INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 2-3, 2018, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Harbor 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on an inspection of the physical plant conducted during the onsite inspection, the facility failed to ensure client privacy during group counseling sessions. The glass door for the outside exit to the group counseling room on the lower level is completely transparent and allows the group counseling sessions to be seen from the outside.These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
On Tuesday, February 13, 2018 Harbor Counseling's Assistant Administrator ordered a cordless pleated linen shade to fit the window on the door in the group counseling room. The shade, which is scheduled for delivery on Monday, February 19, will completely cover the glass in the door when it is installed. It will be installed on the door as soon as it arrives. The Assistant Administrator and Clinical Supervisor will be responsible to see that it is installed and that it is pulled down to cover the window during group counseling sessions. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of facility records conducted during the onsite inspection, the facility failed to ensure that the personnel records documented all of the required information. Staff Person #3, a counselor, has been in his or her current position since 07/01/2018. The last signed annual performance evaluation for the staff person was completed 11/22/2016. Staff Person #4, a counselor, has been in his or her current position since 09/30/2013. The last signed annual performance evaluation for the staff person was completed 11/04/2016. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Staff person #3 had met with the Director and Clinical Supervisor during December to have her annual performance evaluation, but due to pressing situations with agency business, the meeting turned into more of a supervision session, rather than a performance evaluation. The performance evaluation was not able to be rescheduled until after the holidays, and was completed on January 2, 2018.
Staff person #4 had been scheduled for his annual performance evaluation, but it had been delayed several times due to illness of the agency's Director. It also was delayed until January 2, 2018 when it was completed.
In order to avoid this situation in the future, we will begin scheduling performance evaluations in early October each year. Our policy is that each staff person be evaluated during the 4th quarter of the year and no more than one year after the last evaluation. The Assistant Administrator will be responsible to see that the performance evaluations are scheduled and actually take place each year within one year of the last evaluation. The Clinical Supervisor and the Director will be responsible for conducting the performance evaluations, and because the Director has chronic health issues which sometimes cause things to be delayed, the Assistant Administrator will fill in for the Director if necessary to see that they are done on time. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to document the frequency of counseling on client treatment plans in 3 of 7 client records reviewed during the onsite inspection. Client #1 was admitted for treatment on 08/31/2017, and was an active client at the time of the onsite inspection. The client received individual counseling on average at least once a month, but there was no individual counseling documented on the client's individualized treatment plan dated 09/25/2017, or on the client's treatment plan update. Client #2 was admitted for treatment on 05/25/2017, and was an active client at the time of the onsite inspection. The client received individual counseling on average at least once a month, but there was no individual counseling documented on the client's individualized treatment plan dated 06/21/2017, or on the client's treatment plan updates. Client #3 was admitted for treatment on 09/20/2017, and was an active client at the time of the onsite inspection. The client received individual counseling on October 12, 2017, and December 14, 2017, but there was no individual counseling documented on the client's individualized treatment plan dated 09/26/2017, or on the client's treatment plan update. These findings were reviewed with the facility staff as part of the inspection process.
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Plan of Correction
This citation resulted from our incorrectly thinking that if a client's work schedule did not allow for regular individual sessions, rather than risk being out of compliance for listing "weekly" or "monthly" individual therapy sessions and then failing to make that happen, we would omit listing individual therapy on the treatment plans, but continue to see the client individually, aiming for at least monthly, as their schedule allowed. We now understand that this was a mistake.
We will correct this by updating the current treatment plans for clients #1, #2, and #3, who are still clients who are employed, and listing "individual therapy at least every 60 days and more often as needed" along with the group therapy that is already on the treatment plans.
Our plan going forward will be to always list individual therapy of at least every 60 days on the treatment plans for our outpatient clients. All our clients should and do receive it as part of their treatment, with treatment plan updates occurring every 60 days for outpatient level of care, and so it will be listed as such. If we are unable to be more specific for our clients who are employed, we will list it "at least every 60 days and more often as needed," and for those clients who are able to come on a more scheduled basis, we will list the frequency more specifically ? weekly, bi-weekly, etc.
The Clinical Supervisor will be responsible for seeing that this is done by all clinical staff members doing treatment plans on an ongoing basis. The change in procedure will be communicated to all clinical staff at the staff meeting to be held on Tuesday, February 27, 2018. The Clinical Supervisor will continue to monitor that the treatment plans reflect the treatment being delivered when reviewing treatment plans and updates.
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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
The facility failed to document treatment plan updates at least once every 60 days in 3 of 7 client records reviewed. Client # 5 was admitted for treatment on 05/04/2017, and discharged on 11/06/2017. The client had a treatment plan update dated 05/12/2017, but the next update was not completed until 08/24/2017, and there were no further updates from 08/24/2017, until the client's discharge. Client # 6 was admitted for treatment on 03/01/2017, and discharged on 12/04/2017. The client 's individualized treatment plan was dated 03/23/2017, but was not updated until 07/03/2017, and there were no further updates from 07/03/2017, until the client's discharge. Client # 7 was admitted for treatment on 03/07/2017, and discharged on 10/12/2017. The client had a treatment plan update dated 06/07/2017, but there were no further updates from 06/07/2017, until the client's discharge. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
This citation was a result of a few of our counselors not utilizing our electronic medical records software to its full potential, and failing to follow through in a timely manner with clients who have dropped out of treatment.
In order to correct this problem, our clinical staff are now being trained to use what is called the "CAM (Client Access Management) Dashboard" to manage their caseload. This dashboard alerts each counselor to the date of the last treatment plan update, and to the due date of the next update for each client on his or her caseload. Updates that are due in the next few days appear highlighted in yellow, and those overdue are highlighted in red. This dashboard can be sorted by due date, so that it is possible to see what is due each day as the counselor works. Staff are being trained to look at this CAM Dashboard daily, and to contact clients who have missed appointments to follow up and attempt to re-engage them in a timely manner. Clients who do not respond to our attempts to re-engage will be discharged from treatment per our policies and procedures.
Although each counselor is responsible for managing his or her own caseload and are responsible for making sure each client is contacted and re-engaged in treatment if possible, the Clinical Supervisor will be responsible for seeing that all staff are trained in the use of the CAM Dashboard and in our policies and procedure regarding discharging inactive clients. The Clinical Supervisor, Assistant Administrator and Director as a team are responsible to see that treatment plans and updates are done timely, and clients who have not been attending are discharged from treatment.
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