INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Adams Hanover Counseling Services 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 5, 2009.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to hire a counselor who meets the qualification of a counselor per in one of two records.
Findings:
Five personnel records were reviewed on July 6, 2009. Qualification for the counselor positions was required in two personnel records. An counselor with a Bachelor Degree must have at least 1 year of clinical experience in a health or human service agency. Employee #5 did not have the required experience and did not meet the qualification for the counselor position.
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Plan of Correction
The Clinical Supervisor completed a new Personnel Action Form which was signed on 7-13-09. The therapist signed a new job description on 7-24-09. She is aware of the 40 hours of training and the weekly supervision requirements. The Project Director will sign off on the desription by 7-30-09. Both documentations will be placed in the personnel file and may be reviewed at the Hanover office, Human Resourse Department. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of CPR/First Aid cards and interview with Clinical Supervisor, the facility failed to have sufficient number of staff persons who are CPR certified on site during the project's hours of operation.
Findings
Based on the review of CPR/First Aid cards and an interview with the Clinical Supervisor it was determined that the facility was unable to provide CPR coverage. The facility did not have trained designated people who were CPR certified and able to provide coverage during the times that the facility was in operation.
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Plan of Correction
CPR and First Aid is now being mandated for all Drug and Alcohol Therapists. The expectation will be addressed at the staff meeting on 8-6-09 by the Clinical Supervisor. THe training is being offered on 8-13-09 to all drug and alcohol staff. The Clinical Supervisor will monitor attendance. For those who are unable to attend on that day, they will be directed to the American Red Cross for training. The Clinical Supervisor will monitor compliance through quartely review of the Training Manual. |
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, the facility failed to complete psychosocial evaluations in six of six client records.
Findings:
Six client records were reviewed on July 8, 2009. Psychosocial evaluations were required in six client records. The counselors did not document an evaluation that assessed the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment as well as the counselor's conclusion/impressions of the client in client records #1, 2, 3, 4, 5 and 6.
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Plan of Correction
On 8-6-09, at a staff meeting, the Clinical Supervisor will review charting requirements to include all components of the psychosocial. The Clinical Supervisor will hand out an approved example of a valid psychosocial evaluation with the expectation that all components are included. Compliance will consist of weekly chart reviews. If a chart does not meet expectations, that will be communicated to the therapist via a Supervision Documentation form. The chart will be then reviewed at the next weekly chart review session. |
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 the review of client records, the facility failed to document short and long-term goals in four of six client records.
Findings:
Six client records were reviewed on July 8, 2009. Short and long-term goals were required in six client records. The facility only documented short and long-term goals without measurable action steps in client records #2, 3, 4 and 6.
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Plan of Correction
During the 8-6-09 staff meeting, the Clincial Supervisor will address the need for mearureable goals. We will review the requirement that short and long term goals are required with the expectations that goals be measurable. Compliance will be documented through weekly chart reveiw. If problems are noted, a Supervision Documentation form is sent to the clinicial for corrective action. THe chart will be reviewed again at the next weekly review. |
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 the review of client records, the facility failed to document support services in three of six client records reviewed.
Findings:
Six client records were reviewed on July 8, 2009. Support services were required in six client records. Support services were not documented in records #2, 3 and 4.
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Plan of Correction
During the staff meeting on 8-6-09, the Clinical Supervisor will review the requirement that all areas are to be completed in a chart. This will filling in the Support services section on all goal forms. This will be reviewed by the CLinical Supervisor during chart reviews. If a chart is out of compliance, that is documented with a Supervision Documentation form and will be reviewed again at the next chart review. |
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 client records, the facility failed to document complete treatment plan updates three of five client records.
Findings:
Six client records were reviewed on July 8, 2009. Treatment plans updates were required in five client records. In client record #2, the treatment plan update did not include the client's progress in relationship to the stated goals of the treatment plan, but rather stated generalized comments that were not specific to the client's progress in treatment. Also, record #1 and 6 was updated late. Client record #1 identified that the comprehensive treatment plan completed 3/10/09 and updated completed 7/8/09. Client record #6 provided documentation of a comprehensive treatment plan that was completed 1/9/09 and the first update completed 3/17/09; the next update should have been completed by 5/17/09 but it was not completed prior to the patient's 6/5/09 discharge.
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Plan of Correction
On 8-6-09, the Clinical Supervisor will discuss timeline for goal completion. We will also discuss the need for clinicians to review in detail client's progress in treatment relative to the stated goals in more specific terms. The Clinical Supervisor will also review the need for compliance with dates paperwork is due, that late is not acceptable. This will be reinforced through weekly chart reviews and compliance documented on a Supervision Documentattion form. The chart will be reviewed at the next weekly chart review. |
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 complete case consultations notes in two of four client records.
Findings:
Six client records were reviewed on July 8, 2009. Case consultations were required in four client records. In accordance with the facility's policy and procedure, case consultation notes will be documented every 90 days after admission. Client record #2 was admitted on 1/13/09 and as of the date of survey no case consultation completed. Client record #6 was admitted on 12/17/08 and was discharged on 6/5/09; no case consultation was documented in the record.
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Plan of Correction
On 8-6-2009, the Clinical Supervisor will review the neccessity of Case Consultation time lines. we will review the expectation for compliance. This will be monitored through weekly chart reviews with problems being addressed via a Supervision Documentation form. The chart will be reviewed at the next chart review session. |