INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 22, 2010 through February 23, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A.R.S. of Lancaster, LP 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 March 21, 2010.
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Plan of Correction
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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 the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment in one of two records.
The findings include:
Twenty client records were reviewed on February 22, 2010 and February 23, 2010. Of those twenty client records, only two required documentation of written notification of termination. Client record #13 was missing documentation of written notification of termination.
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Plan of Correction
Executive Director and Clinical Supervisor will meet with Clinical staff by 3/31/2010 to review policy and procedures for discharge. During this review all discharge paperwork will be reviewed. The Clinical Supervisor/designee will review 100 percent of discharged patient records for 6 months and random thereafter to ensure compliance. |
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 the review of client records, the facility failed to document an aftercare plan in one of two client records.
The findings include:
Twenty client records were reviewed on February 22, 2010 and February 23, 2010. Aftercare plans were required in two client records. An aftercare plan was not documented in client record #18.
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Plan of Correction
Executive Director and Clinical Supervisor will meet with Clinical staff by 3/31/2010 to review policy and procedures for discharge. During this review all discharge paperwork will be reviewed. The Clinical Supervisor/designee will review 100 percent of discharged patient records for 6 months and random thereafter to ensure compliance. |
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 the review of client records, the facility failed to document follow-up information in three of ten client records. Based on the review of client records and the facility's follow-up policy, the facility failed to document follow-up information within the time frame specified in their policy manual in seven of ten client records.
The findings include:
Twenty client records were reviewed on February 22, 2010 and February 23, 2010. Ten client records required follow-up. Follow-up was not documented in client records #16, 18, and 19. Follow-up was documented late, as per facility policy in client records #11, 12, 13, 14, 15, 17, and 20. According to facility policy, follow-up is to be completed within thirty days of discharge. Client #11 was discharged on 7/27/09. The documented follow-up was dated 2/22/10. Client #12 was discharged on 4/7/09. The documented follow-up was dated 2/1610. Client #13 was discharged on 12/9/09. The documented follow-up was dated 2/19/10. Client #14 was discharged on 9/17/09. The documented follow-up was dated 2/16/10. Client #15 was discharged on 9/1/09. The documented follow-up was dated 2/16/10. Client #17 was discharged on 9/2/09. The documented follow-up was dated 2/16/10. Client #20 was discharged on 10/23/09. The documented follow-up was dated 2/16/10.
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Plan of Correction
Executive Director and Clinical Supervisor will meet with Business Office staff by 3/31/2010 to review policy and procedures for follow-up. The Clinical Supervisor/designee will review 100 percent of discharged patient records for 6 months and random thereafter to ensure compliance. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on the review of personnel records, the facility failed to ensure that each counselor complete at least 25 hours of training annually in one of two personnel records.
The findings include:
Ten personnel records were reviewed on February 22, 2010. Of those ten records, only six were counselors. Four of those counselors were recently hired and were not required to have 25 annual training hours completed. Only 18 annual training hours were documented in personnel record # 4. In speaking with the project/facility director, it was confirmed that this staff person did not receive all of their required annual training hours.
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Plan of Correction
Executive Director will review training requirements for all staff in Management Meeting by 3/31/10. Individual Training plans will be reviewed quarterly by Clinical Supervisor and Lead Counselor to ensure staff is on track to receive training based on training plan and individual supervision needs. Executive Director will review all completed trainings quarterly to ensure compliance. |