INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9, 2009 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 5, 2009.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of CPR/First Aid cards and interview with Clinical Supervisor, the facility failed to have sufficient number of staff persons who are CPR certified on site during the project's hours of operation.
Findings
Based on the review of CPR/First Aid cards and an interview with the Clinical Supervisor it was determined that the facility was unable to provide CPR coverage. The facility did not have enough trained designated people who were CPR certified to provide the needed coverage during the facility's hours of operation.
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Plan of Correction
The drug and alcohol therapist assigned to this location received her CPR/First Aid credentials on 7-16-09. The Clinical Supervisor will monitor the certifications of all clinicians through monthly review of the Training Manual to ensure that these credentials remain up to date. Documentation is in the Training Manual housed in Hanover and with the individual clinician. |
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 a review of personnel records, the facility failed to ensure and document that counselors completed at least 25 hours of training for the training year 2007/2008 in one of one records.
Findings:
Four personnel records were reviewed on July 7, 2009. One personnel record was required to contain documentation of twenty-five training hours during a year. Personnel record #5 failed to document the required twenty-five hours of training for training year 2007/2008.
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Plan of Correction
The Drug and Alcohol therapsit has 18 hours of training on record for this training year. THe Clinical Supervisor will monitor the additional needed training hours through direct supervision/staff meetings. This requirement, since we are coming up to the end of this training year, has been presented to this therapist to remind her of the requirement. The Clinical Supervisor will provide ongoing guidance to ensure compliance. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one of four client records.
Findings:
Four client records were reviewed on July 9, 2009. Consent to release information forms were required in four client records. Client record #3 was a re-admit and his consent to release forms was not documented in client record reviewed.
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Plan of Correction
The Clinical Supervisor is formally meeting with this therapist on 8-7-09 to review the requirements of paperwork for readmission to the program. As part of the training, it will be discussed that new releases are required for each treatment episode. COmpliance will be in the form of weekly chart reviews, with problems documented on the Supervision Documentation form. If a chart is out of compliance, the chart will be flagged and re-reviewed for compliance. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records, the facility failed to have demonstrated efforts toward informing clients of their client rights in two of four records reviewed.
Findings
Four client records reviewed on July 9, 2009. Documentation that Client rights were provided was required in four client records reviewed. Client records #2 and 4 did not provide documentation that patient rights had been provided.
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Plan of Correction
The Clinical Supervisor will formally meet with this therapist on 8-7-09 to review the expectations of paperwork. During this interview, we will review the requirements governing ensuring clients are aware of their rights and expectations in treatment. Charts will be reviewed on a weekly basis, if a chart is not in compliance, the chart is returned to the therapist for correction and the chart re-reviewed for compliance. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to have demonstrated intake procedures in client records two of four records reviewed.
Findings
Four client records reviewed on July 9, 2009. Intake procedures were required in four client records reviewed. Clients #3 and 4 were readmitted to the program; there was no documentation of completed admission paperwork upon their readmissions in client records' 3 & 4.
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Plan of Correction
On 8-7-09, the Clinical supervisor will formally meet with this clinician to review the expectations that if a client is returning to treatment within a 6 month time frame, it will be explained that the orginal intake packet must be reviewed and updated as needed, at the next Intake visit, preferably in contrasting ink. The evaluation is to be one at each Intake visit, regardless of the time lapse. This documentation expectation will be monitored through chart reviews. If a chart is not in compliance, a Supervision Docuemtnation form will be sent to the therapsit and the chart reviewed again during the next chart review visit |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to have demonstrated intake procedures in client records two of four records reviewed.
Findings
Four client records reviewed on July 9, 2009. Intake procedures were required in four client records reviewed. Client records #3 and 4 did not contain documentation that facility policies had been reviewed.
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Plan of Correction
On 8-7-09, the Clinical Supervisor will meet with this therapist to discuss the requirements of our paperwork. It will be pointed out that if the appropriate documentation is not in the chart, we are out of compliance. A review of the required paperwork will review our compliance expectations. This will be monitored through weekly chart reviews with problems returned to the therapist for correction and a follow up review of the chart. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to have demonstrated intake procedures in client records two of four records reviewed.
Findings
Four client records reviewed on July 9, 2009. Intake procedures was required in four client records reviewed. Client records #3 and 4 did not have documentation in records reviewed.
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Plan of Correction
The Clinial Supervisor will formally meet with the therapist on 8-7-09 to review the paperwork standards that are required. During that review, we will review the necessity of reviewing information the client needs to have when entering treatment. Compliance will be in the form of weekly chart reviews, with charts not meeting the standard returned to the therapsit for correction. The chart is then reeviewed for 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, the facility failed to complete psychosocial evaluations in four of four client records.
Findings:
Four client records were reviewed on July 9, 2009. Psychosocial evaluations were required in four client records. The facility failed to document a clinical assessment by the counselors that included an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor's conclusion and impressions of the client in client records #1, 2, 3 and 4.
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Plan of Correction
The CLinical Supervisor will meet with this therapist to review the required components of the psychosocial evaluations. The therapist will be given an example of the expectation. Charts will be reviewed on a weekly basis to ensure that all components are included. The Inake packet is being redone to provide better promting for the required information and will be ready to use by 8-30-09. |
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 the review of client records, the facility failed to individualize treatment plans in two of four records reviewed.
Findings:
Four records were reviewed on July 9, 2009. Treatment plans were required in four records reviewed. Treatment plans long and short term goals were not individualized and specific to the needs to the client, records #1 and 2 contained the same treatment plans.
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Plan of Correction
The clinical Supervisor will formally meet with the therapist on 8-7-09 to review the requirements of making treatment goals individualized for each client. THis expectation will be reviewed during weekly chart reviews and if a chart does not meet that standard, that therapist will be notified that the chart needs correcting. The chart is then reviewed for 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, the facility failed to document complete treatment plan updates four of four client records.
Findings:
Four client records were reviewed on July 9, 2009. Treatment plans updates were required in four client records. In client records #1, 2, 3 and 4 the treatment plan update did not include the client's progress in relationship to the stated goals of the treatment plan, but rather stated generalized comments that were not specific to the client's progress in treatment.
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Plan of Correction
The Clinical Supervisor will formally meet with this clinician on 8-7-09, to review the requirements that include the client's progress in relationshop towards stated goals, not generalized statements. This standard will be reviewed through weekly chart reviews and if a chart requires information, the therapist is notified and the chart will then be reviewed for compliance. |
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 a review of client records, the facility failed to document complete case consultations notes in two of two client records.
Findings:
Four client records were reviewed on July 9, 2009. Case consultations were required in two client records. In accordance with the facility's policy and procedure case, consultation notes will be documented every 90 days after admission. Client record #3 was admitted on 10/24/08 and discharged on 4/28/09; no case consultation was documented. Client record #4 was admitted on 12/18/08 and discharged on 6/10/09; no case consultation was documented.
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Plan of Correction
The Clinical Supervisor will meet with the therapist on 8-7-09 to review Case Consultation guidelines. Charts will be reviewed on a weekly basis to ensure that our standards are met. If a chart is out of compliance the therapist is notified that an action is required, and the case will be reviewed again and the next review. |
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, the facility failed to complete documentation of discharge summaries in two of two client records reviewed.
Findings:
Four client records reviewed on July 9, 2009. Discharge summaries were required in two client records. Client records #3 and 4 did not document the client's reason for treatment and client's response to treatment.
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Plan of Correction
On 8-7-09, the Clinical Supervisor will meet with the therapist to review requirements for paperwork. During this review, the required components of discharge summaries will be reviewed. Chart reviews of closed cases will review compliance. If not in compliance the chart is returned to the therapist for correction and the chart reviewed for follow through. |