INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 15, 2010 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 15, 2010.
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Plan of Correction
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility's policies and procedures manual and an interview with the clinical supervisor, the facility failed to prepare and annually update a written manual delineating project policies and procedures.
The findings include:
The facility's policies and procedures manual was reviewed on July 12 and 13, 2010. The manual contained contained conflicting policies and procedures due to outdated policies that were never removed when the new policies were implemented.
The clinical supervisor confirmed that the policies and procedures manual had not been updated.
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Plan of Correction
The Program Director and the CLinical Supervisor will review the current Policy and Procedure manual and remove all outdated materials and ensure that the newest policies are in the manual. The Clinical Supervisor, under the direction of the Project Director, will be responsible for keeping the manual up to date. This will be done over the next 3 months, to be completed no later than the 31st of October 2010. |
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 a review of client records, the facility failed to document support services on the individual treatment plan in three of five client records.
The findings include:
Five client records were reviewed on July 15, 2010. Five client records were required to have individualized treatment plans with documented support services. Support services were not documented on the individual treatment plan in client records #1, 2 and 3.
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Plan of Correction
The Clinical Supervisor is scheduled to meet with staff at the end of August to review the required paperwork and the need to completely fill in a document. The Clinical Supervisor will be reviewing charts monthly via our new electronic medical record to ensure that this requirment is in compliance. Any problems will be documented and addressed with staff. These standards will be reinforced through bi monthly staff meetings. |
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 facility policy and client records, the facility failed to document case consultation notes in three of five client records.
The findings include:
Five client records were reviewed on July 15, 2010. According to the facility's policy and procedure manual, case consultations are due to be completed every 90 days. Five client records were required to have a case consultation.
Client #1 was admitted on 2/8/10. A case consultation was due by 5/8/10, but was not documented until 6/23/10.
Client #2 was admitted on 2/25/10. A case consultation was due by 5/25/10. As of 7/15/10, there was no case consultation documented in client record #2.
Client #3 was admitted on 4/14/10. A case consultation was due by 7/14/10. As of 7/15/10, there was no case consultation documented in client record #3.
Client #4 was admitted on 12/21/09. A case consultation was due by 3/21/10, but was not documented until 4/21/10.
Client #5 was admitted on 10/5/09. A case consultation was due by 1/5/10. As of 3/12/10, the date of the client's discharge, there was no case consultation documented in client record #5.
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Plan of Correction
The Clinical Supervisor has scheduled a meeting the end of August to review paperwork requirements and the date sensitivity of each document. This will be reinforced at supervision/treatment team meetings. The Clinical Supervisor will review this requirment via our electronic medical records to ensure that the Case Consults are being done within the 90 day requirement. Any problems will be documented and addressed at bi monthly staff meetings. |
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 facility policy and client records, the facility failed to document an aftercare plan in one of one client record.
The findings include:
Five client records were reviewed on July 15, 2010. Only one client record was required to have an aftercare plan. According to the facility's policy and procedure manual, the aftercare plan is developed with the client at the last session. An aftercare plan was not documented in client record #4.
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Plan of Correction
The Clinical Supervisor has scheduled a meeting at the end of August to review paperwork requirements and the need to complete an aftercare plan at the last session. This will be reinforced at individual supervision meetings as well. The Clinical Supervisor will also be able to veiw via our Electronic Medical records the compliance requirement with this standard. The Clinical Supervisor will document and address any problems with this requirment on an on going basis. |
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 facility policy and client records, the facility failed to document follow-up in one of one client record.
The findings include:
Five client records were reviewed on July 15, 2010. Only one client record was required to have follow-up. According to the facility's policy and procedure manual, follow-up is completed two months after the client is discharged. Client #4 was discharged on 5/3/10. As of 7/15/10, follow-up was not documented in client record #4.
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Plan of Correction
The Clinical Supervisor has met with the individuals responsible for the 60 day follow up letters in each office, the week of the 19th of July. This requirement was reviewed so that each office knew what was needed and when. The Clinical Supervisor is also able to view the record directly via our Electronic Medical Record to record compliance. If there are problems with this standard, then additional meetings will be set up to address the problems. |