INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18, 2014 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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704.6(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, the Project failed to provide for a full time clinical supervisor for every 8 Full Time Equivalent (FTE) counselors.The findings include:The "Staffing Requirements Facility Summary Reports" for the three facilities that make up the Project were reviewed March 19, 2014 and revealed that there are 9 FTE counselors working for the Project. The project does not have a clinical supervisor on staff.The findings were reviewed and confirmed with the Project Director on March 19, 2014.
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Plan of Correction
Our project is in full compliance
with this standard as of March 28,
2014. We failed to provide a full
time clinical supervisor as required
in the regulations for Clinical
Supervisor Qualifications. Our
project was unaware that we had 8
full time counselors employed. This
mistake was discovered during the
on-site licensure renewal inspection.
The proper steps were taken and our
project is in compliance with this
standard and we have hired a
Facility Director and Clinical
Supervisor. In the future the Project
Director will review the staff and
staff caseloads to ensure that the
proper staff is supervised and we are
in compliance with this standard. |
709.28(c) 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:
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Observations
Based on a review of the client records, the facility failed to document consents to release information which include the name of the person agency, or organization to which the disclosure is made, the specific information to be disclosed, and/or the purpose of the disclosure. The findings include:Eight client records were reviewed for consent forms on February 18, 2014. The consents to release information forms did not document all required information in two out of eight client records, specifically records #1 and 2. The findings include:Client # 1 was admitted to treatment on December 11, 2013. A consent form had been signed by the client on December 11, 2013 but it did not specify what information was being released. An additional consent was signed on December 11, 2013 and specified that information would be released to "Co" there was no indication of a proper name for whom the information was to be released. Client # 2 was admitted to treatment on October 3, 2013. Client specific information had been released to a "Natalie B." on 12/11/13 and 1/3/14. There was no documentation of a completed consent form signed by the client that permitted the release of this information. The findings were discussed and confirmed with the project director and clinical staff.
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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
relative to this standard will be
reviewed with all counselors at our
next staff meeting on April 10, 2014.
The proper completion of consents
including purpose of disclosure and
to whom we disclose information to
of client information will begin
immediately. To ensure correct
completion of consents forms the
Quality Assurance manager will
verify completion during quarterly
reviews. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of three client records.The findings include:Eight client records were reviewed on March 18, 2014. Four of those records represented discharged clients, of which three were required to include documentation of a termination letter. One out of three clients did not receive notice of their involuntary termination, specifically client #7. Client # 7 was involuntarily terminated from the program on December 24, 2013. As of the date of inspection, there was no documentation of written notification of the decision to terminate client #7 from treatment. The findings were reviewed and confirmed with the project director prior to the exit interview.
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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
relative to this standard will be
reviewed with all counselors at our
next staff meeting on April 10, 2014.
A written notification of termination
of treatment has been sent to client
#7 and documentation is filed in the
client chart. The proper completion
of client notification of termination
will begin immediately. This
standard and policy will also be
reviewed with all therapists by the
Clinical Supervisor during
individual supervision to assure
compliance. In the future all
therapists will bring their closed
charts to supervision and the Clinical
Supervisor will verify that the
notification of termination is in the
chart. |
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 client record review, the facility failed to document biopsychosocial evaluations in two out of five client records. The findings include:Eight client records were reviewed on March 18, 2014. Five client records were required to have a psychosocial evaluation completed. The facility failed to document a biopsychosocial evaluation in two out of five client records; specifically #2 and 8.Client #2 was admitted to treatment on October 3, 2013. As of the date of inspection, there was no biopsychosocial evaluation documented for client #2.Client #8 was admitted to treatment on June 5, 2013 and discharged on September 12, 2013. As of the date of inspection, there was no biopsychosocial evaluation documented for client #8.The findings were reviewed and confirmed by the project director.
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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
relative to this standard will be
reviewed with all counselors at our
next staff meeting on April 10, 2014.
The biopsychosocial evaluation
(consolidated assessment) by our
standards is to be completed by the
end of the 5th session. Clients #2
and #8 were sporadic with
attendance and were only seen 5/6
times so the clinician was unable to
compile the information to complete
a consolidated assessment. However,
the clinicians reviewed both client
#2 and #8's records and made the
necessary documentation of a
consolidated assessment. 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(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 client records, the facility failed to document a treatment plan update which includes the clients' progress on goals. The findings include:Eight client records were reviewed on March 18, 2014. Three of those records required documentation of a treatment plan update. The treatment plan updates did not state the clients ' progress on goals in two out of three client records, specifically records #1 and 3. Client #1 was admitted on December 11, 2013. The treatment plan update which occurred on March 11, 2014 did not document the client's progress on goals. Client #3 was admitted on November 26, 2013. The treatment plan update which occurred on February 18, 2014 did not document the client's progress on goals. There was no brief note indicating what progress, if any, had been made in time since the clients' treatment plans had been developed. The findings were reviewed and confirmed by the project director.
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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
relative to this standard will be
reviewed with all counselors at our
next staff meeting on April 10, 2014.
The proper completion and clients'
progress on goals of the treatment
plan update will begin immediately.
The clinician(s) of clients #1 and #3
reviewed the records and updated
their treatment plans and
documented the progress on their
goals. This standard and policy will
also be reviewed with all therapists
by the Clinical Supervisor in
individual supervision to assure
compliance. |