INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 12, 2010 through July 13, 2010 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 August 13, 2010.
|
Plan of Correction
|
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
|
Observations
Based on a review of the facility's policies and procedures manual and an interview with the clinical supervisor, the facility failed to prepare and annually update a written manual delineating project policies and procedures.
The findings include:
The facility's policies and procedures manual was reviewed on July 12 and 13, 2010. The manual contained contained conflicting policies and procedures due to outdated policies that were never removed when the new policies were implemented.
The clinical supervisor confirmed that the policies and procedures manual had not been updated.
|
Plan of Correction
The Project Director and the Clinical Supervisor will review the current Policy and Procedure manual and remove all outdated materials and ensure that the newest policies are in the manual. The Clinical Supervisor, under the direction of the Project Director, will be responsible for keeping the manual up to date. This will be done over the next 3 months to be completed no later than the 31st of October 2010. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
|
Observations
Based on a review of personnel records and discussion with the clinical supervisor, the facility failed to provide documentation of performance evaluations in three of six personnel records.
The findings include:
Six personnel records were reviewed on July 12, 2010 through July 13, 2010. Five of those staff were required to have a performance evaluation.
The performance evaluation for staff #1 was dated 6/30/09. According to the clinical supervisor, a current performance evaluation had not yet been completed for 2010.
Staff #5 was hired 10/19/09. According to facility policy, a performance evaluation was due by 4/19/10 following the six month probationary period. There was no performance evaluation documented in personnel record #5.
The performance evaluation for staff #6 was dated 9/28/07. According to the clinical supervisor, a current performance evaluation had not yet been completed for 2010.
|
Plan of Correction
The performance evaluation for staff #1, a letter was sent to the board in June appraising the President of the Board that an evaluation is needed. The board does not meet over the summer. Staff #1 will meet with the board in September, at the next available meeting and report the need to have an evaluation completed by 1 October 2010. The Clinical Supervisor will check in October that this was done.
For Staff #5, the evaluation was completed, late. The CLinical Supervisor is meeting with the Director of our Human Relations office to set up a trigger system that will remind supervisors that evaluations are needed. This trigger system, we decided, with be sent out monthly to notify staff of the need for evaluations and the date required.
For Staff #6, the Clinical Supervisor and the Director of HR are addressing the problem of multiple supervisors and how to designate a primary, the supervisor in charge of completing the evaluation. This staff will have an evaluation within the next 2 months. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of fire drill records and discussion with the clinical supervisor, the facility failed to conduct fire drills once a month.
The findings include:
Fire drill records were reviewed on July 12, 2010. There was no fire drill documented for June 2010. According to the clinical supervisor, a fire drill was not conducted in June 2010.
|
Plan of Correction
The Clinical Supervisor will review the fire drill records monthly, before the end of the month, to make sure that fire drills were completed on all the offices. This will start for the month of July and continue monthly thereafter. |
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 client records, the facility failed to document treatment plan updates in two of three client records.
The findings include:
Two client records requiring treatment plan updates were reviewed on July 13, 2010.
The individual treatment plan in client record #4 was completed on 1/4/10. The treatment plan update was due by 3/4/10. As of 3/15/10, the date the client was discharged, a treatment plan update was not documented in client record #4.
The individual treatment plan in client record #5 was completed on 4/16/10. The treatment plan update was due by 6/16/10. The treatment plan update in client record #5 was not completed until 6/25/10.
|
Plan of Correction
The Clinical Supervisor has scheduled at staff meeting for August 24, to review the paperwork requirements and the date sensitivity of each document. This will be reinforced in supervision with each staff member. The Clinical Supervisor is also able to view via our new electronic medical records, the compliance requirement for each staff by actually seeing the document and dates completed and signed. The Clinical Supervisor will document and address any problems with that requirement on an ongoing basis. |
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 facility policy and client records, the facility failed to document an aftercare plan in one of one client record.
The findings include:
One client record requiring an aftercare plan was reviewed on July 13, 2010. According to the facility's policy and procedure manual, the aftercare plan is developed with the client at the last session.
Client #4 was admitted on 12/7/09 and discharged on 3/15/2010. An aftercare plan was not documented in client record #4.
|
Plan of Correction
The Clinical Supervisor has scheduled a staff meeting on August 24, to review the paperwork requirements and need to complete an aftercare plan at the last session. This will be reinforced at individual supervision meetings as well. The Clinical Supervisor will also be able to view via our Electronic Medical Record the compliance requirement with this standard. The CLinical Supervisor will document and address any problems with this requirement on an ongoing basis. |