INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5, 2017 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
One personnel record was reviewed for the Facility Director position on June 5-6, 2017. The facility failed to document at least 12 hours of annual training for employee record # 2. Employee # 2 was hired by the project on 2/20/09, and then assumed the project director position on 1/1/14. The facility's last complete training year of July 1, 2015 - June 30, 2016 was reviewed. Documentation in the employee's record indicated that the employee completed 4.5 hours of annual training for the training year reviewed. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard by 06/30/2018, which is the end of our current training year. By that date the Facility Director will have received 12 training hours as is required by the standard. Employee #2 had failed to complete the required trainings. This employee will seek out & attend trainings throughout the year, which will address the areas set forth by the standard. The Clinical Supervisor and Project Director are responsible for ensuring the corrective action(s) is implemented. In the future, the Clinical Supervisor and Project Director will conduct quarterly reviews of all training hours as well as monthly clinical supervision to ensure that this standard is being complied with. |
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
Three personnel records were reviewed for the Counselor position on June 5-6, 2017. The facility failed to document at least 25 hours of annual training for employee record # 6. Employee # 6 was hired by the facility on 9/6/06 as a counselor. The facility's last complete training year of July 1, 2015 - June 30, 2016 was reviewed. Documention in the employee's record indicated that the employee completed 16.5 hours of annual training for the training year reviewed.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard by 06/30/2018, which is the end of our current training year. By that date each employee will have received 25 training hours as is required by the standard. Employee #6 had failed to complete the required trainings. This employee will seek out & attend trainings throughout the year, which will address the areas set forth by the standard. The Clinical Supervisor and Project Director are responsible for ensuring the corrective action(s) is implemented. In the future, the Clinical Supervisor and Project Director will conduct quarterly reviews of all training hours as well as monthly clinical supervision to ensure that this standard is being complied with. |
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.
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Observations
Seven client records were reviewed on June 5, 2017. The facility failed to obtain an informed and voluntary consent where consent was applicable in client records # 3 and 5. Client # 3 was admitted into treatment on 8/8/16 and was discharged on 12/12/16. A consent to release information to the treatment funding source was not documented in the client's record. Client # 5 was admitted into treatment on 10/21/16 and was discharged on 4/27/17. A consent to release information to the treatment funding source was not documented in the client's record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard was reviewed during our agency staff meeting on June 21, 2017. The proper completion and documentation of the consent to release information to the treatment funding source will be obtained during the clients first session. Our facility will obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The proper completion of the required consent forms, including date, event, and condition as well as the expiration date of the consent.
To ensure correct completion of consents forms the Clinical Director and Project Director will verify completion during weekly supervision. The Clinical Supervisor will also review individual counselor's client records on a weekly basis and during weekly supervision to insure compliance.
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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
Seven client records were reviewed on June 5, 2016. The facility failed to document a psychosocial evaluation for client records # 3 and 7. Client # 3 was admitted into treatment on 8/8/16 and was discharged on 12/12/16. A psychosocial evaluation was not documented in the client's record. Client # 7 was admitted into treatment on 11/22/16 and was discharged on 3/3/17. A psychosocial evaluation was not documented in the client's record.This finding was was reviewed with facility staff during the licensing inspection.
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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 were reviewed with all counselors during staff meeting on June 21, 2017. The biopsychosocial evaluation (consolidated assessment) by our standards is to be completed by the end of the 5th session. However, during our onsite licensing renewal inspection it was brought to the attention that the consolidated assessment must be completed during the intake process. The Project Director has updated the agency policy and procedure to include the consolidated assessment must be completed during the intake process which is by the end of the clients first session. The Clinical Supervisor and Project Director will also review updated policy and procedures with all counselors in individual supervision weekly as an added measure to insure compliance. The Clinical Supervisor will also review individual counselor's client records on a weekly basis and during weekly supervision to insure compliance. |
709.92(a) 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:
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Observations
Seven client records were reviewed on June 5, 2017. The facility failed to document that an individual treatment and rehabilitation plan was developed with the client for client records # 3 and 6. In addition, the facility failed to document a complete individual treatment and rehabilitation plan in client records # 1, 2, 3, 5, and 7. Client # 1 was admitted into treatment on 10/7/16 and was still active in treatment. An individual treatment and rehabilitation plan was completed for the client on 11/7/16. The treatment plan did not specify the type and frequency of counseling therapy. Client # 2 was admitted into treatment on 11/11/16 and was still active in treatment. An individual treatment and rehabilitation plan was completed for the client on 12/11/16. This treatment plan did not specify the type of counseling therapy. Client # 3 was admitted into treatment on 8/8/16 and was discharged on 12/12/16. An individual treatment and rehabilitation plan was completed for the client on 9/1/16. Documentation in the client's record failed to indicate that the treatment plan was developed with the client. Client # 5 was admitted into treatment on 10/21/16 and was discharged on 4/27/17. An individual treatment and rehabilitation plan was completed for the client on 11/21/16. The treatment plan did not specify the type of counseling therapy. Client # 6 was admitted into treatment on 12/5/16 and was discharged 1/16/17. An individual treatment and rehabilitation plan was completed for the client on 12/5/16. Documentation in the client's record failed to indicate that the treatment plan was developed with the client. Client # 7 was admitted into treatment on 11/22/16 and was discharged on 3/3/17. An individual treatment and rehabilitation plan was not documented in the client's record. These findings were reviewed with facility staff during the licensing inspection.
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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 were reviewed during our agency staff meeting on June 21, 2017. The comprehensive (master) treatment plan will be completed at the end of the client's first session. The comprehensive treatment plan will be developed with the clients input, signed and dated by the client. The primary therapist will document the specific type and/or frequency of treatment services on all individual client treatment plans. To ensure the comprehensive (master) treatment plan is completed by the end of the client's first session the Clinical Director and Project Director will verify completion during weekly clinical supervision. The Clinical Supervisor will also review individual counselor's client records on a weekly basis. |
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
Four client records requiring the documentation of treatment plan updates were reviewed on June 5, 2017. The facility failed to document a treatment plan update at least every 60 days for client records # 1 and 5. Client # 1 was admitted into treatment on 10/7/16 and was still active in treatment. A comprehensive treatment plan was completed for the client on 11/7/16. A treatment plan update was due to be completed for the client by 1/7/16, and one was not documented in the client's record. Client # 5 was admitted into treatment on 10/21/16 and was discharged on 4/27/17. A treatment plan update was completed for the client on 1/21/17. A subsequent treatment plan update was due to be completed for the client by 3/21/17, and one was not documented in the client's record. These findings were reviewed with facility staff during the licensing inspection.
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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 were reviewed during our agency staff meeting on June 21, 2017. The individual treatment plan update will be completed at least every 60 days. To ensure completion of treatment plan updates at least every 60 days the Clinical Director and Project Director will verify completion during weekly clinical supervision. The Clinical Supervisor will also review individual counselor's client records on a weekly basis and during weekly supervision to insure compliance. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Seven client records were reviewed on June 5, 2017. The facility failed to provide documentation that demonstrated counseling was provided to the client on a regular and scheduled basis for client records # 1, 2, 5, and 7. Client # 1 was admitted into treatment on 10/7/16 and was still active in treatment. The client received individual counseling sessions on 11/4/16 and 2/3/17. A counseling session scheduled for 12/5/16 was cancelled by the client. Documentation in the client's record indicated that counseling services were not provided to the client during the time period of 11/5/16 - 2/2/17. Client # 2 was admitted into treatment on 11/11/16 and was still active in treatment. The client received individual counseling sessions on 1/25/17, 3/28/17, and 5/4/17. Documention in the client's record indicated that counseling services were not provided to the client during the time periods of 1/26/17 - 3/27/17 and 3/29/17 - 5/3/17. Client # 5 was admitted into treatment on 10/21/16 and was discharged on 4/27/17. The last counseling session attended by the client occurred on 1/27/17. The client then failed to attend scheduled individual counseling sessions on 2/20/17 and 2/27/17. Documentation in the client's record indicated that counseling services were not provided to the client during the time period of 2/28/17 - 4/27/17. Client # 7 was admitted into treatment on 11/22/16 and was discharged on 3/3/17. The last counseling session attended by the client occurred on 12/28/16. Documentation in the client's record indicated that counseling services were not provided to the client during the time period of 12/29/16 - 3/3/17. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. It is the agency policy that if a client has not attended treatment within 30 days their client record will be closed. This standard and our agency policy relative to this standard have been reviewed with all staff during our agency staff meeting on June 21, 2017. The proper documentation that the clinicians (staff) are attempting to engage the clients in treatment will be completed in the client's progress notes. This standard and policy will also be reviewed with all counselors by the Clinical Supervisor and Project Director during individual clinical supervision to assure compliance. The Clinical Supervisor will also review individual counselor's client records on a weekly basis and during weekly supervision to insure compliance. |