INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights, 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 June 27, 2009.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure and document that counselors completed at least 25 hours of training for the training year 2007/2008 in one of three records.
Findings:
Five personnel records were reviewed on May 28, 2009. Twenty-five hour of training were required in one personnel records. Regulations require that counselors must completed 25 hours of training annually. This was not documented in personnel record #3 who had 22.5 hours of training for the training year 2007/2008.
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Plan of Correction
The tally of staff training hours and balance of % of external trainings (min 50%) are reviewed quarterly by the Executive Director. Upon hire all employees receive an Individual training Plan. The plan indicates any required or sugguested trainings, and the total number of required hours for the training year. The employee in question (#3-York facility) was hired soon after the end of the training year on October 1st, 2007 (07-08 training year). Upon quarterly review by the Executive Director, if any employee is deficient in total training hours (or) the balance of internal/external training hours,the employee will be notified and a specific plan will be developed and documented to assure compliance. This document will be an attached addendum to their annual individual training plan. |
709.81(b)(6) LICENSURE Intake and admission
709.81. 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 eight client records.
Findings:
Sixteen client records were reviewed on May 28, 2009. Psychosocial evaluations were required in six client records. The counselors did not document an evaluation of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment in client record #1, 2, 3, 4, 6 and 8.
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Plan of Correction
The clinical supervisor will provide training on effective psycho-social evaluation documentation specifically addressing evaluation of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment at staff meeting on 7/30/09. Examples of proper documentation will be provided at the training. Quality assurance will be maintained by having the clinical supervisor review each psychosocial evaluation when the master treatment plan is reviewed. The clinician will submit the psychosocial evaluation for review when the master treatment plan is submitted for approval. Clinicians will be provided with specific feedback of the psychosocial evaluation/composite at that time and complete changes as necessary to meet compliance, with 709.81(b)(6) |
709.83(a)(9) LICENSURE Client records
709.83. 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) Progress notes.
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Observations
Based on the review of client records, the facility failed to document a complete progress note in five of eight client records.
Findings:
Eighteen client records were reviewed on May 28, 2009. Group progress notes were required in five client records. The facility did not have documentation of the therapist assessment and/or data of the client participation in group notes in client records #9, 10, 11, 12 and 14. Also, individual notes repeated the same assessment for notes in records #9, 10, 11, 12 and 14.
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Plan of Correction
The clinical supervisor will provide training on group note documentation with emphasis on providing more evaluative data. This training will occur at staff meeting 7/30/09. Examples of proper documentation will be provided. Quality assurance will be maintained by reviewing group notes with each group counselor at each bi-weekly supervision session with the clinical supervisor. |
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 eight client records.
Findings:
Sixteen client records were reviewed on May 28, 2009. Psychosocial evaluations were required in six client records. The counselors did not document an evaluation of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment in client record #1, 2, 3, 4, 5 and 6.
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Plan of Correction
The clinical supervisor will provide training on effective psycho-social evaluation documentation specifically addressing evaluation of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment at staff meeting on 7/30/09. Examples of proper documentation will be provided at the training. Quality assurance will be maintained by having the clinical supervisor review each psychosocial evaluation when the master treatment plan is reviewed. The clinician will submit the psychosocial evaluation for review when the master treatment plan is submitted for approval. clinicians will be provided with specific feedback of the psychosocial evaluation/composite at that time and complete changes necessary to meet compliance with 709.91(b)(6). |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the review of client records, the facility failed to document a complete progress note in six of eight client records.
Findings:
Eighteen client records were reviewed on May 28, 2009. Group progress notes were required in six client records. The facility did not have documentation of the therapist's assessment and/or data of the client participation in group notes in client records #1, 2, 3, 4, 5 and 6. Also, individual notes repeated the same assessment for each notes in records #1, 2, 3, 4, 5 and 6.
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Plan of Correction
The clinical supervisor will provide training on group note documentation with emphasis on providing more evaluative data. This training will occur at staff meeting on 7/30/09. Examples of proper documentation will be provided. Quality assurance will be maintained by reviewing group notes at each bi-weekly supervision session with the clinical supervisor. |