INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25, 2008 through June 27, 2008 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 July 23, 2008.
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Plan of Correction
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the fire drill record, the facility failed to conduct fire drills on different staffing shifts from October 2007 through May 2008. All fire drills were conducted between the hours of 8:30 a.m. and 5:00 p.m. The facility's hours of operation are from 8:30 a.m. to 9:00 p.m.
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Plan of Correction
Fire drills will be performed on all shifts, to include evening hours, at all sites, between the hours of 8:30am and 9om. The fire drills will be performed by the Clinical Supervisor or by the Office Manager. The Clinical Supervisor will oversee the fire drills to ensure that all shifts are included. This will start with the month of July, 2008. |
709.23(b)(3) 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:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a performance report summarizing the progress towards meeting goals and objectives for the 2007/2008 fiscal year.
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Plan of Correction
In September, 2008 at the next Board Meeting, the Project Director will present and discuss progress meeting agency goals and objectives with the Board. |
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 complete psychosocial evaluations in five of six records reviewed, #1, 2, 3, 4 and 6. Psychosocial evaluations did not include a clinical assessment of the client's problems/needs, assets and strengths, support systems, coping mechanisms, negative factors that my inhibit treatment and client's attitude towards treatment.
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Plan of Correction
A meeting with clinical staff has been set up for August 7, 2008, by the Clinical Supervisor to address the necessity and expectation of completing the psycho/social assessment in its entirety. A review of deficient areas is on the agenda. The Clinical Supervisor will monitor progress on a bi-monthly basis by reviewing charts at random. Deficiencies still found, will be addressed with the clinician to assure 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, the facility failed to document a complete treatment plan in five of six records reviewed, #1, 2, 3, 4 and 6. Treatment plan goals were not stated in terms of measurable criteria.
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Plan of Correction
A meeting of the clinical staff has been set up for Aug 7, 2008 by the Clinical Supervisor to review expectations of treatment planning. This will include the need to write treatment plans in terms of mearuable goals. The Clinical Supervisor will monitor progress, through random chart reviews, on a bi-monthly basis to ensure compliance. Deficiencies still found will be addressed with the clinician to assure 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 a complete treatment plan updates in five of six client records reviewed, #1, 2, 3, 4 and 6. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the treatment plan.
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Plan of Correction
A meeting of the clinical staff has been set up for Aug 7, 2008, by the Clinical Supervisor to address the need to include an interpretive assessment in how our clients are meeting stated goals. This will be monitored by the Clinical Supervisor thru a bi-monthly review of charting by the Clinical Supervisor. |