clinical supervisor-2 charts/counselor for 6 months. |
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
In 2 out of 4 client records reviewed, specifically #1 and 10, the psychosocial evaluation was more a repeat of the history than clinical impressions. In addition, the evaluation was disjointed and missing defense mechanisms and negative factors.
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Plan of Correction
Clinical Supervisor will review in clinical team meeting by 9/29/06 aspects of an evaluative summary. Evaluative Summaries will be reviewed during monthly chart audits by Clinical Supervisor for a period of 4 months and when needed, individual training will occur. |
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
In 4 out of 5 client records reviewed, specifically #2, 3, 5 and 6, the drug and alcohol history was missing lengths and patterns attributing to the client's progression of use. In addition, the client's perception of use was unclear in that it simply listed areas of the client's life, i.e. legal, financial and/or social.
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Plan of Correction
The WDR/CFBH forms committee has been notified of this deficiency. The forms committee is scheduled to meet on 8/30/2006 at which time corrections will be made to the Drug and Alcohol History. The corrections will then be reviewed by the Senior Leadership and Quality Improvement Committees on 9/13/2006 and either modify or approve for implementation. Revised forms will be distributed for use no later than 9/15/2006. Clinical supervisor to inservice staff by 9/21/2006 regarding completion of Drug and Alcohol History. Monthly chart audits to be completed by clinical supervisor-2 charts/counselor for 6 months. |
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
In 2 out of 5 client records reviewed, specifically # 2 and 6, the psychosocial evaluation was more a repeat of the history than clinical impressions. In addition, the evaluation was disjointed and missing defense mechanisms and negative factors.
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Plan of Correction
Clinical Supervisor will review in clinical team meeting by 9/29/06 aspects of an evaluative summary. Evaluative Summaries will be reviewed during monthly chart audits by Clinical Supervisor for a period of 4 months and when needed, individual training will occur. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
In 2 out of 5 client records reviewed, specifically #11 and 15, the aftercare plans did not include realistic goals with time frames. In addition, aftercare plans in client records #11 and 13 did not contain a phone number for the reentry process.
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Plan of Correction
Clinical Supervisor will complete a training on Aftercare Planning and Goal Setting with the clinical treatment team by Oct 1, 2006. Compliance will be ensured through monthly chart audits for 4 months.
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