INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25-30, 2012 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:
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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:
One personnel records requiring documentation of HIV/AIDS and TB/STD training were reviewed on July 25, 2012. One of one personnel record, specifically record # 4, did not contain the required documentation.
Employee #4, 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 #4.
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 #4, using the guidelines from the Licensing Alerts to train Staff #4. 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.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to prohibit the use of heaters that are not permanently mounted or installed.
The findings include:
A physical plant inspection was conducted on July 30, 2012 at approximately 9:35 AM. At the time of the inspection it was observed there was a non-mounted space heater in office # 4 and another was detected in office #7.
The clinical supervisor was present during the inspection and confirmed the findings
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Plan of Correction
The Clinical Supervisor met with the Outpatient Supervisor for the site on August 9, 2012, and discussed the requirement. Both the Outpatient Supervisor and the Clinical Supervisor will review this requirement with prospective staff. The Clinical Supervisor has met with each therapist using offices about this requirement. The Office Manager was also instructed to check each office each morning when she opens up the offices to make sure that we are in compliance. The Clinical Supervisor will also conduct random and monthly office inspections to ensure compliance. Should this citation recur, then a meeting with the speific therapist and the Supervisor will take place to review the requirements. This will start by the end of August 2012.
The heaters discovered in offices #4 and #7 have since been removed from the building. |
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:
One personnel record was 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 one of one personnel record reviewed, specifically employee #5.
Employee # 5 was hired as a counselor on May 22, 2012. As of the date of inspection, there was no documentation to verify that employee #5 received emergency training.
The findings were confirmed with the 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 were presented at the staff meetings for each site. A signed copy of the responsibilities will be placed in each staff personnel file to review. The Clinical Supervisor had this completed, 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. Our orientations are considered the first day of paid employment. The Supervisor will have the disaster training sign off sheet added to the fire extinguisher training to ensure that the instruction is completed prior to starting the first day of clinical employment.
Staff #5 and staff #6 were trained as of September 24, 2012. Staff #7 has not worked in the project since August 24, 2012.
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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 regarding 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)(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, negative factors that may affect treatment, and/or the client's attitude towards treatment.
The findings include:
Four client records were reviewed for psychosocial evaluations on July 27, 2012. Four out of four client records lacked documentation of a psychosocial evaluation that included a clinical assessment, specifically client records #1, 2, 3, and 4.
Client #1 was admitted to treatment on June 12, 2012. The psychosocial evaluation was completed on June 12, 2012 and did not include the client's composite picture, a clinical assessment of the client's assets and strengths, support systems, coping mechanisms, and negative factors that may affect treatment.
Client #2 was admitted to treatment on January 23, 2012. The psychosocial evaluation was completed on January 23, 2012 and did not include the client's composite picture or a clinical assessment of the client's assets and strengths.
Client #3 was admitted to treatment on February 29, 2012 and discharged on May , 2012. The psychosocial evaluation was completed on February 29, 2012 and did not include the client's composite picture, a clinical assessment of the client's assets and strengths, support systems, and negative factors that may affect treatment.
Client #4 was admitted to treatment on April 24, 2012 and discharged on June 12, 2012. The psychosocial evaluation was completed on April 24, 2012 and did not include the client's composite picture, a clinical assessment of the client's assets and strengths, support systems, coping mechanisms, and 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 August 28, 2012. The Clinical Supervisor will start with weekly case reviews starting October 22,2012 to verify compliance with staff. Should staff remain in compliance for the next 2 months, the Clinical Supervisor will go to monthly reviews to document compliance. The documentation will be available for review. The Clinical Supervisor also met with the EMR (Electronic Medical Records) supervisor to review the assessment form to make changes that prompt staff to provide the required information. This was completed by October 15, 2012.
For clients #1 and #2, a note will be made in the NOTE section to add a completed biopsychsocial evaluation as we are unable to alter an exiting medical record. This will be completed by 10/31/2012. |
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 two of four client records.
The findings include:
Four client records were reviewed for treatment plans on July 27, 2012. Two out of four client records lacked documentation of a treatment plan that included the type and frequency of treatment and rehabilitation services, specifically client records # 1 and 2.
Client #1 was admitted to treatment on June 12, 2012. The treatment plan was completed on July 15, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client #2 was admitted to treatment on January 23, 2012. The treatment plan was completed on February 22, 2012 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 10/22/2012 to ensure that staff is addressing the type and frequency of treatment in the treatment plan. Beginning 11/22/2012, 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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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include the proposed type of support services in two of four client records.
The findings include:
Four client records were reviewed for treatment plans on July 27, 2012. Two out of four client records lacked documentation of a treatment plan that included the proposed type of support services, specifically client records # 1 and 2.
Client #1 was admitted to treatment on June 12, 2012. The treatment plan was completed on July 15, 2012 and did not include the proposed type of support services.
Client #2 was admitted to treatment on January 23, 2012. The treatment plan was completed on February 22, 2012 and did not include the proposed type of support services.
The findings were discussed with the clinical supervisor on July 27, 2012
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Plan of Correction
The Clinical Supervisor will meet with staff on August 28, 2012 to review this finding. Staff will be instructed to document support services on the treatment plan. The Clinical Supervisor will conduct chart audits weekly starting 10/22/2012 to ensure that all staff are compliant with documenting support services for all clients. If by 11/22/2012, staff have been in compliance with this standard, the Clinical Supervisor will start reviewing charts monthly.
Staff were instructed to document support services in the progress notes of each client. For clients #1 and #2, a note will be added to the NOTE section of the EMR. |
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 treatment plan updates to include the client's progress as it relates to the goals identified on the individual treatment plan in one of two client records.
Two client records were reviewed for treatment plan updates on July 27, 2012. One of two client records lacked documentation of a treatment plan update that included the client ' s progress on goals, specifically client record # 2.
Client #2 was admitted to treatment on January 23, 2012. The treatment plan update was completed on February 22, 2012 and did not document the client ' s progress on the goals identified on the individual treatment plan.
The findings were reviewed with the clinical supervisor.
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Plan of Correction
The Clinical Supervisor met with staff on 28 August 2012 to review this citation. The Clinical Supervisor reviewed this requirement to document progress on treatment plans relative to the goal. THe Clinical Supervisor will be doing weekly chart reviews starting 10/22/2012 to ensure compliance.
The Clinical Supervisor will do monthly chart reviews if staff remain in compliance starting 11/22/2012.
For Client #1 and #2, a note will be added to the NOTE section of the EMR to update progress towards meeting goals for the listed time frame as we are unable to alter an existing EMR. |
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.
One client records requiring documentation of a case consultation was reviewed on July 27, 2012. One client record did not have documentation of a case consultation, specifically #2.
Client #2 was admitted to treatment on January 23, 2012. A case consultation was due by April 23, 2012 for client #2. As of the date of inspection, there was no documentation of a case consultation for client #2.
The findings were reviewed and confirmed with the clinical supervisor on July 27, 2012.
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Plan of Correction
The Clinical Supervisor documented the finding to staff during the meeting on August 28, 2012. Staff meetings will be held once a month to review Case Consultations to ensure compliance. The Clinical Supervisor will do monthly case reviews as well starting in September to verify compliance with staff. The documentation will be available for review.
A Case Consultation will be added to Client #2 by October 31, 2012.
With the assistance of the Facilities Manager, we have added a notification through the EMR for cases open for 90 days, triggering a reminder to staff that a Case Consulation form is due. This notification shows up on staff schedules at 80 days that a Case Consulation is coming due and for each 80 days thereafter until the case is closed.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based upon a review of the facility's policies and procedures and client records, the facility failed to document aftercare plans 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 which specified the timeframe for the completion of aftercare plans included the following language:
Aftercare plans are to be completed upon successful discharge during the last scheduled outpatient session.
Two discharged client records were reviewed on July 27, 2012. Two of two client records reviewed represented a client who was successfully discharged from treatment at the project. The facility failed to document and aftercare plan for client #4.
Client #4 was admitted to treatment on April 24, 2012. The client's last session and discharge date was June 12, 2012. As of the date of inspection, there was no documentation of an aftercare plan for client #4.
The findings were reviewed and confirmed with the clinical supervisor on July 27, 2012.
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Plan of Correction
The Clinical Supervisor reviewed this finding with staff on August 28, 2012 at the staff meeting. The Clinical Supervisor will conduct weekly chart reviews of the Aftercare Plans to ensure compliance starting 10/22/2012. If by 11/22/2012, the Aftercare Plans are being completed according to standards, the chart reviews will be done monthly. The chart reviews will start by the 10/22/2012. |