INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on December 12-13, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Aldie Counseling Center 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(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 the review of personnel records, the facility failed to ensure that each counselor complete at least 25 clock hours of training annually for the 2010 training year.
The findings include:
On December 13, 2011, one counselor's personnel record requiring documentation of 25 hours of training during the 2010 training year was reviewed. The facility did not document 25 hours of training from the 2010 training year in personnel record # 4.
Personnel record # 4 contained training certificates for only 11 hours of training completed during the 2010 training year.
An interview with the facility director on December 13, 2011 confirmed the findings.
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Plan of Correction
At a facility staff meeting, the clinical director and facility director reminded staff of the annual training requirements for all staff according to their position. Program coordinators shall monitor compliance through the preparation and review of each counselor's individual annual training plan. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's fire drill log, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
The facility's fire drill log was reviewed on December 13, 2011. From January 2011 to November 2011, the facility's fire drill log indicated all staff exited through the side doors during each of the fire drills.
The findings were confirmed by the facility director on December 13, 2011.
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Plan of Correction
The office manager will designate alternate exit routes when conducting monthly fire drills, and will document this in the fire drill log entry for each drill. The facility director shall review the log to unsure that alternate exit routes are utilized and documented. |
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.
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Observations
Based on a review of the facility's client census reports, the facility failed develop a data collection and record keeping system that allows for the efficient retrieval of data needed to measure the project's performance.
The findings include:
The client census reports were reviewed on December 12, 2011. The client census reports did not include the dates of admission for clients currently enrolled in the program.
The findings were confirmed by the Project Director on December 12, 2011.
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Plan of Correction
Changes were made to the electronic data system to add a field that specifies the admission date, which may vary according to the criteria of each program, and changes were made to the Internal Utilization Review Policy to clarify and define the admission dates for these programs. Data entry staff was instructed on how to appropriately complete the admission date field. A client census report can now be generated that lists the applicable admission date for each program. When running this report, the fiscal manager will check to ensure the admission date field is being properly completed by the data entry staff. |
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 the review of client records, the facility failed to document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, conclusions regarding the client's appearance, behavior and reactions during the intake process and/or conclusions regarding the client's attitude towards and ability to participate in the treatment process.
The findings include:
On December 12-13, 2011, psychosocial evaluations in eleven client records were reviewed, specifically records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 14. The facility failed to document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, conclusions regarding the client's appearance, behavior and reactions during the intake process and/or conclusions regarding the client's attitude towards and ability to participate in the treatment process in eleven of eleven records reviewed, # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 14.
Client # 1 was admitted on 7/20/11. The psychosocial evaluation in client # 1's record did not include an assessment of the client ' s assets/strengths, support systems, coping mechanisms, negative factors, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client ' s attitude towards and ability to participate in the treatment process.
Client # 2 was admitted on 7/2/11. The psychosocial evaluation in client # 2's record did not include an assessment of the client's support systems, coping mechanisms, negative factors, and conclusions regarding the client's appearance, behavior and reactions during the intake process.
Client # 3 was admitted on 6/4/11. The psychosocial evaluation in client # 3's record did not include an assessment of the client's support systems and conclusions regarding the client's appearance, behavior and reactions during the intake process.
Client # 4 was admitted on 8/17/11. The psychosocial evaluation in client # 4's record did not include an assessment of the client's assets/strengths, coping mechanisms, negative factors, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude towards and ability to participate in the treatment process.
Client # 5 was admitted on 8/6/11. The psychosocial evaluation in client # 5's record did not include an assessment of the client's assets/strengths, support systems, negative factors, and conclusions regarding the client's appearance, behavior and reactions during the intake process.
Client # 6 was admitted on 6/4/11. The psychosocial evaluation in client # 6's record did not include an assessment of the client's negative factors and conclusions regarding the client's appearance, behavior and reactions during the intake process.
Client # 7 was admitted on 8/25/11, but at the time of review, client # 7's record did not contain a psychosocial evaluation.
Client # 8 was admitted on 8/2/11. The psychosocial evaluation in client # 8's record did not include an assessment of the client's assets/strengths, support systems, coping mechanisms, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude towards and ability to participate in the treatment process.
Client # 9 was admitted on 7/7/11. The psychosocial evaluation in client # 9's record did not include an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude towards and ability to participate in the treatment process.
Client # 10 was admitted on 6/14/11. The psychosocial evaluation in client # 10's record did not include an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client ' s appearance, behavior and reactions during the intake process.
Client # 14 was admitted on 7/22/11. The psychosocial evaluation in client # 14's record did not include an assessment of the client's assets/strengths, support systems, coping mechanisms, and conclusions regarding the client ' s appearance, behavior and reactions during the intake process.
The findings were confirmed by the Project Director on December 13, 2011.
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Plan of Correction
The clinical director made revisions to the form to include prompts that indicated what types of information should be included in each section of the psychosocial evaluation. The outpatient and NTP program coordinators explained the required elements of the psychosocial evaluation at their respective staff meetings, and will monitor compliance through individual counselor supervision and their quality reviews of client records. |
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 the review of client records, the facility failed to document a case consultation at least every 90 days as per facility policy.
The findings include:
On December 12-13, 2011, eleven client records requiring case consultations were reviewed, specifically records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 14. The facility did not document a case consultation at least every 90 days, as per facility policy in eight of eleven client records reviewed, # 1, 2, 3, 4, 7, 8, 9 and 10.
Client # 1 was admitted on 7/25/11, but the case consultation in client # 1's record was dated 11/29/11.
Client # 2 was admitted on 7/2/11, but the case consultation in client # 2's record was dated 10/22/11.
Client # 3 was admitted on 6/4/11, but the case consultation in client # 3's record was dated 12/5/11.
Client # 4 was admitted on 8/17/11, but the case consultation in client # 4's record was dated 12/5/11.
Client # 7 was admitted on 8/25/11, but client # 7's record did not contain a case consultation at the time of review.
Client # 8 was admitted on 8/2/11, but the case consultation in client # 8's record was dated 12/9/11.
Client # 9 was admitted on 7/7/11, but client # 9's record did not contain a case consultation at the time of review.
Client # 10 was admitted on 6/14/11, but client # 10's record did not contain a case consultation at the time of review.
The findings were confirmed by the facility director on December 13, 2011.
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Plan of Correction
Internal Utilization Review Policy and Procedure was revised to clarify and define program admission dates, which may vary according to the criteria of each program, and the corresponding due date for case consultation notes. Program coordinators shall monitor the timely completion of the case consultation notes via individual counselor supervision and their quality reviews of client records. |