INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 11, 2011 through July 14, 2011 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:
|
Plan of Correction
|
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel records on July 12, 2011 and a discussion with the clinical supervisor, the facility failed to provide documentation of fire extinguisher training in one of two client records reviewed..
The findings include:
Two new counselors were hired since the previous licensing inspection. One of those two new counselors did not have documentation of fire extinguisher training in their personnel record, #5.
Staff #5 was hired on 5/27/11. Fire extinguisher training is required upon employment. As of 7/12/11, there was no documentation of fire extinguisher training in personnel record #5.
This was discussed with the clinical supervisor and she confirmed that there was no documentation of fire extinguisher training in personnel record #5.
|
Plan of Correction
The Clinical Supervisor completed the missing fire extinguisher training of 7/14/2011 to correct this oversite. Documentaion was placed in the personnel file on the same date for review. The Clinical Supervisor and Facilities Director will monitor compliance with any future new hires. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records on July 12, 2011 and a discussion with the clinical supervisor, the facility failed to provide documentation that all staff were trained to perform assigned tasks during emergencies in one of two personnel records reviewed.
The findings include:
Two new counselors were hired since the previous licensing inspection. One of those two new counselors did not have documentation of emergency training in their personnel record, #5.
Staff #5 was hired on 5/27/11. Emergency training is required upon employment. As of 7/12/11, there was no documentation of emergency training in personnel record #5.
This was discussed with the clinical supervisor and she confirmed that there was no documentation of emergency training in personnel record #5.
|
Plan of Correction
Emergency training was provided on July 14, 2011 with this staff person to correct this oversite. Documentation was placed in the staff's personnel file for review. The Clinical Supervisor and Facilities Dirctor will monitor compliance to make sure that new hires are properly trained. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
|
Observations
Based on a review of administrative materials and a discussion with the facility director and the clinical supervisor, the facility failed to formulate project goals and objectives that included time frames for completion and available resources.
The findings include:
Administrative materials were presented for review on July 11, 2011 and July 12, 2011. The goals and objectives presented did not include time frames and available resources.
This was confirmed during a discussion with the facility director and the clinical supervisor.
|
Plan of Correction
The Clinical Supervisor and the Project Director will create goals and objectives that will include time frames and available resources in time to present to the governing board on September 14, 2011, the first meeting following the summer break. The Project Director and Clinical Supervisor will make sure that we are incompliance with the requirements for our goals and objectives. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
|
Observations
Based on a review of administrative materials and a discussion with the facility director and the clinical supervisor, the facility failed to formulate a performance report on the annual goals and objectives.
The findings include:
Administrative materials were presented for review on July 11, 2011 and July 12, 2011. The goals and objectives were presented, but a performance report was not presented for review.
This was confirmed during a discussion with the facility director and the clinical supervisor.
|
Plan of Correction
The Clinical Supervisor and Facilities Director will create a performance report on the progress made towards meeting the annual goals and objectives presented at the licensing visit. The progress report will be completed by the 31 of August 2011. The Facilities Director and Clinical Supervisor will be responsible for the performance reports being completed. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
Based on a review of client records and a discussion with the clinical supervisor, the facility failed to have a system in place to gather a medical history which contains a family medical history and a history if illnesses and symptoms in 5 of 5 client records.
The findings include:
Five client records were reviewed on July 12, 2011. A medical history was documented in all five client records. However, the medical history did not gather a medical history which contains a family medical history and a history if illnesses and symptoms in 5 of 5 client records, #1, 2, 3, 4 and 5.
Client # 1 was admitted on 1/4/11. The medical history documented in client #1's record did not include a family medical history and a history if illnesses and symptoms.
Client # 2 was admitted on 11/3/10. The medical history documented in client #2's record did not include a family medical history and a history if illnesses and symptoms.
Client # 3 was admitted on 10/29/10. The medical history documented in client #3's record did not include a family medical history and a history if illnesses and symptoms.
Client # 4 was admitted on 1/5/11. The medical history documented in client #4's record did not include a family medical history and a history if illnesses and symptoms.
Client # 5 was admitted on 2/8/11. The medical history documented in client #5's record did not include a family medical history and a history if illnesses and symptoms.
During a discussion with the clinical supervisor, she admitted this was a problem with the new electronic record system and noted it would need to be revised to include this information.
|
Plan of Correction
The CLinical Supervisor and Facilities Director will meet with the Computer Information Services Director to update the medical section of the client record. This will include a more detailed medical history as will as a history of illnesses and a list of symptoms. This will also include a much more detailed medical history for the family. This will be done and ready for use by the end of August 2011. The Clinical Supervisor will monitor changes needed for the medical record. |
709.92(a)(3) 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:
(3) Proposed type of support service.
|
Observations
Based on a review of client records and a discussion with the clinical supervisor, the facility failed to document support services on the individual treatment plan in two of four client records reviewed.
The findings include:
Five client records were reviewed on July 12, 2011. Four of those five records were required to have an individual treatment plan with proposed type of support services. The individual treatment plan in client records #3 and 4 did not include documentation of proposed type of support services.
Client #3 was admitted on 10/29/10. The individual treatment plan was dated 11/19/10, but did not include documentation of proposed type of support services.
Client #4 was admitted on 1/5/11. The individual treatment plan was dated 1/24/11, but did not include documentation of proposed type of support services.
During a discussion with the clinical supervisor, these findings were confirmed.
|
Plan of Correction
The Clinical Supervisor will meet with the clinical staff to review the findings that support services and type of service was not always documented. This will take place by the end of August. The Clinical Supervisor will review the treatment plans monthly to ensure that support services and type of service is documented. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of the facility's policy and procedure manual, client records and a discussion with the clinical supervisor, the facility failed to document a treatment plan update in one of three client records. The facility failed to document a treatment plan update that included an update on the client's progress of the treatment plan goals in one of three client records.
The findings include:
Five client records were reviewed on July 12, 2011. Only three of those client records required documentation of a treatment plan update. According to the facility's policy and procedure manual, treatment plan updates are to be documented every 60 days.
Client #2 was admitted on 11/3/10. The treatment plan was completed on 11/3/10. The treatment plan updates dated 1/3/11, 3/3/11 and 6/2/11 did not include documentation of progress the client made or did not make in relation to the treatment plan goals in client record #2. The treatment plan updates in client record #2 merely re-stated the treatment plan goals.
Client #3 was admitted on 10/29/10 and discharged on 2/14/11. The treatment plan was completed on 11/19/10. The treatment plan update was due on or before 1/19/11. There was no treatment plan update documented in client record #3 as of 7/12/11.
During a discussion with the clinical supervisor, these findings were confirmed.
|
Plan of Correction
The Clinical Supervisor will use the same meeting at the end of August to review the requirements that treatment plans are to done every 60 days and must include progress made in treatment of each of the goals made for each review. The Clinical Supervisor will review charts monthly to ensure that progress is clearly documented on treatment plan 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 and a discussion with the clinical supervisor, the facility failed to document a case consultation in two of four client records.
The findings include:
Five client records were reviewed on July 12, 2011. A case consultation was required four of those five client records, #1, 2, 3 and 4. A case consultation was not documented in two of those four client records, #3 and 4.
According to the facility's policy on case consultations, a case consultation is required to be completed every 90 days for each client.
Client # 3 was admitted on 10/29/10 and discharged on 2/14/11. The case consultation was due on or before 1/29/11. As of 7/12/11, no case consultation was documented in client record #3.
Client # 4 was admitted on 1/5/11 and discharged on 3/2/11. The case consultation was due on or before 4/5/11. As of 7/12/11, no case consultation was documented in client record #4.
During a discussion with the clinical supervisor, she confirmed these findings.
|
Plan of Correction
The Clinical Supervisor at the meeting at the end of August will discuss the time requirements for completing Case Consultations every 90 days. The Clinical Supervisor will review charts monthly to review the timeliness of case consultations and to ensure compliance with this standard. |
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.
|
Observations
Based on a review of client records and a discussion with the clinical supervisor, the facility failed to document follow-up in three of three client records.
The findings include:
Five client records were reviewed on July 12, 2011. Three of those five client records were discharged client records that required follow-up. Follow-up was not documented in client records #3, 4 and 5.
According to the facility's follow-up policy, follow-up is to be completed on all clients two months after their discharge date.
Client # 3 was admitted on 10/29/10 and discharged on 2/14/11. As of 7/12/11, there was no documentation of follow-up in client record #3.
Client # 4 was admitted on 1/5/11 and discharged on 3/2/11. As of 7/12/11, there was no documentation of follow-up in client record #4.
Client #5 was admitted on 2/8/11 and discharged on 4/28/11. As of 7/12/11, there was no documentation of follow-up in client record #5.
During a discussion with the clinical supervisor, she confirmed these findings.
|
Plan of Correction
The Clinical Supervisor will meet with the staff member responsible for sending out the follow up letters by the end of August to make sure that this requirement is being completed within 60 days of discharge. The Clinical Supervisor will review charts monthly to ensure compliance witht this standard. |