INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 4, 2011 licensure renewal inspection.
The follow-up inspection was conducted on October 5, 2011 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the onsite follow-up 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
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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.
This was still out of compliance at the time of the follow-up conducted on October 5, 2011.
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Plan of Correction
The Board of Directors met on November 14, 2011 to discuss the plan for the Project Director position. At that time the Project Director position was filled. He will begin as the project director of Clinical Outcomes Group beginning effective January 1, 2012. Beginning immediately the current Project Director will begin working closely with our new Project Director to transition into the Agency. The Project Director submitted his credentials to the licensing board for approval in October 2011. |
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.
This was still out of compliance at the time of the follow-up conducted on October 5, 2011.
At the time of the follow-up inspection on October 5, 2011 employee # 1 did not have an assessment of staff training needs.
At the time of the follow-up inspection on October 5, 2011 the facility documented an assessment of staff training needs for employee # 3
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Plan of Correction
The facility is in the process of appointing a new Project Director. The employee formally known as employee #1 will be assuming another role in the Project. The new Project Director, employee #1, and all other employees will have written individual training plans, based on an employee's skill level, no later than November 25, 2011. The Human Resource Manager and the Facility Director will monitor employee files to ensure that all employee training assessments are complete. Files will be reviewed no later than June 15th of each year to ensure that training assessment files are complete prior to the end of the fiscal year (June 30th). |
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 and the facility's policies and procedures, the facility failed to provide an individual training plan for each employee in accordance with the facility's policies and procedures.
The findings include:
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 training's 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."
On October 5, 2011, four personnel records were reviewed for documentation of individual training plans. The facility did not document an individual training plan in one of four personnel records reviewed, specifically, record #1.
Employee # 1, the project director, began employment with the project as of May 27, 2010. when the facility began providing D&A treatment services. At the time of the follow-up inspection on October 5, 2011 employee # 1 did not have an individual training plan.
This a repeat citation. The facility was previously cited on January 4, 2011 for noncompliance with this standard.
The facility director confirmed the findings.
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Plan of Correction
The facility is in the process of appointing a new Project Director. The employee formally known as employee #1 will be assuming another role in the Project. The new Project Director, employee #1, and all other employees will have written individual training plans, based on an employee's skill level, no later than November 25, 2011. The Human Resource Manager and the Facility Director will monitor employee files to ensure that all employee training assessments are complete. Files will be reviewed no later than June 15th of each year to ensure that training assessment files are complete prior to the end of the fiscal year (June 30th). |
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 and the facility's policies and procedures, the facility failed to develop a training plan based upon the employee's previous education, experience, current job functions and job performance.
The findings include:
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 training's 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."
On October 5, 2011, four personnel records were reviewed 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 one of four personnel records reviewed, specifically, record #1.
Employee # 1, the project director, began employment with the project as of May 27, 2010. when the facility began providing D&A treatment services. At the time of the follow-up inspection on October 5, 2011 employee # 1 did not have an individual training plan based upon the employee's previous education, experience, current job functions, and job performance.
This a repeat citation. The facility was previously cited on January 4, 2011 for noncompliance with this standard.
The facility director confirmed the findings.
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Plan of Correction
The facility is in the process of appointing a new Project Director. The employee formally known as employee #1 will be assuming another role in the Project. The new Project Director, employee #1, and all other employees will have written individual training plans, based on an employee's previous education, experience, current job functions, and job performance, no later than November 25, 2011. The Human Resource Manager and the Facility Director will monitor employee files to ensure that all employee training assessments are complete. Files will be reviewed no later than June 15th of each year to ensure that training assessment files are complete prior to the end of the fiscal year (June 30th). |
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 the facility's fire drill log, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
On October 5, 2011, the facility's fire drill log was reviewed to ensure that the facility was alternating exit routes during fire drills.
The fire drill log was reviewed for the months of January 31, 2011 through September 15, 2011. The facility failed to document alternate exit routes during fire drills.
The clinical supervisor confirmed the findings.
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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. She was also directed that randomly using alternative exits throughout the drills was required. In response to this survey and unannounced fire drill using alternative exits will be conducted during normal staffing conditions no later than November 5, 2011. Completed fire drills are to be logged in the facilities fire drill log. The exit that was utilized will also be documented each month. The Project Director will review the fire drill log prior to the end of each calendar month to ensure compliance. |
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 a review of the facilities policy and procedure manual, the facility failed to document a psychosocial evaluation that was evaluative and followed the facility's policies and procedures.
The findings include:
The facilities policy titled "Assessment" states:
An assessment session is the initial appointment the client has at COGL.
Specific information completed during this session:
1. Determine the reason counseling is being sought and the presenting problems
2. Complete psycho-social history (the Gains assessment)
After the assessment is completed the counselor will complete the following documentation.
1. Master problem list
2. A summary of the assessment, to include a clinical narrative with clinical thoughts and impressions, as well as recommendations for treatment.
On October 5, 2011, seven client records were reviewed for documentation of a psychosocial evaluation.
The facility failed to document a psychosocial evaluation that was evaluative and followed the facility's policies and procedures in seven of seven client records reviewed.
Client # 1 was admitted to the program on 8/18/11.
The psychosocial evaluation was documented on 8/18/11.
However, the facility failed to document an evaluation that included assets/strengths, support systems, coping mechanisms, and the client's negative factors.
In addition, the psychosocial was not evaluative as the document stated "client reports."
Client # 2 was admitted to the program on 8/24/11.
The psychosocial evaluation was documented; however, the facility failed to indicated the date of assessment.
Client # 3 was admitted to the program on 5/17/11.
The psychosocial evaluation was documented on 5/17/11.
However, the facility failed to document an evaluation that included the client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors.
In addition, the psychosocial was not evaluative as the document contained a list and stated "client reports."
Client # 4 was admitted to the program on 8/22/11.
The psychosocial evaluation was documented on 8/22/11.
However, the facility failed to document an evaluation that included assets/strengths, support systems, coping mechanisms, and the client's negative factors.
In addition, the psychosocial evaluation failed to document conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Furthermore, the psychosocial was not evaluative as the document contained a list and stated "client reports."
Client # 5 was admitted to the program on 6/24/11.
The psychosocial evaluation was documented on 6/24/11.
However, the facility failed to document an evaluation that included the client's problems/needs,assets/strengths, coping mechanisms, and negative factors.
In addition, the psychosocial evaluation failed to document conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Furthermore, the psychosocial was not evaluative as the document contained a list and stated "client reports."
Client # 6 was admitted to the program on 6/21/11 and discharged on 9/23/11.
The psychosocial evaluation was documented on 6/21/11.
However, the facility failed to document an evaluation that included assets/strengths, support systems, coping mechanisms, and the client's negative factors.
In addition, the psychosocial evaluation failed to document conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Furthermore, the psychosocial was not evaluative as the document contained a list and stated "client reports."
Client # 7 was admitted to the program on 6/13/11 and discharged on 9/19/11.
The psychosocial evaluation was documented on 6/13/11.
However, the facility failed to document an evaluation that included the client's problems/needs,assets/strengths, coping mechanisms, and negative factors.
In addition, the psychosocial evaluation failed to document conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Furthermore, the psychosocial was not evaluative as the document contained a list and stated "client reports."
The clinical supervisor did not dispute the findings.
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Plan of Correction
The Clinical Supervisor will review with the counselors the facilities policy and procedures manual relating to the psychosocial evaluations within one week of the date of the survey. The Clinical Supervisor will have the counselors of clients 1 through 7 to update the psychosocial evaluations to include an evaluation that includes the client's problems/needs, assets/strengths, support systems, coping mechanisms and negative factors no later than 30 days following the date of the survey (10/05/11) and the corrections will be reviewed with the Clinical Supervisor.
In addition, the Clinical Supervisor will review the counselors' conclusions and impressions for each client psychosocial evaluation to ensure compliance, with particular attention paid to the counselors' summarization of clients' attitude toward and ability to participate in the treatment process. The Clinical Supervisor will address this issue weekly during supervision of staff and will review client charts weekly for the next 60 days following the date of the survey (10/05/11) to ensure compliance. If compliance is noted then the charts will be reviewed by-monthly by the Clinical Supervisor throughout the year. If the client charts are not in compliance, weekly staff supervision will continue address the issue and additional training will be provided. The counselor will need to re-do the psychosocial evaluation areas that are not in compliance with the policy. Full compliance will be achieved no later than January 5, 2012.
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