INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 26, 2007 of Adams Hanover Counseling Services, Inc 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 October 26, 2007.
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Plan of Correction
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709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on a review of client records, the facility failed to inform clients of the right to appeal a decision limiting access to his/her records to the project director in eight of eight records reviewed. # 7, 8, 9, 10, 11, 12, 13, and 14.
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Plan of Correction
Clients sign a "Client's Rights Form". Included in the listing of rights on this form is the right of the client to inspect their own record, and that under specific circumstances, a portion of the record may be removed prior to examination.
The Project Director will add a statement to the form that the client may appeal the decision to withhold a portion of the record. |
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.
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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 and the reason for the termination in one of one record reviewed, #12.
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Plan of Correction
Typically a letter is sent informing the non-compliant client of the intention to discharge them from treatment.
Through a supervisory meeting, the expectation of this occurring in all cases will be reinforced with the appropriate staff.
Compliance will be monitored through periodic supervisory review of client records. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to notify the client of the opportunity to request reconsideration of a decision to terminating treatment, #12.
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Plan of Correction
Typically a letter is sent informing the non-compliant client of the intention to discharge them from treatment and how to request reconsideration.
Through a supervisory meeting, the expectation of this letter being sent in all cases will be reinforced with the appropriate staff.
Compliance will be monitored through periodic supervisory review of client records.
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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 client records, the facility failed to document follow up information in two of four records reviewed, #12 and 14.
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Plan of Correction
During the licensing review, a completed response to the follow up questionnaire was found in a case that did not have a copy in the record.
Through a supervisory meeting the appropriate staff will be instructed to make sure that the procedure for sending out follow up questionnaires is followed in all cases, including placing a copy in the client file.
Compliance will be monitored by the supervisor through periodic review of closed charts. |
704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of administrative documentation, the facility failed to identify a project director who performs the functions of this position and reports directly to the Board.
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Plan of Correction
The project director is now identified as the Executive Director.
The Executive Director reports directly to the board and will perform the functions of the project director. |