INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2011 through July 14, 2011 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:
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Plan of Correction
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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 a review of the Staffing Requirements Facility Summary Report, a review of CPR and first aid cards and a discussion with the clinical supervisor, the facility failed to provide CPR certification and first aid training to a sufficient number of staff persons.
The findings include:
One full-time counselor and two part-time counselors work at this facility. According to the CPR and first aid cards provided by the facility, only the one full-time counselor has both CPR and first aid certification. One of the part-time counselors has first aid training, but no CPR certification and the other part-time counselor has neither first aid training nor CPR certification.
Based on this documentation, if the full-time counselor would be out sick or on vacation, there would be no CPR certification at this facility.
During a discussion with the clinical supervisor, she confirmed these findings. The clinical supervisor indicated she would make sure other staff become certified to provide more adequate coverage, but stated that, in the interim, if the full-time counselor were out sick or on vacation then the clinical supervisor, who is certified in CPR and first aid, would work out of this office to provide adequate coverage.
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Plan of Correction
The requirements of the need for a valid CPR/First Aid Certification was reviewed with both of the part-time therapists during the week of July 18-22, 2011. Both therapists are signing up for CPR and First Aid at the next available class, Therapist one on September 24, 2011, therapist 2 by the end of September. In the mean time and until all can be trained, the Clinical Supervisor will be notified by the front office staff should the full time therapist be unavailable to come in. The Clinical Supervisor will provide the coverage for that office by working from that office. The Clinical Supervisor will ask that all new hires from this inspection forward are trained in CPR/First Aid prior to seeing their first client. |
709.23(b)(1) 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:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative materials and a discussion with the facility director and the clinical supervisor, the facility failed to formulate project goals and objectives that included time frames for completion and available resources.
The findings include:
Administrative materials were presented for review on July 11, 2011 and July 12, 2011. The goals and objectives presented did not include time frames and available resources.
This was confirmed during a discussion with the facility director and the clinical supervisor.
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Plan of Correction
The Clinical Supervisor and the Project Diretor will create goals and objectives that include time frames and available resourses in time to present to the governing board at the first meeting after summer break on September 14, 2011. The Clinical Supervisor and Project Director will update goals annually to ensure compliance. |
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 a review of administrative materials and a discussion with the facility director and the clinical supervisor, the facility failed to formulate a performance report on the annual goals and objectives.
The findings include:
Administrative materials were presented for review on July 11, 2011 and July 12, 2011. The goals and objectives were presented, but a performance report was not presented for review.
This was confirmed during a discussion with the facility director and the clinical supervisor.
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Plan of Correction
The Clinical Supervisor and Facilities Director will create a performace report on the progress made towards meeting the annual goals and objectes. This progress report will be completed by 31 August 2011 and placed with the existing goals and objectives. The Clinical Supervisor and Facilities Director will complete the performance reviews for the next set of goals and objectives. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records and a discussion with the clinical supervisor, the facility failed to have a system in place to gather a medical history which contains a family medical history and a history if illnesses and symptoms in 5 of 5 client records.
The findings include:
Five client records were reviewed on July 13, 2011. A medical history was documented in all five client records. However, the medical history did not gather a medical history which contains a family medical history and a history if illnesses and symptoms in 5 of 5 client records, #1, 2, 3, 4 and 5.
Client # 1 was admitted on 2/1/11. The medical history documented in client #1's record did not include a family medical history and a history if illnesses and symptoms.
Client # 2 was admitted on 12/1/10. The medical history documented in client #2's record did not include a family medical history and a history if illnesses and symptoms.
Client # 3 was admitted on 3/1/11. The medical history documented in client #3's record did not include a family medical history and a history if illnesses and symptoms.
Client # 4 was admitted on 11/4/10. The medical history documented in client #4's record did not include a family medical history and a history if illnesses and symptoms.
Client # 5 was admitted on 12/9/10. The medical history documented in client #5's record did not include a family medical history and a history if illnesses and symptoms.
During a discussion with the clinical supervisor, she admitted this was a problem with the new electronic record system and noted it would need to be revised to include this information.
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Plan of Correction
The Clinical Supervisor and the Facilities Director will meet with the Computer Information Services Director to update the medical section of the client record. This will include a more detailed medical history and history of illnesses and symptoms. This will also include a family medical history as well. This will be done by the end of August. The Clinical Supervisor and Facilities Director will monitor any changes to the client record to ensure compliance. |
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 and a discussion with the clinical supervisor, the facility failed to document a case consultation in two of two client records.
The findings include:
Five client records were reviewed on July 13, 2011. A case consultation was required two of those five client records, #1 and 2. A case consultation was not documented timely according to the facility's policy and procedures in two of those two client records, #1 and 2.
According to the facility's policy on case consultations, a case consultation is required to be completed every 90 days for each client.
Client # 1 was admitted on 2/1/11. The case consultation was due on or before 5/1/11. The case consultation in client record #1 was not documented until 5/20/11.
Client # 2 was admitted on 12/1/10. The case consultation was due on or before 3/1/11. The case consultation in client record #4 was not documented until 4/18/11.
During a discussion with the clinical supervisor, she confirmed these findings.
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Plan of Correction
The Clinical Supervisor will meet with the York Office clinicians to review the requirements of completion and time tables for the Case Consultation forms. This will be done by the end of August 2011. The Clinical Supervisor will review charts on a monthly basis to ensure compliance with this requirement. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and a discussion with the clinical supervisor, the facility failed to document an aftercare plan in two of two client records.
The findings include:
Five client records were reviewed on July 13, 2011. Three of those client records were discharged clients, but only two required documentation of an aftercare plan. An aftercare plan was required, but not documented in client records #3 and 5.
According to the facility's policy on aftercare plans, an aftercare plan is required for clients who complete successfully and are documented at the last session.
Client # 3 was admitted on 3/1/11 and discharged on 3/22/11. Client #3 was discharged successfully as completing treatment on 3/22/11, but there was no documentation of an aftercare plan as of 7/13/11.
Client # 5 was admitted on 12/9/10 and discharged on 2/22/11. Client #5 was discharged successfully as completing treatment on 2/22/11, but there was no documentation of an aftercare plan as of 7/13/11.
During a discussion with the clinical supervisor, she confirmed these findings.
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Plan of Correction
At the same meeting, by the end of August, the Clinical Supervisor will review the requirements for Aftercare Plans for successful completions. The Clinical Supervisor will review records on a monthly basis to ensure compliance and provide corrective action as needed. |