INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 3 through January 4, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clinical Outcomes Group, 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 Fbruary 7, 2011.
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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 and interview with the acting project director, the facility failed to ensure that the staff person appointed to the acting project director position met the appropriate qualifications in one of one records reviewed.
The findings include:
On January 4, 2011, one employee's personnel record was reviewed for qualifications for the position of project director. The facility failed to ensure that employee # 1 met the appropriate educational requirements for the position of project director.
The findings include:
A review of the personnel record for Employee # 1 indicated that the documentation for educational requirements for the position of project director was insufficient. The documentation indicated that employee # 1 has a Bachelor of Science Degree in Liberal Arts; however; there was no identified major to verify that Employee # 1 met the educational requirements for the position of project director.
An interview with the project director conducted on January 4, 2011 confirmed the documentation for employee # 1 ' s personnel record did not contain documentation of the major course of study to verify that the educational requirements for the position of Project Director were met..
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Plan of Correction
Following the 12/03/2010 LIC PA DOH on-site survey, the Project Director was informed that, by regulation, he is required to have on-site for review, copies of his college transcript, college diploma, and updated resume on file. Further, the Project Director was directed to submit said copies as soon as possible for LIC PA DOH review as stipulated by regulation.
The Project Director submitted updated copies of his resume, college transcripts, and college diploma to the Division of Drug and Alcohol Program LIC PA DOH on December 28th, 2010. Delay in submission was required to obtain official copies of college transcripts.
Copies of the Project Director's resume college transcripts, and college diploma are now on file as of 1/15/2011 and available for on-site review as required. In addition, all related educational trainings that the Project Director engages in will be charted and included in his HR files and available for on -site review as required.
Clinical Outcomes Group has received verbal communication from LIC PA DOH stating that the Project Director's educational credentials do not meet the qualifications as outlined in the regulations.
The Project Director met with LIC PA DOH staff, in Harrisburg, on 01/11/2011 to discuss possible solutions to this situation. Following this meeting, the Project Director, on 01/14/2011 sent an email request to LIC PA DOH for additional clarification regarding his qualifications so that a final plan of action can be formulized to bring Clinical Outcomes Group into complete regulatory compliance.
A Board of Directors meeting has been scheduled for February 04, 2011 to fully address this situation. This date was chosen to ensure that there was adequate time to receive the LIC PA DOH written evaluation of the Project Director's qualifications and to make appropriate decisions on a corrective course of action based on said review.
Several courses of action are under consideration at this time, and the appropriate course of action will be taken once the Board of Directors reviews the LIC PA DOH written evaluation of the Project Director's qualifications and the Project Director presents his plan of action to correct this situation and ensure the Clinical Outcomes Group is in complete compliance.
The Board of Directors will agree on the appropriate course of action during the February, 2011 meeting and LIC PA DOH will be informed in writing what that course of action and plan of correction will be no later than February 15, 2011.
To ensure that this does not recur, the human resources staff will review the Drug and Alcohol Staffing Regulations to ensure that all personnel meet the minimal requirements for the position that they are being hired for and those documents will be maintained in the employee's personnel record. In addition, the human resources staff will review all personnel records semiannually to ensure that all required documentation is in the individual employee record.
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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of personnel records and an interview with the facility director, the failed to document an assessment of staff training needs in two of four personnel records reviewed.
The findings include:
On January 4, 2011, four personnel records were reviewed for documentation of an assessment of staff training needs. The facility failed to document document an assessment of staff training needs in two of four personnel records reviewed, specifically, records # 1 and 3.
An interview with the facility director conducted on January 4, 2011 confirmed the facility did not document an assessment of staff training needs in the personnel records # 1 and 3.
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Plan of Correction
The Project Director and Facility Director will complete an individualized training program for each employee within 30 days following the date the Survey was completed (1/04/2011). New training planning and documentation forms will be completed and placed in employee personal files. Training plans will be reviewed by the Facility Director and Project Director 60 days following the date the Survey was completed (1/04/2011) to ensure compliance.
The Facility Director will review each individualized training program quarterly, for the first year following the date of the Survey was completed (1/04/2011) to ensure compliance and to update individualized training programs for each employee. Following this one year of quarterly reviews, the Facility Director will meet annually with each employee to draft and implement annual individualized training programs. These annual individualized employee training programs will be reviewed by the Project Director for approval.
The Facility Director will update policy to include time frames and plans within 30 days following the date the Survey was completed (1/04/2011).
The Facility Director will be responsible to ensure that employee record #3 is updated according to the policies and time frames listed above. The Board of Directors will be responsible to ensure that employee record #1 is updated according to the policies and time frames listed above.
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704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on an interview with the facility director and project director, the facility failed to provide an overall plan for addressing staff training needs.
The findings include:
On January 4, 2011 the Licensing Specialist asked to see a copy of the facility's overall plan for addressing staff development. An overall plan for addressing staff training needs was not presented for review.
An interview with the facility director and project director conducted on January 4, 2011 confirmed that the facility did not have an overall plan for addressing staff training needs.
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Plan of Correction
The Project Director and Facility Director will meet within 60 days following the date of the Survey (1/04/2011) to discuss and complete an overall staff training needs plan. Once completed, the staff training needs plan will be submitted to the Board of Directors for their review and approval.
To ensure that this does not recur, the human resources staff will review the Drug and Alcohol Staffing Regulations to ensure that an overall plan for addressing staff development is in place. The human resources staff, the Project Director and the Facility Director will meet semi-annually to review and update staff training needs. |
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 personnel records, the facility ' s administrative material, and an interview with the facility director, the facility failed to provide an individual training plan for each employee in four of five records reviewed.
The findings include:
On January 4, 2011, five personnel records were reviewed for documentation of individual training plans. The facility did not document an individual training plan in personnel records # 1, 3, 5, and 6.
The facility ' s policy titled: " Staff Development, " sections 1 and 2 states:
" 1. Assessment of staff training needs- This will be done at the end of the fiscal year, to be completed by June 30. Each staff member will complete a training assessment questionnaire. This will include trainings they feel they need, as well as training that were not obtained last year.
2. Plan for addressing these needs- The Clinical Director will develop an individual training plan, based on the questionnaire and supervisory input. The Clinical Director will review the plan with each staff member. The will sign and be given a copy. These plans are to be completed by July 31st. "
Employee # 1 is the project director, employee # 5 is the HR director, and employee # 6 is the office coordinator. The facility began providing services on May 27, 2010. Employees # 1, 5, and 6 have been employed in their positions since the program began providing services. However, personnel records # 1, 5, and 6 did not include documentation of an individual training plan as of January 4, 2011.
Employee# 3 was hired December 1, 2010; however, personnel record # 3 did not include documentation of an individual training plan as of January 4, 2011.
An interview with the facility director on January 4, 2011 confirmed that personnel records # 1, 3, 5, and 6 did not include documentation of an individual training plan.
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Plan of Correction
The Clinical Supervisor will complete an individualized training plan for staff # 3, 5, and 6 within 30 days following the date the Survey was completed (01/04/2011). The Board of Directors will work with the Project Director to complete the Project Director's individualized training plan within 60 days following the date the Survey was completed (01/04/2011). New individualized training assessments will be completed once again for the next fiscal year beginning 07/01/2011. The Clinical Supervisor will complete Individualized training plans for staff # 3, 4, 5, and 6. The Board of Directors will complete the individualized training plan for staff # 1.
To ensure that this does not recur, the human resources staff will review the Drug and Alcohol Staffing Regulations to ensure that all personnel have a completed individualized training plan.
The Facility Director will be responsible to ensure that all new hires have a completed individualized training plan within 30 days of hire.
The Project Director and Facility Director will meet semiannualy to review and update staff individualized training plans. |
704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of personnel records, the facility ' s administrative material, and an interview with the facility director, the facility failed to develop a training plan based upon the employee ' s previous education, experience, current job functions and job performance in four of five records reviewed.
The findings include:
On January 4, 2011, five personnel records were for documentation of individual training plans based upon the employee ' s previous education, experience, current job functions, and job performance. The facility did not document an individual training plan in personnel records # 1, 3, 5, and 6.
The facility ' s policy titled: " Staff Development, " sections 1 and 2 states:
" 1. Assessment of staff training needs- This will be done at the end of the fiscal year, to be completed by June 30. Each staff member will complete a training assessment questionnaire. This will include trainings they feel they need, as well as training that were not obtained last year.
2. Plan for addressing these needs- The Clinical Director will develop an individual training plan, based on the questionnaire and supervisory input. The Clinical Director will review the plan with each staff member. The will sign and be given a copy. These plans are to be completed by July 31st. "
Employee # 1 is the project director, employee # 5 is the HR director, and employee # 6 is the office coordinator. The facility began providing services on May 27, 2010. Employees # 1, 5, and 6 have been employed in their positions since the program began providing services. However, personnel records # 1, 5, and 6 did not include documentation of an individual training plan as of January 4, 2011.
Employee# 3 was hired December 1, 2010; however, personnel record # 3 did not include documentation of an individual training plan as of January 4, 2011.
An interview with the facility director on January 4, 2011 confirmed that personnel records # 1, 3, 5, and 6 did not include documentation of an individual training plan.
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Plan of Correction
The Clinical Supervisor will complete an individualized training plan for staff # 3, 5, and 6 within 30 days following the date the Survey was completed (01/04/2011). The Board of Directors will work with the Project Director to complete the Project Director's individualized training plan within 60 days following the date the Survey was completed (01/04/2011). New individualized training assessments will be completed once again for the next fiscal year beginning July 1, 2011. The Clinical Supervisor will complete Individualized training plans for staff # 3, 4, 5, and 6. The Board of Directors will complete the individualized training plan for staff # 1.
To ensure that this does not recur, the human resources staff will review the Drug and Alcohol Staffing Regulations to ensure that all personnel have a completed individualized training plan based upon the employee's previous education, experience, current job functions and job performance.
The Facility Director will be responsible to ensure that all new hires have a completed individualized training plan based upon the employee's previous education, experience, current job functions and job performance, within 30 days of hire. The Project Director and Facility Director will meet semiannualy to review and update staff individualized training plans. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on observations on January 4, 2011 and an interview with the Facility Director, the facility failed to ensure that the water temperature did not exceed 120 F in two of two bathrooms where temperatures were taken.
The findings include:
A physical plant inspection was conducted on January 4, 2011. On January 4, 2011, at approximately 10:45 A.M., temperatures for sinks in the unisex public restroom on the first floor and unisex staff bathroom on the second floor were taken.
The unisex public restroom on the first floor water temperature was 125 F. Also, the unisex staff bathroom on the second floor water temperature was 160 F.
An interview with the facility director conducted on January 4, 2011 confirmed that the water temperatures for the unisex public restroom on the first floor and the unisex staff bathroom on the second floor, exceeded 120 F.
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Plan of Correction
The Project Director solicited bids to correct and ensure that water temperatures in bathrooms did not exceed 120 degrees. Bids arrived December 23, 2010 and work was scheduled to begin in early January, 2011. Works was completed and inspected by the Office Manager on January 12, 2011. The Office Manager tested all three facility bathrooms and found water temperatures to be equal to or less than the stipulated 120 degrees. The Office Manager will continue to test the bathroom water temperatures quarterly to ensure continued compliance. Work bids and invoices relating to the correction of this situation will be kept on file at the office of record for future review if necessary. |
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 personnel records and an interview with the facility director, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment in three of six personnel records reviewed.
The findings include:
On January 4, 2011, six personnel records were reviewed for fire extinguisher training upon employment. Per regulation, the nonresidential facility shall instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records # 1, 2, and 3.
Employee # 1 is the project director and employee # 2 is the facility director. The facility began providing services on May 27, 2010. Employee # 1 and 2 have been employed in their positions since the program began providing services. Employee # 1 and 2 did not complete fire extinguisher training until December 7, 2010.
Employee # 3 was hired on December 1, 2010. There was no documentation that
employee # 3 completed fire extinguisher training.
An interview with the facility director conducted on January 4, 2011 confirmed that employees # 1, and 2 had not completed fire extinguisher training upon employment. Also, on the same day in an interview with the facility director, the facility director confirmed that employee # 3 had not completed fire extinguisher training.
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Plan of Correction
The Project Director has directed the Office Manager to conduct required fire extinguisher training for all employees, including staff # 1, 2, and 3 as cited, no later than 7 days following the date of the Survey (01/04/2011). All conducted trainings are to be noted in employee files. The HR Director will ensure that, upon hire, all new employees will be provided with appropriate fire extinguisher training at time of hire, and that same training will be noted in the employee files. If training cannot be provided on the date of hire, the HR Director will ensure that training is provided within 7 days from date of hire. Upon completion of training, new employees will sign training documentation stating that they have received fire extinguisher training. Signed documents will be stored in employee files. The HR Director will review all newly hired personnel and training records within 7 days of hire to ensure that trainings have been completed. If the HR Director discovers that training has not taken place, fire extinguisher training will be provided that day. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records and an interview with the facility director, the facility failed to conduct fire drills at least once a month.
The findings include:
Fire drill records were reviewed on January 4, 2011. The records were reviewed from the period covering May 2010 to December 2010. Documentation of unannounced fire drills is required at least once a month. The only unannounced fire drill that was conducted in the past seven months was on December 28, 2010 at 12:20 P.M. The facility did not have documentation for unannounced fire drills in all the other months.
An interview with the facility director conducted on January 4, 2011 confirmed that the facility had only conducted an unannounced fire drill on December 28, 2010.
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Plan of Correction
The Project Director has directed the Office Manager to conduct unannounced, monthly fire drills. In response to this Survey, an unannounced fire drill will be conducted no later than 01/31/2011. Completed fire drills are to be logged in the facility's Fire Drill Log. The Project Director will review the Fire Drill Log prior to the end of each calendar month to ensure compliance. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of fire drill records and an interview with the facility director, the facility failed to conduct fire drills during normal staffing conditions.
The findings include:
Fire drill records were reviewed on January 4, 2011. The records were reviewed from the period covering May 2010 to December 2010. Documentation of fire drills during normal staffing conditions is required. The only fire drill that was conducted in the past seven months was on December 28, 2010 at 12:20 P.M. Because the facility had only documented one fire drill in the past seven months, it was not evident that the facility conducted fire drills during normal staffing conditions.
An interview with the facility director conducted on January 4, 2011 confirmed that in the past seven months the facility had only conducted a fire drill on December 28, 2010
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Plan of Correction
The Project Director has directed the Office Manager to conduct unannounced, monthly fire drill during normal staffing conditions. In response to this Survey, an unannounced fire drill will be conducted during normal staffing conditions no later than 01/31/2011. Completed fire drills are to be logged in the facility's Fire Drill Log. The Project Director will review the Fire Drill Log prior to the end of each calendar month to ensure compliance. |
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 personnel records and an interview with the Facility Director, the facility failed to ensure that all personnel on all shifts are trained upon employment to perform assigned tasks during emergencies in five of six records reviewed.
The findings include:
On January 4, 2011, six personnel records were reviewed to verify that all personnel on all shifts had been trained to perform assigned tasks during emergencies. The facility failed to document the completion of emergency training upon employment in five of six records reviewed, specifically. records # 1, 2, 3, 5, and 6.
Employee # 1 is the project director, employee # 2 is the facility director, employee # 5 is the HR director, and employee # 6 is the office coordinator. The facility began providing services on May 27, 2010. Employees # 2, 5, and 6 have been employed in their positions since the program began providing services. However, employees # 2, 5, and 6 did not complete emergency training until December 7, 2010.
Employee # 3 was hired December 1, 2010; however, personnel record # 3 did not include documentation of emergency training as of January 4, 2011.
An interview with the facility director conducted on January 4, 2011 confirmed that employees # 1, 2, 5, and 6 did not complete emergency training until December 7, 2010. Also, on the same day in an interview with the facility director, the facility director confirmed that personnel record # 3 did not include documentation of emergency training.
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Plan of Correction
The Project Director has directed the Office Manager to conduct required emergency training for all employees, including staff # 1, 2, and 3, 5, and 6 as cited, no later than 7 days following the date of the Survey (01/04/2011). All conducted trainings are to be noted in employee files. The HR Director will ensure that, upon hire, all new employees will be provided with appropriate emergency training at time of hire, and that same training will be noted in the employee files. If training cannot be provided on the date of hire, the HR Director will ensure that training is provided within 7 days from date of hire. Upon completion of training, new employees will sign training documentation stating that they have received emergency training. Signed documents will be stored in employee files. The HR Director will review all newly hired personnel and training records within 7 days of hire to ensure that trainings have been completed. If the HR Director discovers that training has not taken place, emergency training will be provided that day. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records and an interview with the facility director, the facility failed to prepare alternate exits routes to be used during fire drills.
The findings include:
Fire drill records were reviewed on January 4, 2011. The records were reviewed from the period covering May 2010 to December 2010. The only fire drill that was conducted in the past seven months was on December 28, 2010 at 12:20 P.M. Because the facility had only documented one fire drill in the past seven months, it was not evident that the facility had prepared alternate exit routes to be used during fire drills.
An interview with the facility director conducted on January 4, 2011 confirmed that the facility had only conducted one fire drill in the past seven months and did not prepare alternate exit routes to be used during fire drills.
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Plan of Correction
The Project Director has directed the Office Manager to conduct unannounced, monthly fire drills during normal staffing conditions utilizing alternate exit routes. The Office Manager, no later than 30 days from the date of the Survey (01/04/2011) will establish alternate exit routes to be used during fire drills. Alternate routes will be documented and training in their use will be provided to all employees within 60 days from the date of the Survey (01/04/2011). Completed fire drills using alternate exit routes are to be logged in the facility's Fire Drill Log. The Project Director will review the Fire Drill Log prior to the end of each calendar month to ensure compliance. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of fire drill records and an interview with the facility director, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
The findings include:
Fire drill records were reviewed on January 4, 2011. The records were reviewed from the period covering May 2010 to December 2010. The only fire drill that was conducted in the past seven months was on December 28, 2010 at 12:20 P.M. Because the facility had only documented one fire drill in the past seven months, it was not evident that the facility had conducted fire drills on different days of the week, at different times of the day and on different staffing shifts.
An interview with the facility director conducted on January 4, 2011 confirmed that the facility had only conducted one fire drill in the past seven months and did not conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Plan of Correction
The Project Director has directed the Office Manager to conduct unannounced, monthly fire drills during normal staffing conditions, on different days of the week. Completed fire drills are to be logged in the facility's Fire Drill Log. The facility will be in complete compliance within 90 days from the date of the Survey. This time frame will allow for a minimum of 3 unannounced, monthly fire dirlls, during normal staffing conditions, to be conducted on different days of the week. The Project Director will review the Fire Drill Log prior to the end of each calendar month to ensure compliance. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility ' s administrative material, and an interview with the facility director, the facility failed to develop a written procedure by the project director that complies with 4 Pa. Code subsection 255.5 (a) (6).
The findings include:
The facility ' s policy titled: " Confidentiality: Release of Information to Employers, " states:
" Consent to Employer is limited to assessment outcome; treatment recommendations and client follow through with those recommendations. A 5-Point consent will be utilized and the client must voluntarily authorize the release of information. " This policy supersedes what the facility is allowed to release to employers under 4 Pa. Code 255.5 (a) (6). 4Pa. Code subsection 255.5 (a) (6) states " Projects may disclose with the consent of a client, in writing, the information to employers of a client to further the rehabilitation of a client or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Such information shall be limited to whether the client has or is receiving treatment with the project. "
An interview with the facility director on January 4, 2011 confirmed that the facility ' s policy supersedes what the facility is allowed to release to employers under 4 Pa. Code subsection 255.5 (a) (6).
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Plan of Correction
The Project Director has instructed the Clinical Supervisor to make all necessary changes required to ensure that the facility's Policy & Procedure Manual reflects and is consistent with DOH D&A LIC regulations and to ensure that at no time will the facility or staff supersede this policy.
In addition, the Project Director has instructed Clinical Supervisor to develope a new consent form to include verbal and written permission to revoke the consent. The Clinical Supervisor will ensure that all active client charts, that were reviewed, will have new releases to replace old consents.
The facility will no longer be using the old form to ensure that this form does not end up in a client file. The old form will be immediately destroyed to ensure that it is not mistakenly used at a future date.
The Clinical Supervisor will conduct a staff meeting no later than 01/15/2011 to instruct counseling staff about the proper use of verbal consents and introduce the new consent form.
The Clinical Supervisor will review client consent forms on a weekly basis for the next 60 days to ensure compliance. If client consent forms are found to be not in compliance within 60 days, weekly supervision with the counselor will be required to ensure compliance.
The facility will be in complete compliance by March 01, 2011 and the Clinical Supervisor, from that point forward, will conduct quarterly reviews of client consent forms, on a random basis, to ensure continued compliance.
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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 and an interview with the facility director, the facility failed to document a psychosocial evaluation that included an assessment of the client's assets/strengths that can contribute to the resolution of client's problems, support systems, coping mechanisms, negative factors that might affect client's treatment, and/or counselor's conclusion/impressions regarding client's attitude toward treatment in three of three client record reviewed.
The findings include:
On January 4, 2011, three client records were reviewed for psychosocial evaluations. The facility failed to document a psychosocial evaluation that included an assessment of the
client ' s assets/strengths that can contribute to the resolution of client's problems, support systems, coping mechanisms, negative factors that might affect client's treatment, and/or counselor's conclusion/impressions regarding client's attitude toward treatment in client records # 2, 3, and 4.
Client # 2 was admitted on December 21, 2010. The psychosocial evaluation was completed on December 21, 2010, but it did not include an evaluation of the client ' s assets/strengths, support systems, coping mechanisms, and counselor ' s conclusion/impression.
Client # 3 was admitted December 28, 2010. The psychosocial evaluation was completed on December 28, 2010, but it did not include an evaluation of the client ' s problems/needs, support systems, coping mechanisms, negative factors, and counselor conclusions/impressions.
Client # 4 was admitted December 28, 2010. The psychosocial evaluation was completed on December 28, 2010, but it did not include an evaluation of the client ' s problems/needs, support systems, coping mechanisms, negative factors, and counselor conclusions/impressions.
An interview with the facility director on January 4, 2011 confirmed that the psychosocial evaluations did not include an evaluation of the information identified in this report.
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Plan of Correction
The Clinical Supervisor will update the psychosocial evaluation to include the required areas to gather and summarize client information within 30 days following the date of the Survey (01/04/2011). The Clinical Supervisor will direct the therapist of client # 2, 3, and 4 to update the psychosocial evaluation to include the area of assets/strengths, factors that might have a negative impact the client's treatment, identify coping skills and support system no later than 30 days following the date of the Survey (01/04/2011) and said corrections will be reviewed by the Clinical Supervisor.
In addition, the Clinical Supervisor will review counselor conclusions and impressions for each client psychosocial evaluation to ensure compliance, with particular attention paid to the counselor's conclusions and impressions regarding the client's attitude toward treatment.
The Clinical Supervisor will address this issue during weekly supervision of staff and client charts will be reviewed weekly for the next 60 days following the date of the Survey (01/04/2011) to ensure compliance. If compliance is noted, client charts will then be checked monthly by the Clinical Supervisor throughout the year. If client charts are not in compliance, weekly staff supervision will continue and additional training provided and completed. Full compliance will be achieved no later than March 29, 2011. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document a discharge summary in one of one records reviewed.
The findings include:
On January 4, 2011, one client record was reviewed for documentation of a discharge summary. The facility did not document a discharge summary in client record # 1.
The facility ' s policy titled: " Discharge Criteria, " states:
" At the time of discharge the counselor and client will complete an aftercare plan. Included will be recommendations for sustaining recovery. The counselor will complete a discharge summary. This summary will include reasons the client came into treatment, the services provided, the client ' s response to treatment, lastly the client ' s status at the time of discharge. The Discharge summary will be completed within 7 days of the client ' s discharge. "
Client # 1 was admitted on August 24, 2010 and was discharge December 23, 2010. Client # 1's record did not include documentation a discharge summary.
An interview with the facility director on January 4, 2011 confirmed that client # 1 ' s record did not include documentation of a discharge plan.
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Plan of Correction
The therapist will complete the discharge summary immediately following the date of the Survey (01/04/2011). The Clinical Supervisor will review the chart to ensure completion of the discharge summary. The therapist will include the reason client entered treatment, services provided, the client's response to treatment, and the client's status at the time of discharge. The Clinical Supervisor will review client charts weekly for 60 days following the date of the Survey (01/04/2011) to ensure compliance. Full compliance will be achieved no later than March 29, 2011. The Clinical Supervisor will make random checks of client charts quarterly to ensure continued compliance. |