INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 21 and 22, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clear Concepts Counseling 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:
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on the review of the Project's organization charts, organization narratives and observations during the inspection, the person acting in the capacity of Project Director failed to meet the educational requirements for the position.The findings include:The credentialing coordinator was performing the duties of the project director in consultation with the Clinical Supervisor and the Bookkeeper who were the other two members of the Advisory Board. The individual identified as the Project Director is a counselor who at times will act in the capacity of lead counselor but was clearly not the Project Director..The person performing the duties of Project Director does not have the minimum education requirements for the position.The findings were reviewed with the Credentialing Coordinator on May 22, 2012 and she did not dispute the findings.
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Plan of Correction
The person acting and has been elected to work in the capacity of Project Director has taken steps in order to meet the educational requirements for the position. The elected person has enrolled in an academic program at Central Penn College which will result in an Associate's Degree in Entrepreneurship and Small Business. The Board of Directors has discussed and agreed to sub contract with Lentha Barron (previous owner & project director) to perform the duties of the Project Director and assist/mentor the Director of Administration until she has obtained the necessary degree to be in compliance with the standard. |
704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" submitted for the three facilities in the project and a review of current caseload assignments, including the cases the Clinical Supervisor has assigned to herself, the Project failed to provide for a full time clinical supervisor even though the Project has 11 Full Time Equivalent (FTE) counselors and/or counselor assistants.The findings include:The "Staffing Requirements Facility Summary Reports" for the three facilities that make up the Project were reviewed and revealed that there are 11 FTE counselors working for the Project. The individual identified as the full time Clinical Supervisor was carrying a caseload of 7 clients at the time of the inspection and was not acting as a full time clinical supervisor.The findings were reviewed with the Credentialing Coordinator on May 24, 2012 and were not disputed.
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Plan of Correction
Our project is in full compliance with this standard as of today 6/8/2012. We mistakenly identified our full time clinical supervisor as also being the facility director on the "Staffing Requirements Facility Summary Report." This mistake was discovered during the on-site licensure renewal inspection. The current full time clinical supervisor's caseload exceeds the limitation due to losing three full time counselors' in a 4 week period. In order to have no delay in treatment for those clients the clinical supervisor took them on her caseload. In the future we will correctly identify these positions on the report. |
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 and personnel training records, the project failed to ensure that all counselors received at least 25 hours of training per year for one of four counselors reviewed.The findings include:Personnel and personnel training records were reviewed on May 21, 2012. The training records for employee # 1 revealed that only 12.5 hours of training had been obtained for the previous training year identified as July 1, 2010 through to June 30, 2011.Employee # 1 was hired on 11/1/93 and was initially identified as the Project Director. A review of records revealed that he is a full time counselor who works at both the Lewistown and Bellefonte facilities and that he sometimes acts in the capacity of Lead Counselor. As a full time counselor, employee # 1 was required to obtain 25 hours of training for the period July 1, 2010 through to June 30, 2011. Records reveal that he obtained 12.5 hours of training for that time period.The findings were reviewed with the Credentialing Coordinator on May 24, 2012 and she did not dispute the findings.
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Plan of Correction
Our project will be in full compliance with this standard by 6/30/2012, which is the end of our current training year. By that date all employees will have received 25 training hours as is required by the standard. Due to a misunderstanding, this employee failed to follow through with the required training. This employee will seek out and attend trainings throughout the year which will address the areas set forth by the standard. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill logs, the facility failed to demonstrate that a smoke detector or fire alarm was set off for each fire drill in seven of 12 monthly drills reviewed.The findings include:The monthly fire drill logs were reviewed for the period from May 2011 through to April 2012. Seven of the twelve log entries clearly stated that a fire alarm or smoke detector had not been set off to initiate the drill.The findings were reviewed with the Credentialing Coordinator on May 24, 2012 and were not disputed.
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Plan of Correction
Our project is in full compliance with this standard as of today 6/8/2012. During the 6/14/2012 staff meeting, this standard will be reviewed with all staff members. The smoke detector will be set off during all fire drills. On 5/25/2012 a fire drill was conducted and the smoke detector was set off and documented. Additionally, a reminder sheet regarding the necessary parts to a fire drill has been posted along with the fire drill log to help with future fire drills. |
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on the review of the Project's organization charts, organization narratives and observations during the inspection, the Project failed to identify the staff person who actually performs the duties of the Project Director.The findings include:The corporate structure of this facility consists of the members of the corporation, the Board of Directors and an Advisory Board of Directors. In this project, the Advisory Board of Directors act as the governing body of the corporation, with full authority to make decisions and direct the operation of the Project. The members of the Advisory Board of Directors consists of the Clinical supervisor (a corporate share holder), the credentialing coordinator (a corporate share holder) and the bookkeeper (a corporate share holder). The credentialing coordinator was performing the duties of the project director in consultation with the Clinical Supervisor and the Bookkeeper. The individual identified as the Project Director is a counselor who at times will act in the capacity of lead counselor.The person identified as the Project Director does not report directly to the Advisory Board of Directors and does not have the authority to act on behalf of the corporation. The credentialing coordinator has that authority.The findings were reviewed with the Credentialing Coordinator on May 22, 2012 and she did not dispute the findings.
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Plan of Correction
The person acting and has been elected to work in the capacity of Project Director has taken steps in order to meet the educational requirements for the position. The elected person has enrolled in an academic program at Central Penn College which will result in an Associate's Degree in Entrepreneurship and Small Business. The Board of Directors has discussed and agreed to sub contract with Lentha Barron (previous owner & project director) to perform the duties of the Project Director and assist/mentor the Director of Administration until she has obtained the necessary degree to be in compliance with the standard. |
709.28(c)(3) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to include the purpose of the disclosure on consent to release information forms documented in 3 of 10 client records reviewed.The findings included:Sixteen client records were reviewed from May 21, 2012 through to May 22, 2012. Ten client records were reviewed for compliance with confidentiality regulations. Consents to release client identifying information documented in client records # 1, 2 and 4 did not include the purpose for the release of information.Client # 1 was admitted on 2/14/11 and was discharged on 2/3/12. Consent to release information forms in the client record did not include the purpose for the release of information, but listed the type of information that would be released in place of the purpose for the release.Client # 2 was admitted on 11/8/11 and was discharged on 4/10/12. Consent to release information forms in the client record did not include the purpose for the release of information, but listed the type of information that would be released in place of the purpose for the release.Client # 4 was admitted on 9/16/11 and was discharged on 4/19/12. Consent to release information forms in the client record did not include the purpose for the release of information, but listed the type of information that would be released in place of the purpose for the release.The findings were reviewed with the Credentialing Coordinator on 5/24/12 and she did not dispute the findings.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy will be reviewed at our 6/14/2012 staff meeting. The proper completion of consents and purpose of disclosure of client information will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision. The Quality Assurance manager will also verify completion during reviews. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records and the project's written procedures for the management of treatment services, the facility failed to ensure that documentation of the clients' personal histories included family history and/or legal history and or employment history and/or recreational history in six of ten client records reviewed.The findings include:Ten client records were reviewed for compliance with the documentation requirements for personal histories on March 21 and 22, 2012. The personal histories documented in six of ten client records were missing some or all of the family history, legal history, employment history and/or recreational history.Client record # 1- The client was admitted on 2/14/11 and was discharged on 2/3/12. The documentation on family history was a list of family members, but did not include any information on interrelationships and did not include the impact of substance abuse on those interrelationships.Client record # 2 - The client was admitted on 11/8/11 and was discharged on 4/10/12. The documentation on family history was a list of family members, but did not include any information on interrelationships and did not include the impact of substance abuse on those interrelationships. Current recreation activities were addressed, but there was no history or mention of the impact of substance abuse on these activities.Client record # 4 - The client was admitted on 9/6//11 and was discharged on 4/19/12. The documentation on family history was a list of family members, but did not include any information on interrelationships and did not include the impact of substance abuse on those interrelationships. Current recreation activities were addressed, but there was no history or mention of the impact of substance abuse on these activities. Only current employment was listed. There was no documentation of the client's employment history. Client record # 12 - The client was admitted on 2/27/12 and is a current client. Current recreation activities were addressed, but there was no history or mention of the impact of substance abuse on these activities. Client record # 13 - The client was admitted on 2/7/12 and is a current client. The documentation on family history was a list of family members, but did not include any information on interrelationships and did not include the impact of substance abuse on those interrelationships. Current recreation activities were addressed, but there was no history or mention of the impact of substance abuse on these activities. Only current employment was listed. There was no documentation of the client's employment history.Client record # 14 - The client was admitted on 1/26/12 and is a current client. The documentation on family history was a list of family members, but did not include any information on interrelationships and did not include the impact of substance abuse on those interrelationships. Current recreation activities were addressed, but there was no history or mention of the impact of substance abuse on these activities. There was no documentation of the employment history.The findings were reviewed with the Credentialing Coordinator on May 24, 2012 and were not disputed.
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Plan of Correction
Our facility will be in full compliance with this standard by 6/14/2012. We will be reviewing this standard and our related agency policy with all staff at our next staff meeting on 6/14/2012. The proper documentation of clients' personal histories including family, legal, employment and recreation histories will be reviewed and explained. The Clinical Supervisor will also review this area with all counselors in individual supervision as an added measure to insure compliance. The Quality Assurance manager will also verify completion during reviews. |
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 and the project's written procedures for the management of treatment services, the facility failed to ensure that documentation of the clients' psychosocial evaluations were either documented at all or were evaluative in 5 of ten client records.The findings include:Ten client records were reviewed for compliance with the documentation requirements for psychosocial evaluations on March 21 and 22, 2012. Psychosocial evaluations were missing in 2 of ten client records and were not evaluative in 3 of ten client records.Client record # 2 - The client was admitted on 11/8/11 and was discharged on 4/10/12. The psychosocial evaluation was not dated. There was no documentation of a composite picture of the client or the client's attitude toward treatment. There was no documentation of evaluations or assessments of the client's problems/needs, assets/strengths, support systems, coping mechanisms or negative factors.Client record # 4 - The client was admitted on 9/6//11 and was discharged on 4/19/12. The psychosocial evaluation was not dated. There was no evaluation or assessment of the client's problems and needs, negative factors and attitude toward treatment. The client's support system and coping mechanisms were not addressed or evaluated. The counselor did not provide his/her conclusions and/or impressions. Client record # 13 - The client was admitted on 2/7/12 and is a current client. The psychosocial evaluation was not dated. The document did not include a composite picture of the client and failed to provide for an evaluation or assessment of the client's support system, coping mechanisms, negative factors and the counselor's conclusions and impressions.Client record # 14 - The client was admitted on 1/26/12 and is a current client. The was no documentation of a psychosocial evaluation as of May 22, 2012.Client record # 16 - The client was admitted on 11/7/11 and is a current client. The was no documentation of a psychosocial evaluation as of May 22, 2012.The findings were reviewed with the Credentialing Coordinator on May 24, 2012 and were not disputed.
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Plan of Correction
Our facility will be in full compliance with this standard by 6/14/2012. We will be reviewing this standard and our related agency policy with all staff at our next staff meeting on 6/14/2012. The proper documentation of clients' psychosocial evaluations will be reviewed and explained. The Clinical Supervisor will also review this area with all counselors in individual supervision as an added measure to insure compliance. The Quality Assurance manager will also verify completion during reviews. |
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.
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Observations
Based on a review of client records, the facility failed to ensure that individualized treatment plans documented in client records included documentation of the type and frequency of treatment (methodology) that would be provided to the client in 5 of ten client records.The findings include:Client record # 2 - The client was admitted on 11/8/11 and was discharged on 4/10/12. The type and frequency of treatment that was to be provided to the client was not documented on the treatment plan.Client record # 4 - The client was admitted on 9/6//11 and was discharged on 4/19/12. The treatment plan included documentation that the client would be provided with IOP (Intensive Outpatient Treatment) but failed to identify the type and frequency of that treatment.Client record # 11 - The client was admitted on 2/27/12 and is a current client. The treatment plan included documentation that the client would be provided with IOP (Intensive Outpatient Treatment) but failed to identify the type and frequency of that treatment.Client record # 14 - The client was admitted on 1/26/12 and is a current client. The treatment plan included documentation that the client would be provided with IOP (Intensive Outpatient Treatment) but failed to identify the type and frequency of that treatment.Client record # 16 - The client was admitted on 11/7/11 and is a current client. The treatment plan included documentation that the client would be provided with IOP (Intensive Outpatient Treatment) but failed to identify the type and frequency of that treatment.The findings were discussed with the Credentialing Coordinator on May 24, 2012 and were not disputed.
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Plan of Correction
Our facility will be in full compliance with this standard by 6/14/2012. This standard and our agency policy relative to this standard will be reviewed at our next staff meeting on 6/14/2012. The proper documentation of frequency of treatment in the client records will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision. The Quality Assurance manager will also review these issues during reviews to ensure correct completion. |