INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2011 through July 14, 2011 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on a supervisor review of the Staffing Requirements Facility Summary Report form completed by the facility on 7/12/11, the facility failed to present to the Department licensing representatives at the time of the project's site visit, a plan documenting the qualifications and training of staff.
The findings include:
The Staffing Requirements Facility Summary Report (SRFSR) completed by the facility on July 12, 2011 and presented to the Licensing Specialist on July 12, 2011 failed to document that the facility staff met the educational and training requirements of chapter 704.
Per the information provided by the facility on the SRFSR, the Project Director (hired into the position 11/1/07), Facility Director (hired into the position 6/18/01), Clinical Supervisor (hired into the position 5/16/94) and the "BO-GBG" (hired into the position 12/28/98), all only completed 4 hours of the mandatory 6 hours HIV/AIDS training.
In addition the facility documented that the CIS person (hired into the position 10/2/89), the R. N. (hired into the position 9/22/99) and the Psychiatrist (hired into the position 4/13/05) never completed any of the required six hours of training and employee #4 only completed 3 of the 6 required hours of training.
Pert the SRFSR form completed by the facility on July 12, 2011, the CIS person (hired into the position 10/2/89) and the R. N. (hired into the position 9/22/99) never completed any of the required four hours of TB/STD and other health related topics training and employee #4 only completed 3 of the 4 required hours of training.
The facility failed to list the dates when the individual training plans were developed for each of the eight employees.
The facility listed the entire training year as the date that the individual training plans were developed for the Project Director, Facility Director, Clinical Supervisor and Counselor.
The facility simply wrote "Oct - 10" for the date that the training plans were developed for the "BO-GBG" staff person, CIS staff person, R.N. and the psychiatrist
The facility failed to document the name of the university from which the Clinical Supervisor and Counselor earned there degrees on page 3 of the SRFSR form.
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Plan of Correction
HIV/AIDS and TB/STD trainings were improperly documented on the SRFSR form, the proper dates and hours are listed as follows:
PROJECT DIRECTOR: 6 HOURS HIV/AIDS AND 4 HOURS OF STD/TB ON 8/18/09
FACILITY DIRECTOR: 6 HOURS OF HIV/AIDS AND 4 HOURS OF STD/TB ON 4/15/02
CLINICAL SUPERVISOR: 6 HOURS OF HIV/AIDS AND 4 HOURS OF STD/TB ON 2/22/05
EMPLOYEE NUMBER 4: 6 HOURS OF HIV/AIDS ON 9/15/10 AND 6 HOURS OF STD/TB ON 9/2/2011.
The PSYCHIATRIST will be trained on HIV/STD/TB by Novemeber 30, 2011.
The RN, BO-GBG, and CIS employees do not interact with D&A clients and we are not using them to provide CPR/First Aid coverage. They should not have been included on the SRFSR form and will not be for future licensing inspections.
Training plans will include dates the plan was created and staff signatures, when the Clinical Supervisor meets with staff in September to develope these plans.
For future SRFSR reports, the SRFSRs were corrected on 8/8/2011 and are on file for reference only. One week prior to our next licensing visit, the Facility Director and the Clinical Supervisor will verify that all of the required information is included and accurate. The Facility Director and Clinical Supervisor will also review the SRFSRs to verify that all contain the names of colleges and universities where staff received their degrees. |
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 supervisor review of the Staffing Requirements Facility Summary Report form completed by the facility on 7/12/11, the facility failed to ensure that staff received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted disease and other health related topics training using a Department approved curriculum within the time frames as outlined in the regulation.
The findings include:
Per the Staffing Requirements Facility Summary Report (SRFSR) completed by the facility on July 12, 2011 and presented to the Licensing Specialist on July 12, 2011, the Project Director (hired into the position 11/1/07), Facility Director (hired into the position 6/18/01), Clinical Supervisor (hired into the position 5/16/94) and the "BO-GBG" (hired into the position 12/28/98), all only completed 4 hours of the mandatory 6 hours HIV/AIDS training.
In addition the facility documented that the CIS person (hired into the position 10/2/89), the R. N. (hired into the position 9/22/99) and the Psychiatrist (hired into the position 4/13/05) never completed any of the required six hours of training and employee #4 only completed 3 of the 6 required hours of training.
Pert the SRFSR form completed by the facility on July 12, 2011, the CIS person (hired into the position 10/2/89), the R. N. (hired into the position 9/22/99) and the Psychiatrist (hired into the position 4/13/05) never completed any of the required four hours of TB/STD and other health related topics training and employee #4 only completed 3 of the 4 required hours of training.
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Plan of Correction
HIV/AIDS and TB/STD trainings were improperly documented on the SRFSR form, the proper dates and hours are listed as follows.
PROJECT DIRECTOR: 6HRS HIV/AIDS AND 4 HRS OF STD/TB ON 8/19/09
FACILITIES DIRECTOR: 6 HRS HIV/AIDS AND 4 HRS OF STD/TB ON 4/15/02
CLINICAL SUPERVISOR: 6HRS HIV/AIDS AND 4 HRS STD/TB ON 2/22/05
THERAPIST: 6 HRS OF HIV/AIDS ON 9/15/10 AND 6 HRS STD/TB ON 9/2/11.
The PSYCHIATRIST will be trained in the appropriate number of hours by the end of November 2011.
The CIS and RN do not interact with D&A clients and will not be included on the SRFSR form for future licensing visits. We do not count them for coverage for CPR/First Aid. The Facilities Director and Clinical Supervisor will review the SRFSR form one week prior to our next licensing visit to verify that the information on the SRFSR form provides correct information. |
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 a review of the Staffing Requirements Facility Summary Report, a review of CPR and first aid cards and a discussion with the clinical supervisor, the facility failed to provide CPR certification and first aid training to a sufficient number of staff persons.
The findings include:
One part-time counselor works at this facility. According to the CPR and first aid cards provided by the facility, the sole part-time counselor who works at this facility has CPR certification, but does not have first aid training.
During a discussion with the clinical supervisor, she confirmed these findings. The clinical supervisor indicated she would make sure the counselor becomes certified for first aid training to provide more adequate coverage, but stated that, in the interim, the clinical supervisor, who is certified in CPR and first aid, would work out of this office when the part-time counselor works in order to provide adequate coverage.
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Plan of Correction
This part time employee is in the process of signing up for First Aid Training. She will have this completed by 10/1/2011. In the interim, the Clinical Supervisor will work out of this office when the part time counselor works in order to provide adequate coverage. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility and an interview with the clinical supervisor, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
On July 11, 2011 and July 12, 2011, the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed one part-time counselor, a clinical supervisor, project director and facility director as clinical staff .The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 37.5 hours per week.
Based the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week 37.5, and the total number of clients assigned to the following employees on July 12, 2011 employee # 4 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients 'treatment by the facility's standard workweek.
The number of hours per week devoted by employee # 4 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 10 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that employee #4 had 15 active clients on July 12, 2011.
Employee # 4 (10/37.5 = .266 FTE 15 clients/.266 FTE = 56.39:1 caseload)
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Plan of Correction
The Clinical Supervisor has met with this part time employee, on 8/3/2011 to address the caseload issues. She is in the process of changing her work hours. Her scheduled clients will be counted daily to make sure that she stays within the staffing FTE number of hours. The number of clients will be counted and she will adjust her schedule as needed to keep her numbers correct.
Her hours were changed effective 9/2/11. Her caseload was brought into compliance at that time. |
709.23(b)(1) 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:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative materials and a discussion with the facility director and the clinical supervisor, the facility failed to formulate project goals and objectives that included time frames for completion and available resources.
The findings include:
Administrative materials were presented for review on July 11, 2011 and July 12, 2011. The goals and objectives presented did not include time frames and available resources.
This was confirmed during a discussion with the facility director and the clinical supervisor.
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Plan of Correction
The Clinical Supervisor and the Project Director will create goals and objectives that will include time frames and available resources on 9/14/2011, the first meeting following the summer break. The Project Director and Clinical Supervisor will make sure that we are in compliance for our goals and objectives. |
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 administrative materials and a discussion with the facility director and the clinical supervisor, the facility failed to formulate a performance report on the annual goals and objectives.
The findings include:
Administrative materials were presented for review on July 11, 2011 and July 12, 2011. The goals and objectives were presented, but a performance report was not presented for review.
This was confirmed during a discussion with the facility director and the clinical supervisor.
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Plan of Correction
The clinical supervisor and Facilities Director will create a performance report on the progress made towards meeting the annual goals and objectives presented at the licensing visit. The progress reort will be ompleted by 8/31/2011. The Facilities Director and Clinical Supervisor will be responsible for the performance reports being completed. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records and a discussion with the clinical supervisor, the facility failed to have a system in place to gather a medical history which contains a family medical history and a history if illnesses and symptoms in 4 of 4 client records.
The findings include:
On July 12, 2011, four client records were reviewed for documentation of a medical history in the client records. A medical history was documented in all four client records; however, the medical history did not include a family medical history and a history if illnesses and symptoms in 4 of 4 client records, #1, 2, 3 and 4.
Client # 1 was admitted on 12/1/10. The medical history documented in client #1's record did not include a family medical history and a history if illnesses and symptoms.
Client # 2 was admitted on 3/22/11. The medical history documented in client #2's record did not include a family medical history and a history if illnesses and symptoms.
Client # 3 was admitted on 11/3/10. The medical history documented in client #3's record did not include a family medical history and a history if illnesses and symptoms.
Client # 4 was admitted on 11/17/10. The medical history documented in client #4's record did not include a family medical history and a history if illnesses and symptoms.
During a discussion with the clinical supervisor, she admitted this was a problem with the new electronic record system and noted it would need to be revised to include this information.
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Plan of Correction
The Clinical Supervisor and the Facilities Director will meet with the Computer Information Services Director to update the medical section of the client record. This will include a more detailed medical history as well as a history of illnesses and a list of symptoms. THis ewill also include a much more detailed medical history for the family. THis will be done and ready for use by the end of August. The Clinical Supervisor will monitor changes needed for the medical record. |
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 the facility's policy and procedure manual, client records and a discussion with the clinical supervisor, the facility failed to document a treatment plan update within the required time frame in one of three client records.
The findings include:
On July 13, 2011, three client records requiring documentation of treatment plan updates were reviewed. According to the facility's policy and procedure manual, treatment plan updates are to be documented every 60 days. The treatment plan update was documented late, as per facility policy, in one of those three client records, #1.
Client #1 was admitted on 12/1/10. The treatment plan was completed on 12/28/10. The first treatment plan update was due on or before 2/28/11. The first treatment plan update was not documented until 3/7/11. The second treatment plan update was due to be documented 60 days after 3/7/11, which would be 5/7/11. The second treatment plan update was not documented until 6/2/11.
During a discussion with the clinical supervisor, these findings were confirmed.
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Plan of Correction
The Clinical Supervisor will meet with the clinical staff to review the findings that treatment plan updates are due within 60 days of the initial treatment plan and 60 thereafter. The Clinical Supervisor will reivew treatment plans monthly to ensure that the treatment plan updates are done in the required time frame. |
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 and a discussion with the clinical supervisor, the facility failed to document a case consultation in two of two client records.
The findings include:
On July 13, 2011, two client records requiring documentation of case consultations were reviewed. A case consultation was not documented in two of two records reviewed, specifically records #1 and 2.
According to the facility's policy on case consultations, a case consultation is required to be completed every 90 days for each client.
Client # 1 was admitted on 12/1/10. A case consultation was due on or before 3/1/11 and 6/1/11. A case consultation was only documented 4/18/11 in client record #1.
Client # 2 was admitted on 3/22/11. A case consultation was due on or before 6/22/11. A case consultation was not documented until 7/12/11 in client record #2.
During a discussion with the clinical supervisor, she confirmed these findings.
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Plan of Correction
The Clinical Supervisor at the meeting at the end of August will discuss the time requirements for completeing Case Consultation notes every 90 days. The Clinical Supervisor will review charts monthly to review the timeliness of case consultations and to ensure compliance with this standard. |