INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 2, 2008 through December 3, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Harwood House 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 December 31, 2008.
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Plan of Correction
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709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a complete drug/alcohol history in six of six client records reviewed.
The findings include:
Six client records were reviewed on December 3, 2008. The facility did not document the client's lengths and patterns of use in client records #1, 2, 3, 4, 5 and 6.
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Plan of Correction
The current drug and alcohol history section will be revised to make it easier to complete with the needed information. It is the responsibility of the primary counselor to document the clients lengths and patterns of use in the drug and alcohol history. It is the clinical supervisors responsibility to ensure that the counselors appropriately complete the history. The facility director has overall responsibility for ensuring that the standard is maintained.
Time frame for compliance: The new history will be implemented and all clinical staff will be trained in proper documentation by January 20th, 2009. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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, the facility failed to document a complete aftercare plan in two of two client records reviewed.
The findings include:
Six client records were reviewed on December 3, 2008. Aftercare plans were required in two client records. The facility did not document measurable aftercare goals with specific timeframes in client records #4 and 5.
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Plan of Correction
It is the responsibility of the primary counselor to fully complete aftercare plans that document measurable goals with specific time frames. It is the responsibility of the clinicas supervisor to ensure that the counselors adequately complete the aftercare plans.
Time frame for compliance. All clinical staff will be trained on properly completing after care plans by 1/20/2009. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 the facility's policy and procedure manual and client records, the facility failed to document timely follow-up information in one of two client records reviewed.
The findings include:
Six client records were reviewed on December 3, 2008. Follow-up information was required in two client records. According to the facility's policy, follow-up was due to be completed within thirty days following the client's date of discharge. The facility failed to document follow-up information within thirty days in client record #6. Client record #6 had a discharge date of 9/1/08. Follow-up information for client record #6 was due on 10/1/08, but was not documented until 11/1/08.
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Plan of Correction
It is the responsibility of the assigned program worker to document follow-up information in the client records within a 30 day period. It is the responsibility of the clinical supervisor to ensure that the follow up information is documented in the chart within the timeframe.
Time frame for compliance: All staff who complete follow up documentation will be trained in timely and proper documentation by January 20, 2009. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records, the facility failed to document at least thirty hours of annual training for a counselor assistant in one of one personnel record reviewed.
The findings include:
Six personnel records were reviewed on December 2, 2008. At least thirty hours of annual training was required in one personnel record. The facility did not document thirty hours of annual training in personnel record #6. Personnel record #6 had twenty-four hours of training documented for the facility's annual training year.
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Plan of Correction
It is the responsibility of each staff member receive the required number of annual training hours. It is the responsibility of the clinical supervisor to assist staff in receiving trainings during supervisions. It is the responsibility of the director to ensure overall compliance with this standard.
Time frame for compliance: Beginning January, 2009. The clinical supervisor will document training progress, upcoming trainings, training needs during the supervision sessions. |