INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Addictive Disease- Main Line Affiliates 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 November 12, 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 five personnel records on October 16, 2008, the facility failed to ensure that each counselor met the qualifications for the position in one of three records, as required.Findings:In personnel record #5, the counselor did not meet the qualifications for the position of counselor based on a Master of Science in Human Service Organization and a Bachelor of Arts in Criminal Justice. In addition, a review of the Master of Science degree course transcripts were reviewed by the Division and were found not to meet the educational component for the position of counselor.
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Plan of Correction
The employee in question has been reassigned the position of Counselor Assistant. She will begin pursuing her CAC certification, attend required supervision with the Clinical Director and submit progress reports as dictated by the regulations. |
711.91(b)(3)(iii) LICENSURE Personal History
711.91. 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 a review of four client records on October 16, 2008, the facility failed to document a complete personal history in two of four records, as required.Findings:In client records #1 and 2, the personal history contained incomplete information in the areas of family, employment, legal, recreation and sexual. Questions were left unanswered and it was unclear as to whether or not the client was asked these questions or if the client did not want to respond to the questions.
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Plan of Correction
The Clinical Director will hold a supervision training session with all Clinicians who perform evaluations. The need to complete the form, answering all questions, and documenting a refusal will be stressed.
Additionally, completeness of the evaluation will be incorporated into the quarterly record review that is performed by the Clinical Director. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of four client records on October 16, 2008, facility failed to document a psychosocial evaluation in four of four records reviewed, as required.Findings:In client records, #1, 2, 3 and 4, the psychosocial evaluation was based on client reported comments with a list of adjectives for each identified area and did not provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
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Plan of Correction
The Clinical Director will hold a supervsion training session with all Cliinicians where the need to provide a composite picture of the individual will be stressed. Clinicians will learn to document more than client reported comments.
The psychosocial evaluation will be a focus of the quarterly record review performed by the Clinical Director. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of four client records on October 16, 2008, the facility failed to develop an individual treatment and rehabilitation plan in one of three records, as required.Findings:In client record #3 there was no documentation of an individual treatment and rehabilitation plan. The individual treatment and rehabilitation plan is to be developed by the sixth group session as required by the project's policies and procedures for individual treatment and rehabilitation plans. The client was admitted to treatment on May 6, 2008. Based on the record of service form and progress notes, the client's sixth group session occurred on May 29, 2008. The client was discharged from treatment on August 12, 2008. The facility did not provide an individual treatment and rehabilitation plan during the licensing inspection.
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Plan of Correction
A training session will be held by the Clinical Director with all clinicians to stress that individual treatment plans must be completed upon recommendation for treatment and again updated upon the sixth session.
The Front Desk performs a chart audit and if individual treament plans are missing from a client record, the Clinical Director will be notified. |
711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) 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 four client records on October 16, 2008, the facility failed to develop short and long-term goals in individual treatment and rehabilitation plans in three of three records, as required.Findings:In client records #2 and 4 the short and long-term goals for treatment were identical and did not address specific individual needs as identified by the both staff and client, as requiredIn client record #3 there was no documentation of an individual treatment and rehabilitation plan. The individual treatment and rehabilitation plan is to be developed by the sixth group session as required by the project's policies and procedures for individual treatment and rehabilitation plans. The client was admitted to treatment on May 6, 2008. Based on the record of service form and progress notes, the client's sixth group session occurred on May 29, 2008. The client was discharged from treatment on August 12, 2008. The facility did not provide an individual treatment and rehabilitation plan during the licensing inspection.
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Plan of Correction
A training session will be held by the Clinical Director with all clinicians to assure the understanding of the policy and timeframes for individual treatment plans. Individualized goals will be a focus, and random charts will be reviewed quarterly by the Clinical Director to assure individualization. |
711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) 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 four client records on October 16, 2008, the facility failed to document proposed support services in the individual treatment and rehabilitation plan in two of three records, as required.Findings:In client records #3 and 4 there was no documentation of proposed support services in the individual treatment and rehabilitation plan. In addition, this documentation was not presented during the licensing inspection.
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Plan of Correction
A training will be held by the Clinical Director for all clinicians to stress the importance of documenting support services in the individual treatment and rehabilitation plan.
The Clinical Director will ensure support services are documented on the individual treatment team through the quarterly chart audit. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of four client records on October 16, 2008, the facility to review and update treatment and rehabilitation plans at least every 60 days in one of two records, as required.Findings:In client record #2, the treatment plan update did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan. In addition, goals were dropped from the individual treatment and rehabilitation and new ones added with no reason indicated in the record. This documentation was not presented during the licensing inspection.
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Plan of Correction
The Clinical Director will provide a supervision training to all clinicians to stress that an assessment of the client's progress in relationship to the stated goals of the treament plan are reviewed and updated every 60 days.
Front desk will notify the Clinical Director during the chart auditing process if updates are not completed within the stated timeframes.
Clinical Director will review random charts quarterly to asess quality of treatment plan updates. |