INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 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:
|
Plan of Correction
|
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.
|
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.
|
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.
|
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.
|
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. |
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.
|
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.
|
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)(2) 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:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to ensure that the specific information that would be released was listed on the consent to release information form in one of four client records reviewed.The findings include:Eight client records were reviewed during the licensing inspection on May 22, 2012. Four client records were reviewed for compliance with confidentiality requirements. One client record contained a consent to release information form that did not include the specific information the client agreed to release.Client # 3 was admitted on 1/13/12 and was discharged on 5/17/12. A consent to release information form for a release of information to the court did not include a list of the specific information that would be released.The findings were reviewed with the Credentialing Coordinator on 5/22/12 and were not disputed.
|
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 documentation of specific information disclosed on the client 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.
|
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 four of four client records reviewed.The findings include:Eight client records were reviewed for compliance with the documentation requirements for personal histories on March 22, 2012. Four client records were reviewed for compliance with documentation requirements for personal histories. The personal histories documented in four of four 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 1/3/12 and was 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. Employment history listed the client's current employment status but did not provide for the employment history. Current recreation activities were addressed, but there was no history or mention of the impact of substance abuse on these activities.Client record # 2 - The client was admitted on 2/6/12 and was a current client. There was no documentation of the personal history in the client record as of 5/22/12.Client record # 3 - The client was admitted on 1/13/12 and was discharged on 5/17/12. 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. Employment history listed the client's current employment status but did not provide for the employment history. 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 4/3/12 and was 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.The findings were reviewed with the Credentialing Coordinator on May 24, 2012 and were not disputed.
|
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.
|
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 completed prior to the development of the individualized treatment plan in 2 of 4 client records.The findings include:Four client records were reviewed for compliance with the documentation requirements for psychosocial evaluations on March 22, 2012. Psychosocial evaluations were missing in 1 of four client records and on psychosocial evaluation was not completed until after the development of the individualized treatment plan.Client record # 1- The client was admitted on 1/3/12 and was a current client. The psychosocial evaluation was dated 2/7/12. The individualized treatment plan that was to be based on the psychosocial evaluation was dated 2/3/12. The psychosocial evaluation was not completed until after the development of the individualized treatment plan. The composite picture did not include an assessment or evaluation of the client's attitude toward treatment.Client record # 2 - The client was admitted on 2/6/12 and was a current client. There was no documentation of the psychosocial evaluation in the client record as of 5/22/12.The findings were reviewed with the Credentialing Coordinator on May 24, 2012 and were not disputed.
|
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. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document a case consultation in one of three client records where due.The findings include:Eight client records were reviewed on 5/22/12. Four client records were reviewed for compliance with documentation requirements for case consultations. Three client records were due to include documentation of at least one case consultation. Documentation of a case consultation was missing from one of three client records.Client record # 3 - The client was admitted on 1/13/12 and was discharged on 5/17/12. Documentation of a case consultation was due by 4/13/12. There was no documentation of a case consultation in the client record.This was discussed with the Credentialing Coordinator who did not dispute the findings.
|
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 with all counselors at our next staff meeting on 6/14/2012. The proper completion and the appropriate timing of completion of case consultation notes will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. The Quality Assurance manager will also review these issues during reviews to ensure correct completion. |
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 on a review of client records, the facility failed to document aftercare plans in two of three client records were due.The findings include:Eight client records were reviewed on May 22, 2012. Three client records represented clients who had been discharged with successful completions and were required to include documentation of aftercare plans. Aftercare plans were missing from two of three client records.Client record # 3 - The client was admitted on 1/13/12 and was discharged with a successful completion on 5/17/12. There was no documentation of an aftercare plan as of 5/22/12.Client record # 5 - The client was admitted on 12/8/11 and was discharged with a successful completion on 4/12/12. There was no documentation of an aftercare plan as of 5/22/12.The findings were reviewed with the Credentialing Coordinator on 5/24/12 and were not disputed.
|
Plan of Correction
Our facility will be in full compliance with this standard immediately. This standard and our agency policy relative to this standard will be reviewed with all counselors at our next staff meeting on 6/14/2012. The proper completion and timing of aftercare plans will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. The Quality Assurance manager will also review these issues during reviews to ensure correct completion. |