INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 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:
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on a supervisor review of the Staffing Requirements Facility Summary Report form completed by the facility on 7/12/11, the facility failed to present to the Department licensing representatives at the time of the project's site visit, a plan documenting the qualifications and training of staff.
The findings include:
The Staffing Requirements Facility Summary Report (SRFSR) completed by the facility on July 12, 2011 and presented to the Licensing Specialist on July 12, 2011 failed to document that the facility staff met the educational and training requirements of chapter 704.
Per the information provided by the facility on the SRFSR, the Project Director (hired into the position 11/1/07), Facility Director (hired into the position 6/18/01), Clinical Supervisor (hired into the position 5/16/94) and one counselor, employee #4 (hired into the position 1/19/2004), all only completed 4 hours of the mandatory 6 hours HIV/AIDS training.
In addition the facility documented that the the CIS person (hired into the position 10/2/89), the R.N. (hired into the position 9/22/99) and the Psychiatrist (hired into the position 4/13/05) never completed any of the required six hours of training.
Pert the SRFSR form completed by the facility on July 12, 2011, the the CIS person (hired into the position 10/2/89) and the R. N. (hired into the position 9/22/99) never completed any of the required four hours of TB/STD and other health related topics training.
The facility failed to list the dates when the individual training plans were developed for each of the eight employees.
The facility listed the entire training year as the date that the individual training plans were developed for the Project Director, Facility Director, Clinical Supervisor and three Counselors.
The facility simply wrote "Oct - 10" for the date that the training plans were developed for the CIS staff person, R.N. and the psychiatrist
The facility failed to document the name of the university from which the Clinical Supervisor and Counselor earned there degrees on page 3 of the SRFSR form.
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Plan of Correction
The deficiencies related to the Staffing Requirements Facility Summary Report and HIV/STD/TB training was incorrect. The correct information is listed below for HIV/STD/TB training.
PROJECT DIRCTOR - 6 hrs HIV on 8/18/2009
FACILITY DIRECTOR-6 hrs HIV on 4/15/02
CLINICAL SUPERVISOR-6 hrs HIV on 2/22/05
THERAPIST-6 hrs HIV on 2/22/05
PSYCHIATRIST-will be scheduled within the next 2 months by 30 Nov.
PROJECT DIRECTOR-4 HR STD/TB ON 8/18/09
FACILITY DIRECTOR-4 hrs STD/TB on 4/15/02
CINICAL SUPERVISOR-4 HRS STD/TB ON 2/22/05
THERAPIST-4 HRS ON 2/22/05
PSYCHIATRIST will be scheduled within the next 2 months by 30 Nov
Training plans will be developed with staff through out the month of September by the Clinical Supervisor and completed by 10/1/2011. Each training plan will include the dates completed and signed by each individual.
The SRFSR, was updatd on 8/8/2011, to reflect the names of the universities and colleges staff attended. This was completed by the Clinical Supervisor.
The Clinical Supervisor updated the SRFSR to reflect the correct information about HIV/STD/TB training, the correct number of hours attended, and and will refer to this for our next licensing visit to ensure that this error is not repeated. The Clinical Supervisor will check with the actual certificate to make sure the dates and hours are correct. The Facilities Director will double check the information.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a supervisor review of the Staffing Requirements Facility Summary Report form completed by the facility on 7/12/11, the facility failed to ensure that staff received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted disease and other health related topics training using a Department approved curriculum within the time frames as outlined in the regulation.
The findings include:
Per the Staffing Requirements Facility Summary Report (SRFSR) completed by the facility on July 12, 2011 and presented to the Licensing Specialist on July 12, 2011, the Project Director (hired into the position 11/1/07), Facility Director (hired into the position 6/18/01), Clinical Supervisor (hired into the position 5/16/94) all only completed 4 hours of the mandatory 6 hours HIV/AIDS training.
In addition the facility documented that the CIS person (hired into the position 10/2/89), the R. N. (hired into the position 9/22/99) and the Psychiatrist (hired into the position 4/13/05) never completed any of the required six hours of training and employee #4 only completed 4 of the 6 required hours of training.
Pert the SRFSR form completed by the facility on July 12, 2011, the CIS person (hired into the position 10/2/89) and the R. N. (hired into the position 9/22/99) never completed any of the required four hours of TB/STD and other health related topics training.
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Plan of Correction
The Project Director had 6 hours of HIV training and 4 hours of STD/TB training on 8/18/09
The Facility Director had 6 hours of HIV training on 4/15/02 and 4 hours of STD/TB training on 4/15/02.
The Clinical Supervisor had 6 hours of HIV training on 2/22/05 and 4 hours of STD/TB training on 2/22/05.
This was incorrect on the SRFSR.
The CIS and RN are not part of the D&A Project and were listed incorrectly on the form and listed only given their specialties. The RN and CIS staff do not interact with D&A clients and they are not utilized to provide CPR and/or First Aid coverage. The Psychiatrist will be trained in the HIV/STD/TB required training by the end of November.
The SRFSR was updated for our records (only) to reflect the correct information by the Clinical Supervisor. For future licensing visits, the Facility Director and Clinical Supervisor will review the SRFSR one week prior to the licensing visit and will refer to the corrected information to ensure that this deficiency does not recurr. The Facility Director will review all future SRFSRs to ensure compliance.
For any new employees, this training has been added to the list of required trainings to make sure that all staff have received this training within the required first year of employment. The Clinical Supervisor will review progress towards this standard on a quarterly basis for all new hires. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, a review of CPR and first aid cards and a discussion with the clinical supervisor, the facility failed to provide CPR certification and first aid training to a sufficient number of staff persons.
The findings include:
Three part-time counselors work at this facility. According to the CPR and first aid cards provided by the facility, only one part-time counselor has both CPR and first aid certification. One of the part-time counselors has first aid training, but no CPR certification and the other part-time counselor has neither first aid training nor CPR certification.
Based on this documentation, if the part-time counselor who is certified in both CPR and first aid would be out sick or on vacation, there would be no CPR certification at this facility.
During a discussion with the clinical supervisor, she confirmed these findings. The clinical supervisor indicated she would make sure other staff become certified to provide more adequate coverage, but stated that, in the interim, if the part-time counselor certified in both CPR and first aid were out sick or on vacation then the clinical supervisor, who is certified in CPR and first aid, would work out of this office to provide adequate coverage.
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Plan of Correction
This office now has 2 part time therapists. The one that was missing the CPR and First Aid received her training on September 9. The other therapist had all her trainings at the time of the inspection. The Clinical Supervisor will review the training manual on a quarterly basis to make sure that all keep CPR up to date. Both now have had, at least once, First Aid. |
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.
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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.
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Plan of Correction
The Clinical Supervisor and the Project Director will create goals and objectives that include time frames and available resources in time to present to the governing board at the first meeting after summer break on September 14, 2011. The Clinical Supervisor and the Project Director will update goals annually to ensure compliance. |
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.
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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.
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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, This progress report will be competed by 8/31/2011 and placed with the existing goals and objectives. The Clinical Supervisor and Facilities Director will compete the performance reviews for the next set of goals and objectives. |
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.
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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 4 of 4 client records.
The findings include:
Seven client records were reviewed on July 13, 2011. Four client records were reviewed for the medical history. A medical history was documented in all four client records, # 1, 2, 3 and 4. However, the medical history did not gather a medical history which contains a family medical history and a history of illnesses and symptoms in 4 of 4 client records, #1, 2, 3 and 4.
Client # 1 was admitted on 1/20/11. 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 10/25/10. 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 2/17/11. 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 1/4/11. The medical history documented in client #4'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.
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Plan of Correction
The Clinical Supervisor and the Facilities Director undated the actual electronic medical record on August 22, 2011 in response to the licensing visit. The medical history section of the record was expanded and now includes a more detailed history of illnesses and symptoms and a section to document a family medical history. It was put in use on August 22, 2011. The Facilities Director is monitoring the electronic medical record and any potential changes to the actual format and the Clinical Supervisor is reviewing charting content on a bi weekly basis to make sure that staff are in compliance with the changes.
Records #1, #2, #3 and #4 were reviewed. All four records are closed and these clients are no longer in services with Adams Hanover Counseling Services. If any return to treatment, a new assessment will be completed on the updated form and a more detailed individual and family medical history will be captured. If any medical information comes into the agency regarding the 4 clients listed above, the information will be scanned into the record and made a permanent part of the record.
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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.
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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 within the required time frame in two of three client records.
The findings include:
Five client records were reviewed on July 13, 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. The treatment plan update was documented late, as per facility policy, in one of those three client records, #2. The treatment plan update was not documented in one of those three client records, #4.
Client #2 was admitted on 10/25/10. The treatment plan was completed on 10/25/10. The first treatment plan update was due on or before 12/25/10. The first treatment plan update was not documented until 1/24/11. The second treatment plan update was due to be documented 60 days after 1/24/11, which would be 3/24/11. The second treatment plan update was not documented until 4/4/11. The third treatment plan update was due to be documented 60 days after 4/4/11, which would be 6/4/11. The third treatment plan update was not documented until 6/16/11.
Client #4 was admitted on 1/4/11 and discharged on 4/12/11. The treatment plan was completed on 1/10/11. The first treatment plan update was due on or before 3/10/11. As of 7/1/311, there was no treatment plan update documented in client record #4.
During a discussion with the clinical supervisor, these findings were confirmed.
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Plan of Correction
The Clinical Supervisor will meet with the clinical staff to review the findings that treatment plan updates are due within 60 days of the initial treatment plan and 60 days thereafter. The Clinical Supervisor will review treatment plans monthly to ensure that the treatment plan updates are done in the required time frames. |
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 and a discussion with the clinical supervisor, the facility failed to document a case consultation in two of four client records and the case consultation was documented late, as per facility policy in one of one client record.
The findings include:
Seven client records were reviewed on July 13, 2011. A case consultation was required in three of those seven client records, #1, 2 and 4.
A case consultation was not documented in two of those three client records, #1 and 4. The case consultation on one of one client record was documented late as per facility policy, #2.
According to the facility's policy on case consultations, a case consultation is required to be completed every 90 days for each client.
Client # 1 was admitted on 1/20/11. The case consultation was due on or before 4/20/11. As of 7/13/11, no case consultation was documented in client record #1.
Client # 2 was admitted on 10/25/10. A case consultation was due on or before 1/25/11. Another case consultation was due on or before 4/25/11. The only case consultation documented in client record #2 was dated 4/19/11.
Client # 4 was admitted on 1/4/11 and discharged on 4/12/11. The case consultation was due on or before 4/2/11. As of 7/13/11, no case consultation was documented in client record #4.
During a discussion with the clinical supervisor, she confirmed these findings.
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Plan of Correction
The Clinical Supervisor met with the clinician on August 1, 2011, to review the status of the incomplete case consults. During that session, we updated the case consults. The standard when case consults are due, every 90 days was reviewed with the therapist. The Clinical Supervisor reviews charting monthly, and will monitor compliance and take actions as indicated. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and a discussion with the clinical supervisor, the facility failed to adhere to the authorized maximum client capacity of 28 clients.
The findings include:
The Staffing Requirements Facility Summary Report was reviewed on July, 12, 2011. Based on the information the facility provided, the facility exceeded its authorized maximum capacity of 28 clients.
The number of clients recorded on the Staffing Requirements Facility Summary Report was 38 clients. During a discussion with the clinical supervisor, she acknowledged that the number of active clients was currently 38. She also acknowledged that she was aware the facility was over its authorized maximum capacity of 28 clients.
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Plan of Correction
The Clinical Supervisor will review and make a daily count of all discharges and admissions at the start of each day to make sure that we are at or below the allowed 28 clients. The clinicians will be made aware of these counts to ensure that we are addressing discharging clients in a timely fashion to stay at or below 28 clients. |