INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 17 through 18, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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 and a plan of correction is due on February 25, 2008.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document the educational qualifications for a counselor in one of five records reviewed, #6.
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Plan of Correction
Aldie identified with the DOH, through direct discussion and review of transcripts, prior to hire, that a foreign educated employee would need to complete the application process as defined by The World Education Services. Upon hire it was identified that this clinician had already completed and forwarded her WES application. At the time of licensing, a response had not yet been received.
The identified staff member will develop a documented timeline by 3/1/08 for tracking and completion of her World Educational Services (WES) application. The Clinical coordinator will maintain oversight of this process to identify completion.
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of personnel records and training records, the facility failed to document assessment of staff training needs for the 2007 - 2008 training year in eight of nine personnel records reviewed, #1, 2, 3, 4, 5, 6, 8 and 9.
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Plan of Correction
In recent months there have been several staff changes which impacted the identification of a point person to manage staff training needs.
The site coordinator will develop and implement a timeline for identifying and insuring that all staff training needs are identified, assessed and documented. All current training files, included those noted during the inspection, will be brought into compliance. Both actions will be completed by 4/1/08
Site coordinators will ensure compliance through the development of a system of checks and balances across sites to monitor training benchmarks
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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, the facility failed to document complete psychosocial evaluations in two of two client records reviewed, #1 and 2. Psychosocial evaluations did not include the counselor's assessment of the client's assets/strengths, support systems and coping mechanisms in client record #1 and the support systems, coping mechanisms and the negative factors that may inhibit treatment in client record #2.
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Plan of Correction
Clinicians do not consistently fully comprehend the need to synthesize the factual information gathered in the intake into a clinical evaluation of assets/strengths/ support systems and coping mechanisms, as well as the required timeframes for completion of this document.
Program coordinator will provide training by 3/1/08 regarding the completion of an evaluative, not merely historical, biopsychosocial assessment. Specific attention will be paid to the assessment of collected clinical data.
Program coordinator will insure compliance by reviewing the biopsychosocial assessments prior to cosigning clinicians signature.
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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, the facility failed to document goals stated in terms of measurable criteria in two of two client records reviewed, #1 and 2.
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Plan of Correction
Clinicians do not consistently fully comprehend the clinical benefits and need to provide measurable observable goals when formulating the treatment plan.
The program coordinator will train clinical staff on the completion of treatment plans with observable, measurable goals by 3/1/08. The coordinator will insure compliance by reviewing all treatment plans prior to cosigning clinicians signature
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709.82(e)(6) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(6) Vocational.
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Observations
Based on a review of administrative documentation, the facility failed to document assisting the clients in obtaining vocational support services. The letter of agreement with the Bucks County Office of Employment and Training had expired on July 25, 2007.
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Plan of Correction
All referral agreements were mailed out in a timely manner. At the time of licensing a response from The Bucks County Office of Employment and Training had not been received.
The office manager will obtain a current referral agreement with the Bucks County office of Employment and Training. The Program Coordinator will train all clinical staff on case management and resource development as a key element in the development of treatment plan goals. A spread sheet will also be developed to track the distribution and receipt of all referral agreements. All actions will be completed by 3/1/08.
The program coordinator will insure compliance with the utilization of comprehensive support services through the review and cosigning of client case consultations.
The office manager will be responsible for the maintenance of the referral agreement tracking sheet.
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709.23(b) 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:
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Observations
Based on a review of administrative materials, the facility failed to document that the 2007-2008 project goals and objectives were presented to the Board.
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Plan of Correction
The project goals were scheduled to be presented at a board meeting where a quorum was not present for review. This item was rescheduled for a following board meeting and was subsequently overlooked.
The Project Director will present the 2007 ? 2008 project goals at the next board meeting. Compliance will be indicated by documentation in the minutes.
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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, the facility failed to document a complete psychosocial evaluation in four of eight client records reviewed, #2, 4, 5 and 7. The psychosocial evaluations in #2, 5 and 7 did not provide the counselor's assessment of the client's assets/strengths, coping mechanisms, and negative factors that may inhibit treatment. Additionally, #4 had a psychosocial evaluation that was completed a year and half ago from the current admission of the client.
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Plan of Correction
Clinicians do not consistently fully comprehend the need to synthesize the factual information gathered in the intake into a clinical evaluation of assets/strengths/ support systems and coping mechanisms, as well as the required timeframes for completion of this document.
Program coordinator will provide training by 3/1/08 regarding the completion of an evaluative, not merely historical, biopsychosocial assessment. Specific attention will be paid to the assessment of collected clinical data and the allowable timeframes for completion.
Program coordinator will insure compliance by reviewing the biopsychosocial assessments prior to cosigning clinicians signature.
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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, the facility failed to document goals stated in terms of measurable criteria in seven of eight client records reviewed, #1, 2, 3, 5, 6, 7 and 8.
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Plan of Correction
Clinicians do not consistently fully comprehend the clinical benefits and need to provide measurable observable goals when formulating the treatment plan.
The program coordinator will train clinical staff on the completion of treatment plans with observable, measurable goals by 3/1/08.
The coordinator will insure compliance by reviewing all treatment plans prior to cosigning clinicians signature
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