INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19 through 21, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Treatment Services 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 25, 2008.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the staffing requirements facility summary report and staff interview on February 20, 2008, the facility failed to employ a full-time clinical supervisor for every eight full-time equivalent (FTE) counselors or counselor assistants. A review of the staffing requirements facility summary report showed that the project had 15.5 full-time equivalent (FTE) counselors or counselor assistants. A review of four of four clinical supervisor positions held by employee #2, 5, 8 and 12 revealed that only staff person #12 was functioning as a full-time clinical supervisor. A total of 77.5 clinical supervision hours per week are needed for 15.5 FTE counselors and the project had only 55 clinical supervision hours per week documented.
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Plan of Correction
The hours of Clinical Supervisory staff have already been increased to a total of 78 hours per week to meet the staffing requirements.
This situation is being reviewed in semi-weekly supervisory meetings with the Executive Director to assure compliance. |
709.81(b)(6) LICENSURE Intake and admission
709.81. 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 on February 20 and 21, 2008, the facility failed to document a complete psychosocial evaluation in three of four client records reviewed, #1, 2 and 3. Psychosocial evaluations were more historical than evaluative and did not include a clinical analysis of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, client's attitude toward treatment and overall impressions.
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Plan of Correction
The Clinical Director will hold in-services over the next few Thursdays during staff meetings to address all deficiences in particular the Psochosocial evaluations specific to the evaluative piece. On May 9th the Clinical Director will hold a training addressing all deficiencies as a review allowing us time to arrange CAC credit hours as part of our Annual Training Plan. Patient files are reviewed(randomly) quarterly in case file reviews by the Clinical Director and all Clinical Supervisors. There will be a focus on Pscho./social evaluations to make sure thay are meeting criteria as outlined. |
709.82(a)(1) LICENSURE Treatment and rehabilitation services
709.82. 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.
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Observations
Based on a review of client records on February 20 and 21, 2008, the facility failed to document a complete treatment plan in three of four records reviewed, #1, 2 and 3. Treatment plans were not individualized to address each clients' problems/needs.
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Plan of Correction
Treatment planning issues will be addressed by the Clinical Director over the next several weeks in staff meetings. On May 9th we will facilitate an in-house traing adressing all defecient areas. We will apply for approval of CAC hours to help with our Annual Traing Plan. Quarterly case file reviews will be used to monitor compliance along with weekly supervisory sessions.
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709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records on February 20 and 21, 2008, the facility failed to identify proposed support services on the individual treatment and rehabilitation plan in three of four records reviewed, #1, 2 and 3. Support services were AA/NA for each client with no individualized services identified specific to each clients' problems/needs.
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Plan of Correction
The problem of individualized support services on treatment plans will be addressed over the next two weeks at staff metings bt the Clinical Director. As mentioned previously the Agency will hold an in-house traing May 9th to address all outlined deficiencies. Quarterly case file reviews will be used to monotor compliance along with weekly supervisory sessions. |
709.83(a)(9) LICENSURE Client records
709.83. 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:
(9) Progress notes.
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Observations
Based on a review of client records on February 20 and 21, 2008, the facility failed to document complete progress notes in three of four records reviewed, #1, 2 and 3. Group progress notes did not include a comment relative to each individual's response or participation in group.
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Plan of Correction
The clinical Director will update all treatmenrt staff on progress notes over the next two staff meetings 3/13 & 3/20. Along with an in-house training on May 9th. Quartely case file reviews will be used to monitor compliance along with weekly supervisory sessions. |
709.83(a)(10) LICENSURE Client records
709.83. 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:
(10) Discharge summary.
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Observations
Based on a review of client records on February 20 and 21, 2008, the facility failed to document complete discharge summaries in two of two records reviewed, #3 and 4. Discharge summaries did not include the reasons for this treatment experience or the client's response to treatment plan goals.
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Plan of Correction
The Clinical Director will review correct & complete discharge summaries over the next two staff meetings (3/13 & 3/20/08). Along with the in-service scheduled for May 9th. Quarterly case file reviews, supervisor review of all discharged files along with weekly supervisory sessions will be used to monitor compliance. |
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 on February 20 and 21, 2008, the facility failed to document a complete psychosocial evaluation in six of six records reviewed, #5, 6, 10, 11, 12 and 13. Psychosocial evaluations were more historical than evaluative and did not include a clinical analysis of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, client's attitude toward treatment and overall impressions.
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Plan of Correction
The clinical Director will be holding an in-service in a staff meeting on March 27th to adress the areas as outlined in 1871. Along with an in-service to be held on May 9th. Quarterly case file reviews, discharge file reviews and weekly supervisory sessions will be used to monitor compliance. |
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.
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Observations
Based on a review of client records on February 20 and 21, 2008, the facility failed to document a complete treatment plan in five of six records reviewed, #6, 10, 11, 12 and 13. Treatment plans were not individualized to address each clients' problems/needs.
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Plan of Correction
The Clinical Director will adress treatment planning in a staff meeting on March 27th addressing the concerns outlined in 1877. It will also be part of an in-service at the Agency scheduled for May 9th. Quarerly case file reviews, discharge case file reviews along with weekly supervisory sessions will be used to monitor compliance. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records on February 20 and 21, 2008, the facility failed to identify proposed support services on the individual treatment and rehabilitation plan five of six records reviewed, #6, 10, 11, 12 and 13. Support services were AA/NA for each client with no individualized services identified specific to each clients' problems/needs.
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Plan of Correction
The Clinical Director will again address the issues identified pertaining to treatment planning in a staff meeting on March 27th. It will also be part of training addressing all areas sited. Quarterly case file reviews, discharge file reviews and weekly supervisory sessions will be used to monitor compliance. |
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
Based on a review of client records on February 20 and 21, 2008, the facility failed to document a complete treatment plan update in seven of seven records reviewed, #5, 6, 7, 9, 10, 11 and 13. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the individual treatment plan.
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Plan of Correction
The Clinical Director will include treatment plan updates as part of his training on March 27th and it will also be included in a training scheduled for May 9, 2008. Quarterly case file reviews, discharge file reviews and weekly supervisory sessions will be used to monitor compliance. |
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.
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Observations
Based on a review of client records on February 20 and 21, 2008, the facility failed to document complete progress notes in six of six records reviewed, #5, 6, 10, 11, 12 and 13. Group progress notes did not include a comment relative to each individual's response or participation in group.
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Plan of Correction
Group progress notes will be part of in-service done on either March 20 or 27th facilitated by Clinical Diresctor and again in the general training on May 9, 2008. Quarterly case file reviews, discharge file reviews and weekly supervisory sessions will be used to monitor compliance. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records on February 20 and 21, 2008, the facility failed to document a complete aftercare plan in two of three records reviewed, #7 and 9. Aftercare plans did not include personal goals with time frames. Support services specific to the individual were not identified in client record #9.
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Plan of Correction
Will be addressed in staff meeting on March 20, 2008 by the Clinical Director. Also on May 8th as part of a Agency training led by the Clinical Director. Quarterly case file reviews, discharge case file reviews and weekly supervisory sessions will be used to monitor compliance. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records on February 20 and 21, 2008, the facility failed to document completed discharge summaries in four of four records reviewed, #7, 8, 9 and 10. Discharge summaries did not address the client's reasons for this treatment experience in four records, #7, 8, 9 and 10. The client's response to treatment plans goals were not addressed in three records, #7, 8 and 10.
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Plan of Correction
Discharge summaries will be reviewed on March 27th by the Clinical Director and again in the general training adressing all areas sited on May 9, 2008. Quarterly case file reviews, discharge case file reviews and weekly supervisory sessions will be used to monitor compliance. |