INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 13, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northwestern Human Services of Delaware County, 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 March 18, 2008.
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Plan of Correction
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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 a review of counselor staff development records during the licensing inspection on February 13, 2008, Counselors failed to obtain twenty-five hours of training annually. The facility failed to document twenty-five hours of training for the staff development year of July 1, 2006 through June 30, 2007 in two of two staff development records reviewed. Counselor #1 is twelve hours short of the twenty-five hour requirement. Counselor #2 is fifteen hours hours short of the twenty-five hour annual requirement.
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Plan of Correction
The NHS Administrative Services Unit of Delaware County will develop an annual training schedule for the program outlining at least 25 hours of on site training. Each counselor will be required to attend the on site trainings. The NHS Administrative Unit of Delaware County will also alert the Program Director to possible trainings within the area which counselors can take advantage of. The Program Director will ensure compliance with this standard through regular supervision. The ASU will ensure compliance with this standard through auditing of the employee credentialing record.
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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
Based on a review of client records during the licensing inspection of February 13, 2008, the project failed to complete psychosocial evaluations in a timely manner as defined in the organizations treatment management procedures. Evaluations are to be completed and documented in the client record within thirty-day of admission. Four of eight client records reviewed failed to document the completion of psychosocial evaluations within thirty days of admission.
Record # 2 - Admitted August 18, 2007. Evaluation completed October 10, 2007.
Record # 4 - Admitted October 31, 2007. Evaluation completed January 3, 2008.
Record # 7 - Admitted July 30, 2007. Evaluation completed September 5, 2007.
Record # 8 - Admitted October 4, 2007. Evaluation completed December 15, 2007
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Plan of Correction
All biopsychosocial evaluations will be completed within thirty days of the client's admission into treatment. To ensure that this standard is met, the Program Director has instituted that all biopsychosocial evaluations be completed by the intake worker upon admission. This procedure was instituted on February 25, 2008. The Program Director will ensure compliance with this standard through regular supervision and auditing of the clinical records.
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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
Based on a review of client records and the policy and procedure manual on February 13, 2008, the project failed to complete individual treatment and rehabilitation plans within thirty days as required in the organizations treatment management procedures manual. This was evident in the following client records:
Record # 2 - Admitted 8/18/2007. Plan established October 8, 2007.
Record #4 - Admitted 10/31/2007. Plan established January 3, 2008
Record # 7 - Admitted 7/30/2007. Plan established September 13, 2007
Record # 8 - Admitted October 4, 2007. Plan established November 11, 2007
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Plan of Correction
All comprehensive treatment plans will be completed within 30 days of the client's admission into treatment. The Program Director and/or Clinical Supervisor will ensure compliance with this standard through regular supervision with the counselor and auditing of the counselor's clinical records. The ASU department will train clinical staff on the timeline for completion of the document. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on client record reviews during the licensing inspection of February 13, 2008, the project failed to complete case consultations on a quarterly basis in two of eight records reviewed. The client represented by client record # 4 was admitted 10/31/2007 but no case consultation was documented as of February 12, 2008. The client represented by client record # 7 was admitted on 07/30/2007, but no case consultation was documented as of January 18, 2008.
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Plan of Correction
All case consultations will be completed, minimally, at the 3, 6, 9 and 12 month anniversaries of the client's admission date. They will also be completed annually thereafter. The Program Director and/or Clinical Supervisor will ensure compliance with this standard through regular supervision with the counselor and auditing of the counselor's clinical records. By 4/15/08, the ASU department will train clinical staff on the timeline for completion of the document. |
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 a review of client records during the licensing inspection of February 13, 2008, the project failed to conduct and document client follow-up. Five of five discharged records reviewed failed to document follow-up attempts.
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Plan of Correction
The Program Director will ensure that follow up is completed by the counselor of record for each discharged client. The Program Director and/or Clinical Supervisor will ensure compliance with this standard through regular supervision with the counselor and auditing of the counselor's discharged clinical records. By 4/15/08, the ASU department will train clinical staff on the timeline for follow up procedures.
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