INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 20 - 21, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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 March 18, 2008.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the personnel records and conversations with the Clinical Supervisor during the licensing inspection of February 21, 2008, the facility failed to provide documentation of supervision for the counselor assistant/intern.
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Plan of Correction
While there was supervision provided and documented for the University, the Clinical Supervisor did not have copies of the supervision.
Copies of documentation for the University have been obtained. Additionally, from here forward, agency documentation will be kept in the same manner as employees. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the training information for 2006-2007 during the licensing inspection of February 21, 2008, the facility failed to ensure that staff complete training feedback forms.
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Plan of Correction
This was addressed in the visit from 06/07 and was instituted at the beginning of the 2007 fiscal year. Records reviewed this visit fell before the identification of the problem and instituting the new procedure.
Currently, all trainings attendedd include a follow-up questionaire for feedback. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the personnel records during the licensing inspection of February 21, 2008, the facility failed to complete and document the fire extinguisher training within 7 days of employment. Refer to personnel record #4.
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Plan of Correction
Beginning May 1, 2008, training in the use of fire extinguishers will be provided on the same day as hire paperwork is completed. This will avoid the problem of discrepencies between the 7 day limit and the monthly scheduled orientation for all new hires. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the personnel records during the licensing inspection of February 21, 2008, the facility failed to complete and document the emergency preparedness training within seven days of the hire date. Refer to personnel record #4.
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Plan of Correction
Beginning May 1, 2008, a review of the emergency protocols will be provided on the same day as the paperwork is completed for hiring.
This will eliminate the possibility of discrepencies between the 7 day requirement and the agency-wide scheduled orientation scheduled monthly.
This information will be covered again at that time. |
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 conversations with the facility CQI director during the licensing inspection of February 21, 2008, the facility failed to activate the smoke detector or fire alarm during each fire drill.
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Plan of Correction
A request for Exception has been sent to the licensing board, based on the fact that additional services are provided in this building and the disruption caused by the actual use of the alarms.
We are awaiting a response. |
709.28(c) 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:
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Observations
Based on a review of client records during the licensing inspection of February 21, 2008, the facility failed to provide an informed consent in seven of seven client records. Release of information forms do not indicate the specific information to be disclosed and the forms are blank for the purpose section. Refer to client records # 1, 3, 5, 6, and 8. Records # 2 and 4 do not include release of information forms for the funding source.
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Plan of Correction
Within the new software program, forms can be developed to specifications. Therefore, the information released to the County will be entered as a part of the form, as well as the purpose, as these are always the same. Additionally, a review inservice on Confidentiality will be provided to the affected staff. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client record during the licensing inspection on February 21, 2008, the facility failed to document that the clients are made aware of their right to inspect their own record in accordance with 28 Pa. Code Subsection 709.30(a)(3)(i-iv). Refer to client records # 1, 2, 3, 4, 5, and 6.
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Plan of Correction
This information was inadvertantly omitted when our forms were entered into the new software program. It will be re-inserted as part of the client rights. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records during the licensing inspection on February 21, 2008, the facility failed to remove a duty to warn statement from the form. The duty to warn statement was not consistent with the federal regulation at 42 CFR Part 2, Subpart E, Subsection 2.63. The form was found in all client records reviewed.
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Plan of Correction
This line has been taken off of the consent to treatment form. |
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 February 21, 2008, the facility failed to complete a psychosocial evaluation in two of six records. Refer to client records # 2 and 4. The psychosocial evaluation in record #1 was incomplete and did not include the composite picture, support systems, the clients' attitude towards treatment, and the counselor's impressions.
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Plan of Correction
The new software went live in November of 2007. However, we have had a number of setbacks since that time; including difficulty with the save function. For that reason, portions of the biopsychosocial were missing.
Additionally, we will have an inservice reviewing the completion of the biopsychosocial and domains covered in the narrative. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records during the licensing inspection of February 21, 2008, the facility failed to include support services on treatment plans in two of two client records. Refer to client records # 1 and 2.
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Plan of Correction
The treatment plan will be amended to include an area to specifically identifying support systems and services. |
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 client records on February 21, 2008, the facility failed to complete follow-up for three of three client records where follow up documentation was due. Refer to client records # 6, 7, and 8.
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Plan of Correction
With the new software system, closings can be monitored and alerts can be set to automatically send out follow-up questionaires. This process is currently being mapped into the system. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the policy manual during the licensing inspection on February 20, 2008, the facility failed to provide a complete follow-up policy. The policy refers to completing follow-up as outlined on the aftercare plan. Aftercare plans are only completed for successful discharges, so the policy fails to address follow-up for those clients who do not receive an aftercare plan.
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Plan of Correction
The current policy will be amended to include all discharges. The policy will reflect the electronic process developed. |