INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 30, 2012 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff .
The findings include:
One personnel record requiring documentation of HIV/AIDS and TB/STD training was reviewed on July 25, 2012. One client record, specifically record # 4, did not contain the required documentation.
Employee #4, a counselor, was hired on May 27, 2011. Training was due by May 29, 2012. As of the licensing inspection, there was no documentation of HIV/AIDS or TB/STD training for employee #4.
The findings were confirmed with the clinical supervisor during the administrative review on July 26, 2012.
|
Plan of Correction
The Clinical Supervisor received the letter of resignation on employee #4 effective August 17, 2012. The letter is in her personnel file for review.
From this point forward, for any new hires, the Clinical Supervisor will outline the training requirements and the their timeframe within the first week of employment. The Clinical Supervisor, through monthly documented staff meetings, will reivew the progress towards getting the required trainings within the first year. The Clinical Supervisor will monitor the progress on a monthly basis to ensure compliance. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
The findings include:
The record representing one newly hired personnel was reviewed on July 26, 2012 to verify that all personnel on all shifts had been trained to perform assigned tasks during emergencies. The facility failed to document the completion of emergency training in one of one personnel record reviewed, specifically employee #5.
Employee # 5 was hired by the project on October 4, 2011 and became an drug and alcohol counselor on March 1, 2012. As of the date of inspection, there was no documentation to verify that employee #5 received emergency training.
The findings were confirmed during a conversation with clinical supervisor on July 26, 2012.
|
Plan of Correction
The Clinical Supervisor and the Facilities Director met on August 9, 2012 to discuss this requirement. The Clinical Supervisor and the Facilities Director have created a document from our Agency Disaster Plan that outlines individual responsibilities in the event of an emergency. These responsibilities will be presented at the next staff meetings for each site. A signed copy of the responsibilities will be placed in each staff personnel file to review. The Clinical Supervisor will have this done by September 28, 2012.
For Employee #5 - the Clinical Supervisor met with this staff on September 21, 2012 to review the emergency training requirements and to give him a copy of the emergency training form. There will be a signed copy available for review in his personnel file.
For all new hires, prior to the start of emploment, a review of the emergency training form will be done by the Clinical Supervisor. A signed and dated copy will be put in the personnel file for review. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
|
Observations
Based on a review of the facility's administrative documentation, the facility failed to provide verification of a written agreement with a licensed hospital or physician, for 24 hour emergency psychiatric and medical coverage.
The findings include:
The administrative documents were reviewed on July 25, 2012. The facility was unable to provide a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric and medical coverage, as required.
An interview with the facility director confirmed the facility did not secure a current contract for emergency psychiatric or medical coverage.
|
Plan of Correction
The Clinical Supervisor contacted both the Facilities Director and Project Director of this citation. The Project Director has reported that the request for Letters of Agreement for Medical and Psychiatric coverage has been made verbally and that there will be written documentation to that effect by the end of September, September 28, 2012. The Clinical Supervisor will monitor the progress and once we have the Letters of Agreement will make sure that copies are available in the Policy and Procedure Manual. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of one client record.
The findings include:
Two discharged client records were reviewed on July 27, 2012. One of the two client records reviewed represented a client who was involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 3.
Client # 3 was admitted into treatment on November 17, 2011 and was involuntarily terminated from the project on March 22, 2012. There was no documentation of a written notification provided to the client as of the date of inspection. The clinical supervisor confirmed the findings.
|
Plan of Correction
The Clinical Supervisor will document this citation for staff by the 28th of September. The Clinical Supervisor will conduct weekly chart reviews for the first 2 months, then monthly after that, to ensure that letters of discharge are being sent to all clients who are involuntarily terminated.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included an assessment of the client's composite picture, assets and strengths, support systems, coping mechanisms, negative factors that may affect treatment, and/or the client's attitude towards treatment.
The findings include:
Four client records were reviewed for psychosocial evaluations on July 27, 2012. Four out of four client records lacked documentation of a psychosocial evaluation that included a clinical assessment, specifically client records #1, 2, 3, and 4.
Client #1 was admitted to treatment on June 25, 2012. The psychosocial evaluation was completed on May 22, 2012 and did not include the client's composite picture, a clinical assessment of the client's assets and strengths, and negative factors that may affect treatment.
Client #2 was admitted to treatment on May 7, 2012. The psychosocial evaluation was completed on April 30, 2012 and did not include a clinical assessment of the client's assets and strengths, support systems, and negative factors that may affect treatment.
Client #3 was admitted to treatment on November 17, 2011 and discharged on March 22, 2012. The psychosocial evaluation was completed on November 17, 2011 and did not include a clinical assessment of the client's support systems and negative factors that may affect treatment.
Client #4 was admitted to treatment on September 28, 2011 and discharged on March 22, 2012. The psychosocial evaluation was completed on September 28, 2011 and did not include a clinical assessment of the client's support systems and negative factors that may affect treatment.
The findings were reviewed with the clinical supervisor.
|
Plan of Correction
The Clinical Supervisor will document the finding to staff during the next staff meeting on September 21, 2012. The Clinical Supervisor will do weekly case reviews starting in September 28, 2012 to verify compliance with staff. The documentation will be available for review. The Clinical Supervisor will also meet with the EMR (Electronic Medical Records) supervisor to review the assessment form to make changes that will prompt staff to provide the required information. This is to be completed by 10/15/2012. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document treatment plans to include the type and frequency of treatment and rehabilitation services in two out of four client records.
The findings include:
Four client records were reviewed for treatment plans on July 27, 2012. Two out of four client records lacked documentation of a treatment plan that included the type and frequency of treatment and rehabilitation services, specifically client records # 3 and 4.
Client #3 was admitted to treatment on November 17, 2011 and discharged on March 22, 2012. The treatment plan was completed on November 22, 2011 and did not include the type and frequency of treatment and rehabilitation services.
Client #4 was admitted to treatment on September 28, 2011 and discharged on March 22, 2012. The treatment plan was completed on October 13, 2011 and did not include the type and frequency of treatment and rehabilitation services.
The findings were reviewed and confirmed with the clinical supervisor on July 27, 2012.
|
Plan of Correction
The Clinical Supervisor will document the finding to staff during the next staff meeting on September 21, 2012. The Clinical Supervisor will start with weekly chart reviews starting 09/28/2012 to ensure that staff are addressing the type and frequency of treatment in the treatment plan. Begining 10/28/2012, the Clinical Supervisor will start with monthly reviews of this citation to verify compliance with staff. The documentation will be available for review. |
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.
|
Observations
Based upon a review of the facility's policies and procedures and client records, the facility failed to document aftercare plans as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from July 25-26, 2012.
The policy which specified the timeframe for the completion of aftercare plans included the following language:
Aftercare plans are to be completed upon successful discharge during the last scheduled outpatient session.
Two discharged client records were reviewed on July 27, 2012. One of the two client records reviewed represented a client who was successfully discharged from treatment at the project. The facility failed to document and aftercare plan for client #4.
Client #4 was admitted to treatment on September 28, 2011, the client ' s last session and discharge date was March 22, 2012. As of the date of inspection, there was no documentation of an aftercare plan for client #4.
The findings were reviewed and confirmed with the clinical supervisor on July 27, 2012.
|
Plan of Correction
The Clinical Supervisor will review this finding with staff on September 21, 2012 at the staff meeting. Starting 09/28/2012, The Clinical Supervisor will conduct weekly chart reviews and Discharge Summary reviews to ensure that aftercare plans are being completed. If all are in compliance within the month, the Clinical Supervisor will review this requirement on a monthly basis starting 10/28/2012. |