INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Adams Hanover Counseling Services 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 August 1, 2008.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records on June 30, 2008, the facility failed to document the required 25 hours of training for training year 2006/2007 in one of two personnel records reviewed, specifically personnel record #5.
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Plan of Correction
The Project Director and Clinical Supervisor will review the Training Manual by August 27, 2008. This will ensure that each clinician have a training plan and documented training hours posted. |
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 the fire drill record, the facility failed to conduct fire drills on different staffing shifts from October 2007 through May 2008. All fire drills were conducted between the hours of 8:30 AM and 5:00 PM. The hours of operation are from 8:30 AM to 9:00 PM.
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Plan of Correction
The Clinical Supervisor will ensure that fire drills are conducted on a monthly basis and varied throughout our hours of operation, between 8.30am and 9:pm. This will start in August 2008. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to document a performance report summarizing the progress towards meeting goals and objectives for the fiscal year 2007/2008.
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Plan of Correction
In September, 2008, at the next Board Meeting, the Project Director will present and address progress of our agency's goals and objectives. This will be documented in the minutes of the Board Meeting. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on a review of the facility's record-keeping system, the facility failed to have an efficient system for the retrieval of data in place. The record-keeping system did not reflect the same admission date as documented in the client records. The record- keeping system for discharge dates was inaccurate. The date of discharge was documented as a date that was prior to the client's admission to the facility. The record-keeping system could not distinguish between clients admitted for treatment and individuals who only received an assessment and did not become a client in the facility.
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Plan of Correction
The Clinical Supervisor has met with, on July 9, 2008, and will continue to meet with the agency's computer specialists to come up with a more accurate retrieval system. This will include a program that documents date of initial interview, assigned therapist, date of admission to the program and date of discharge. This system will be tested through out the year to ensure accuracy and compliance by the Clinical Supervisor. |
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 eight client records, the facility failed to document complete psychosocial evaluations in eight of eight records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8. Psychosocial evaluations were historical rather than an assessment of the client's assets and strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, and the counselors' conclusions/impressions regarding the client status.
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Plan of Correction
The Clincical Supervisor has set up a meeting on August 4, 2008 with the clinical staff to review expectations and the necessity of completing the psycho/social assessment in a more interpretive fashion. Compliance will be monitored on a bi-monthly basis through a rendom chart review. Deficiencies still found will be addressed with the clinician to assure compliance. Follow up meetings will also be scheduled as needed. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of 8 client records, the facility failed to clearly document short and long term goals for treatment as formulated by both staff and client in five of eight client records reviewed, #3, 5, 6, 7 and 8. Items documented as action steps were actually short-term goals.
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Plan of Correction
The Clinical Supervisor has scheduled a meeting on Aug 4, 2008 with the clinical staff to review expectations in goal planning. This will include the need to break down our goals into more manageble parts. Ramdom chart reviews and periodic meetings conducted by the Clinical Supervisor will assure that staff is in compliance with the requirement. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of 8 client records, the facility failed to document complete treatment plan updates in eight of eight client records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8. Treatment plan updates did not include the client's progress in relationship to the stated goals of the treatment plan, but rather documented generalized comments that were not specific to each client's progress in treatment.
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Plan of Correction
A meeting of the clinical staff has been set up for Aug 4, 2008 by the Clinical Supervisor to address the need to include an interpretive assessment of clients' progress towards stated goals. These assessments will be goal specific. Compliance will be monitored through random chart reviews and periodic meetings with the clinical staff. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultation notes in six of eight records reviewed, #1, 2, 4, 5, 6 and 8.
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Plan of Correction
The Clinical Supervisor has scheduled a meeting with clinical staff on Aug 4, 2008 to review descrepancies regarding Case Consultations. Case Consultation requirements will be reviewed, to include when they are to be initially completed and when they need to be updated. Random and periodic chart reviews will be done by the Clinical Supervisor to ensure compliance. |
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 8 client records, 2 client records were required to have follow up documentation. The facility failed to document follow-up information in one of two discharge records reviewed, #5.
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Plan of Correction
The Clinical Supervisor will meet with staff to review requirements for follow up documentation for cases being closed. This will be incorporated into the meeting scheduled for Aug 4, 2008. The Clincal Supervisor will do random chart reviews through out the year to address compliance. |