INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 2, 2008 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 1, 2008.
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Plan of Correction
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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 the review of the facility's policy and procedure manual on July 25, 2008, the facility failed to document a performance report summarizing the progress towards meeting goals and objectives for the fiscal year 2007/2008.
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Plan of Correction
In September, 2008 at the next Board Meeting, the Project Director will present and discuss progress meeting agency goals and objectives with the Board. This will be documented in the Board minutes. |
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 review of six client records on August 2, 2008, the facility failed to document complete psychosocial evaluations in six of six records reviewed, #1, 2, 3, 4, 5 and 6. Psychosocial evaluations were historical rather than an assessment of the client's assets and strengths, support systems, coping mechanisms, negative factors that my inhibit treatment, and the counselors' conclusions/impressions of the client.
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Plan of Correction
A meeting of the clinical staff has been set up on August 20, 2008, by the Clinical Supervisor to address the necessity and expectation of completing the psycho/social assessment in its entirety. A review of deficient areas is on the agenda. The Clinical Supervisor will monitor progress on a bi-monthly basis by reviewing charts at random. Deficiencies still found will be addressed with the clinician to assure compliance. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of six client records on August 2, 2008, the facility failed to clearly document short and long term goals for treatment as formulated by both staff and client in five of six records reviewed, #1, 2, 4, 5 and 6. Items documented as action steps were actually short-term goals.
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Plan of Correction
A meeting of the clinical staff has been set up for August 20, 2008 by the Clinical Supervisor to review expectations of treatment and goal planning. This will include the need to write treatment plans in terms of measurable goals. The Clinical Supervisor will monitor progress, through random chart reviews, on a bi-monthly basis to assure compliance. Deficiencies still found will be addressed with the clinician to assure compliance. |
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 six client records on August 2, 2008, the facility failed to document complete treatment plan updates in five of six client records reviewed, #2, 3, 4, 5 and 6. Treatment plan updates did not include the client's progress in relationship to the stated goals of the treatment plan, but rather documented generalized comments that were not specific to each client's progress in treatment.
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Plan of Correction
A meeting of clinical staff has been set up for August 20, 2008 by the Clinical supervisor to address the need to include an inperpretive assessment in how our clients are meeting stated goals. This will be monitored by the Clinical Supervisor through a bi-monthly review of charting by the Clinical Supervisor. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of six client records on August 2, 2008, the facility failed to document complete progress notes in three of six records reviewed, #2, 5 and 6. Progress notes for group counseling failed to include the clinician's assessment and data for each client.
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Plan of Correction
A staff meeting with the clinical staff has been set up for August 20, 2008 by the Clinical Supervisor to address the expectations of progress notes. This will include the need for the clinician to include more interpretive information about each client under assessment and data for each group note. Compliance will be monitored through a bi-monthly random review of charts. Deficiencies still found will be addressed with the clinician. |