INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 26, 2007 of Adams Hanover Counseling Services, Inc, 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 and a plan of correction is due on October 26, 2007.
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Plan of Correction
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709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on a review of client records, the facility failed to inform the client of the right to appeal a decision limiting access to his/her records with the project director in three of three records reviewed, #15, 16 and 17.
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Plan of Correction
Clients sign a "Client's Rights Form". Included in the listing of rights on this form is the right of the client to inspect their own record, and that under specific circumstances, a portion of the record may be removed prior to examination.
The project director will add a statement to the client rights form that the client may appeal the decision to withhold a portion of the record.
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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.
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Observations
Based on a review of client records, the facility failed to document a case consultation in one of three records reviewed, #16. A case consultation was documented late according to the project's policy and procedure in one record reviewed, #15.
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Plan of Correction
The clinician is now assigned to a more accessible supervisor.
The supervisor will establish a "tickler" system to ensure that the reviews are timely and documented per policy.
Monitoring will occur by supervisor review of charts. |
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.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of two records reviewed, #19.
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Plan of Correction
Typically an aftercare plan is completed with all clients who are not discharged due to non-compliance.
Through a supervisory meeting, the expectation of this occurring in all appropriate cases will be reinforced with the clinician.
Compliance will be monitored through periodic supervisory review of discharged client records.
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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.
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Observations
Based on a review of client records, the facility failed to document follow up information in two of two records reviewed, #18 and 19.
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Plan of Correction
Through a supervisory meeting the appropriate staff will be instructed to make sure that the procedure for sending out follow-up questionnaires is followed in all cases, including placing a copy in the client file.
The supervisor will monitor this through periodic review of closed charts.
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of administrative documentation, the facility failed to identify a project director who performs the functions of this position and reports directly to the Board.
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Plan of Correction
The Executive Director will be designated as the project director.
The Executive Director reports directly to the board of directors and will assume the duties of project director. |