INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25-26, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Adams Havover 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:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff .
The findings include:
Two personnel records requiring documentation of HIV/AIDS and TB/STD training were reviewed on July 25, 2012. Two out of two records, specifically records # 4 and 5, did not contain the required documentation.
Employee #4, a counselor, was hired on May 27, 2011. Training was due by May 29, 2012. As of the licensing inspection, there was no documentation of HIV/AIDS or TB/STD training for employee #4.
Employee #5, a counselor, was hired on July 6, 2011. Training was due by July 6, 2012. As of the licensing inspection, there was no documentation of HIV/AIDS or TB/STD training for employee #5.
The findings were confirmed with the clinical supervisor during the administrative review on July 26, 2012.
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Plan of Correction
The Clinical Supervisor will set up a training for Staff 5, using the guidelines from the Licensing Alerts to train Staff #5. This training will be completed no later than 11/15/2012.
To avoid this problem with new hires, the Clinical Supervisor will meet with new hires monthly to document progress towards meeting the mandatory training requirements. |
705.24 (4) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(4) Provide privacy in toilets by doors.
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Observations
Based on an inspection of the physical plant, the facility failed to provide privacy in toilets with doors.
The findings include:
A physical plant inspection was conducted with the clinical supervisor on July 26, 2012 at approximately 3:00 PM. During the inspection it was found that the second stall in the lady's bathroom did not have a door to provide privacy. The clinical supervisor confirmed the findings.
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Plan of Correction
The Clinical Supervisor discussed this finding with the Project Director. Our Maintenance Director has reported that the door will be installed by September 28, 2012 to bring us into compliance. The Maintenance Director will notify the Clinical Supervisor at the completion of the project. This is the only bathroom that did not have an individual stall door. The rest of the facilities and bathrooms all are stand alone bathrooms and have the capability to be locked at the entrance door or all have stall doors already installed. The Clinical Supervisor will complete daily walk through inspections to make sure that bathrooms have the required stall doors. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
The findings include:
Three personnel records were reviewed on July 26, 2012 to verify that all personnel on all shifts had been trained to perform assigned tasks during emergencies. The facility failed to document the completion of emergency training in three of three personnel records reviewed, specifically employees # ' s 5, 6, and 7.
Employee # 5 was hired as a counselor on July 6, 2011. As of the date of inspection, there was no documentation to verify that employee #5 received emergency training.
Employee # 6 was hired as a counselor on May 22, 2012. As of the date of inspection, there was no documentation to verify that employee #6 received emergency training.
Employee # 7 was hired by the project on October 4, 2011 and became an drug and alcohol counselor on March 1, 2012. As of the date of inspection, there was no documentation to verify that employee #7 received emergency training.
The findings were confirmed during a conversation with clinical supervisor on July 26, 2012.
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Plan of Correction
The Clinical Supervisor and the Facilities Director met on August 9, 2012 to discuss this requirement. The Clinical Supervisor and the Facilities Director have created a document from our Agency Disaster Plan that outlines individual responsibilities in the event of an emergency. These responsibilities will be presented at the next staff meetings for each site. A signed copy of the responsibilities will be placed in each staff personnel file to review. The Clinical Supervisor will have this done, agency wide, by September 28, 2012.
All new hires will receive and sign off on this policy during their orientations and within 7 days of hire. Staff #5 and staff #6 were trained as of September 24, 2012. Staff #7 has not worked in the project since August 24, 2012. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of the facility's administrative documentation, the facility failed to provide verification of a written agreement with a licensed hospital or physician, for 24 hour emergency psychiatric and medical coverage.
The findings include:
The administrative documents were reviewed on July 25, 2012. The facility was unable to provide a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric and medical coverage, as required.
An interview with the facility director confirmed the facility did not secure a current contract for emergency psychiatric or medical coverage.
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Plan of Correction
The Clinical Supervisor contacted both the Facilities Director and Project Director for this citation. The Project Director has reported that the request for Letters of Agreement for Medical and Psychiatric coverage has been made verbally and that there will be written documentation to that effect by the end of September 28, 2012. The Clinical Supervisor will monitor the progress and once we have the Letters of Agreement will make sure that copies are available in the Policy and Procedure Manual.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to document a personal history that included historical information about the client's family, employment, education, military experience, and/ or recreational preferences in two of five client records reviewed.
The findings include:
Five client records were reviewed for documentation of a personal history on July 27, 2012.
Two out of five client records lacked documentation of a personal history that included historical information about the client's family, employment, education, military experience, and/or recreational preferences specifically client records #1 and 4.
Client #1 was admitted to treatment on April 30, 2012. The personal history was completed on April 30, 2012 and did not include information about the client ' s family, employment, education, military experience, and recreational preferences.
Client #4 was admitted to treatment on August 29, 2011 and discharged on February 10, 2012. The personal history was completed on August 25, 2011 and did not include information about the client ' s employment, education, and military experience.
The findings were reviewed with the clinical supervisor on July 27, 2012.
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Plan of Correction
The Clinical Supervisor has documented this finding to staff during the staff meeting on August 28, 2012. The Clinical Supervisor will start with weekly chart reviews on October 2, 2012 to ensure that clinicians are in compliance with documenting the personal history for each client is fully completed. For client #1 a note will be added to the note section of the EMR addressing all required areas of the personal history. If everything is to standard through the month of October, then the Clinical Supervisor will do monthly case reviews to verify compliance with staff. These monthly reviews will continue with each staff member. The documentation will be available for review.
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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 psychosocial evaluation that included an assessment of the client's composite picture, assets and strengths, support systems, coping mechanisms, and/or negative factors that may affect treatment.
The findings include:
Five client records were reviewed for psychosocial evaluations on July 27, 2012. Five out of five client records lacked documentation of a psychosocial evaluation that included a clinical assessment, specifically client records #1, 2, 3, 4 and 5.
Client #1 was admitted to treatment on April 30, 2012. The psychosocial evaluation was completed on April 30, 2012 and did not include the client's composite picture, a clinical assessment of the client ' s assets and strengths and negative factors that may affect treatment.
Client #2 was admitted to treatment on May 1, 2012. The psychosocial evaluation was completed on May 1, 2012 and did not include the client's composite picture, a clinical assessment of the client ' s assets and strengths, and support systems.
Client #3 was admitted to treatment on March 15, 2012 and discharged on June 15, 2012. The psychosocial evaluation was completed on February 15, 2012 and did not include the client's composite picture, a clinical assessment of the client ' s support systems, coping mechanisms, and negative factors that may affect treatment.
Client #4 was admitted to treatment on August 29, 2011 and discharged on February 10, 2012. The psychosocial evaluation was completed on August 25, 2011 and did not include a composite picture of the client or a clinical assessment of the client's support systems.
Client #5 was admitted to treatment on August 12, 2011 and discharged on December 20, 2011. The psychosocial evaluation was completed on August 15, 2011 and did not include a clinical assessment of the client's support systems, or negative factors that may affect treatment.
The findings were reviewed with the clinical supervisor.
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Plan of Correction
The Clinical Supervisor will document the finding to staff during the next staff meeting on September 24, 2012. The Clinical Supervisor will do weekly case reviews starting September 28, 2012 to verify compliance with staff. The documentation will be available for review. The Clinical Supervisor will also meet with the EMR (Electronic Medical Records) supervisor to review the assessment form to make changes that will prompt staff to provide the required information. This is to be completed by 10/15/2012.
Also, information will be added in the NOTE section of the charts reviewed in their prospective EMRs to update missing elements of the biopsychosocial evalations by November 30, 2012. |
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
Based on a review of client records, the facility failed to document treatment plans to include the type and frequency of treatment and rehabilitation services in four of five client records.
The findings include:
Five client records were reviewed for treatment plans on July 27, 2012. Four out of five client records lacked documentation of a treatment plan that included the type and frequency of treatment and rehabilitation services, specifically client records # 1, 3, 4, and 5.
Client #1 was admitted to treatment on April 30, 2012. The treatment plan was completed on May 7, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client #3 was admitted to treatment on March 15, 2012 and discharged on June 15, 2012. The treatment plan was completed on March 29, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client #4 was admitted to treatment on August 29, 2011 and discharged on February 10, 2012. The treatment plan was completed on September 16, 2011 and did not include the type and frequency of treatment and rehabilitation services.
Client #5 was admitted to treatment on August 12, 2011 and discharged on December 20, 2011. The treatment plan was completed on September 20, 2011 and did not include the type and frequency of treatment and rehabilitation services.
The findings were discussed with the clinical supervisor on July 27, 2012.
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Plan of Correction
The Clinical Supervisor documented the finding to staff on September 21, 2012. The Clinical Supervisor will start with weekly chart reviews starting 10/02/2012 to ensure that staff is addressing the type and frequency of treatment in the treatment plan. Beginning 10/28/2012, the Clinical Supervisor will start with monthly reviews of this citation to verify compliance with staff provided we have been in compliance with the weekly checks.
For correcting the treatment plans on clients #1 and #2, the Compliance Officer informed the Clinical Supervisor that we are not permitted to alter an existing document. Alternatively, the type and frequency will be documented in their prospective NOTE section of the EMR. This will be completed by October 31, 2012.
The documentation will be available for review.
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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 upon a review of the facility's policies and procedures and client records, the facility failed to document case consultations as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from July 25-26, 2012.
The policy referencing the time frame for case consultation states: Case consults are to be completed at the 90 day interval and every 90 days thereafter.
Two client records requiring documentation of case consultations were reviewed on July 27, 2012. Two of two client records did not have documentation of a case consultation, specifically #'s 4 and 5.
Client #4 was admitted to treatment on August 29, 2011 and discharged on February 10, 2012. A case consultation was due by November 29, 2011 for client #4. As of the date of inspection, there was no documentation of a case consultation for client #4.
Client #5 was admitted to treatment on August 12, 2011 and discharged on December 20, 2011. A case consultation was due by November 14, 2011 for client #5. As of the date of inspection, there was no documentation of a case consultation for client #5.
The findings were reviewed and confirmed with the clinical supervisor on July 27, 2012.
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Plan of Correction
The Clinical Supervisor will document the finding to staff during the next staff meeting on August 28, 2012. The Clinical Supervisor will meet with staff monthly to review any Case Consultations that need completed. The Clinical Supervisor will do monthly case reviews starting in September to verify compliance with staff. The documentation will be available for review. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based upon a review of the facility's policies and procedures and client records, the facility failed to document a follow up contact as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from July 25-26, 2012.
The policy referencing the time frame for attempting a follow up contact states: In one month the agency will contact the client by phone or mail to complete a brief survey.
Two client records requiring documentation of a follow up attempt were reviewed on July 27, 2012. Two of two client records did not have documentation of a follow up, specifically #'s 4 and 5.
Client #4 was admitted to treatment on August 29, 2011 and discharged on February 10, 2012. A follow up was due by March 10, 2012 for client #4. As of the date of inspection, there was no documentation of a follow up for client #4.
Client #5 was admitted to treatment on August 12, 2011 and discharged on December 20, 2011. A case consultation was due by January 20, 2011 for client #5. As of the date of inspection, there was no documentation of a follow up for client #5.
The findings were reviewed and confirmed with the clinical supervisor on July 26, 2012.
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Plan of Correction
The Clinical Supervisor met with the Medical Records Staff on 8/31/2012 to document this citation. The Clinical Supervisor will initially start with weekly chart reviews October 2, 2012 and through October 31, 2012 to verify compliance with our follow up procedures. Starting November 1, 2012 the Clinical Supervisor will do monthly chart audits to ensure compliance, provided that there are not issues in October.
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