INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 1, 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.
|
Plan of Correction
|
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.
|
Observations
Based on the review of the facility's policy and procedure manual, the facility failed to document a performance report summarizing the progress towards meeting goals and objectives for the fiscal year 2007/2008.
|
Plan of Correction
In September 2008, at the next Board Meeting, the Project Director will present and address progress of our agency's goals and objectives. This will be documented in the minutes of the Board Meeting. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
|
Observations
Based on a review of the facility's record-keeping system on July 1, 2008, the facility failed to have an efficient system for the retrieval of data in place. The record-keeping system did not reflect the same admission date as documented in the client records. The record- keeping system for discharge dates was inaccurate. The date of discharge was documented as a date that was prior to the client's admission to the facility. The record-keeping system could not distinguish between clients when admitted for treatment and individuals who only received an assessment and did not become a client in the facility.
|
Plan of Correction
The Clinical Supervisor has net with, on July 9, 2008, and will continue to meet with the agency's computer specialists to come up with a more accurate retrieval system. This will document date of initial interview, assigned therapist, date of admission to the program and date of discharge. This system will be tested through out the year to ensure accuracy and compliance by the Clinical Supervisor. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of eight client records on July 1, 2008, the facility failed to document complete psychosocial evaluations in six of six records where required, #1, 2, 3, 4, 5 and 6. The therapist did not evaluate the client from the therapist's point of view when it came to documenting a composite picture of the client, the client's problems/needs, an assessment of the client's assets and strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, the client's attitude towards treatment, and the therapist's conclusions/impressions of the client's status.
|
Plan of Correction
The Clinical Supervisor has set up a meeting on August 14, 2008 with the clinical staff to review expectations and the necessity of completing the psycho/social assessment in a more complete and interpretive fashion. Compliance will be monitored on b bi-monthly basis through a random chart review. Deficiencies still found will be addressed with the clinician to assure compliance. Follow up staff meetings will also be scheduled as needed. |
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.
|
Observations
Based on a review of eight client records, the facility failed to clearly document short and long term goals for treatment as formulated by both staff and client in six of eight records reviewed, #1, 2, 3, 4, 5 and 6. Items documented as action steps were actually short-term goals.
|
Plan of Correction
The Clinical Supervisor has scheduled a meeting on August 14, 2008, with the clinical staff to review expectations in goal planning. This will include the need to break down our goals into more manageble parts. Random chart reviews and periodic meetings conducted by the Clinical Supervisor will assure that staff is in compliance with the requirements. |
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 eight client records, the facility failed to document complete treatment plan updates in three of six client records where required, #1, 3 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 clients' progress in treatment in records #3 and 6. The treatment plan update was missing from client record #1.
|
Plan of Correction
A meeting with the clinical staff has been set up on Sugust 14, 2008 by the Clinical Supervisor to address the need provide a more detailed and interpretive assessment of client's progress towards goals for treatment. Initial treatment plans and tratment plan updates will be monitored through a periodic and random review of charting and through periodic staff meetings. |
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.
|
Observations
Based on a review of eight client records on July 1, 2008, the facility failed to document complete progress notes in four of six records where required, #1, 2, 3 and 6. Progress notes for group counseling failed to include the clinician's assessment and data for each client.
|
Plan of Correction
The Clinical Supervisor has set up a staff meeting on August 14, 2008 to address the need for more complete and interpretive data in our charting, to include our progress notes. Progress towards this will be monitored through random chart audits and periodic staff meetings. |
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.
|
Observations
Based on a review of eight client records on July 1, 2008, the facility failed to document or complete timely case consultation notes in three of six client records where required, #3, 5 and 6. Case consultations were not documented in client records #5 and 6 and the case consultation for client record #3 was not completed within the required time frame.
|
Plan of Correction
The Clinical Supervisor has scheduled a meeting with clinical staff on August 14, 2008 to review descrepancies and expectations for Case Consultation. This will include when they are to be initially completed and when they need to be updated. Random and periodic chart reviews will be done by the Clinical Supervisor 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.
|
Observations
Based on a review of eight client records on July 1, 2008, the facility failed to document follow-up information in two of three discharge records where required, #5 and 6.
|
Plan of Correction
The Clinical Supervisor has set up a staff meeting on August 14, 2008, to review expections and requirements for cases that have been closed. This will include the need for after care goals, if required, and our follow up letter. A random review of charting will establish compliance and staff meetings on a bi-monthly basis. |