INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 23, 2006 to August 24. 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 19, 2006.
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Plan of Correction
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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
The facility does not have a statement from the governing body that the project intends to comply with Chapter 704 Staffing Requirements. The facility must provide a statement that verifies the intent of the project to comply with this chapter. This statement must be approved by the governing body and documented via meeting minutes or governing body sign off.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Although the "Annual Inservice" policy and procedure does partially address this standard, it does not appear to include procedures for individual staff training needs assessment and the development of an overall plan. Also, a time frame with regard to the implementation of each step is not clear. The project needs to review all current training policies in relationship to:
1. An assessment of staff training needs.
2. On overall plan for addressing these needs.
3. A mechanism to collect feedback on completing training.
4. An annual evaluation of the overall training plan.
Please refer the the Staffing Regulations 704.11 (a) (1-4) for interpretative guidelines.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(a)(4) LICENSURE Evaluation of Overall 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:
(4) An annual evaluation of the overall training plan.
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Observations
The facility did not have an annual evaluation of the previous year's training plan. This evaluation should determine the extent to which the plan addressed the identified needs, including a determination of the extent to which implementing the plan eliminated or satisfied the identified needs.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
No staff on the D&A staffing requirements facility summary report have had the Department approved 6 hours of HIV/AIDS or the 4 hours TB/STD training. Please refer to Licensing alerts 1-97 and 6-97 for approved curriculums.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
157.21 (b)(1)(ii) LICENSURE Admission - detoxification.
157.21 Admission - detoxification.
(b) Admission procedures shall include documentation of the following:
(1) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The current nursing summary format indicates the substances used but does not clearly identify the length and patterns of use, prior treatment episodes, or the client's perception of use.
Histories should be constructed to collect as much personal information about a patient as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated.
A history documenting the substances most frequently abused, the length and patterns of use, and prior treatment episodes shall be obtained. Include the patient's perception of the effect of substance use/abuse on his/her social, physical and mental state. It is recommended that any substance abuse history within the family, or that of significant others, be noted.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
157.21 (b)(1)(iii) LICENSURE Admission - detoxification.
157.21 Admission - detoxification.
(b) Admission procedures shall include documentation of the following:
(1) Histories, which include the following:
(iii) Personal history.
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Observations
The current nursing summary format includes some family, educational, recreational and employment information but does not include a legal or sexual history. The facility does have a D&A history form that had been used in past years that could be used as a guideline to adding a legal and sexual history, and also to better detail the family, educational, recreational and employment history.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
157.21 (b)(2) LICENSURE Admission - detoxification.
157.21 Admission - detoxification.
(b) Admission procedures shall include documentation of the following:
(2) Consent to treatment.
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Observations
A consent to treatment form was missing in one of two client records reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
157.22 (a) LICENSURE Patient management services.
157.22 Patient management services.
(a) There shall be a written plan that delineates specific service planning and counseling approaches used to promote patient interest in participating in necessary treatment following the detoxification process.
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Observations
The facility did not have a written plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
157.22 (c) LICENSURE Patient management services.
157.22 Patient management services.
(c) The service staff shall develop a written patient follow-up policy.
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Observations
The current follow up policy does indicate patient contact seven days after discharge. The policy does not include a one week referral follow-up.
When a patient has been discharged and referred to an outside resource, the project should, with the written consent of the patient and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented, a project may consider its obligation to the individual fulfilled.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
157.23 (a) LICENSURE Patient records.
157.23 Patient records.
(a) In addition to the requirements contained in 115.32 (relating to contents), the patient's medical record shall contain a drug and alcohol support plan, follow-up information, and an aftercare plan, if applicable.
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Observations
The goals on the support plans reviewed focused primarily on the patient's medical needs. The plan also needs to reflect the project's efforts to support and motivate the patient to seek formal treatment after the detoxification process. This plan should delineate methods the project plans to use to cope with denial, to promote better understanding of chemical dependency and to encourage patient participation in formal treatment.
One of the two charts reviewed did not include a follow-up contact for another treatment facility where the patient was referred for continued services.
Aftercare plans were not applicable as both of the patients were referred to another facility for further treatment.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
157.23 (b) LICENSURE Patient records.
157.22 Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects and coordinating bodies: disclosure of client-oriented information).
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Observations
The "Authorization For Disclosure of Health Information" form has three sections that require correction. They are as follows:
1. The section where the form has a yes and no checklist for Mental Health, Drug and/or Alcohol Abuse/Treatment, and HIV Status needs to be removed. The recipient of a copy of the consent form could assume that the client may have involvement in those areas if the 'no' block is checked.
2. The revocation paragraph includes the statement "I understand that I must revoke it in writing" is incorrect. The patient has to right to revoke their consent verbally or in writing. It is the responsibility of the facility to provide that the client's revocation of a consent to release information is written into the client record.
3. The redisclosure paragraph includes the statement "may no longer be subject to the privacy protections provided to me under the privacy laws", needs to be expanded to include a statement such as " except as indicated by 42 CFR Chapter 1, Part 2 " . It would be advisable to include the following NOTICE TO RECIPIENT OF INFORMATION at the bottom of the authorization form:
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
Secondly, the form titled "Verbal Medical Care Disclosure, is a general consent to release information. This form was found in both patient records reviewed, but was only executed in one of these records. General consents to release information are specifically prohibited at 42 CFR Part 2, Subpart C, Subsection 2.32 and are indirectly prohibited at 42 CFR Part 2, Subpart C, Subsection 2.31 and at 28 Pa. Code Subsection 709.28(c) through (c)(6) and 709.28(d).
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |