INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16, 2010 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 August 15, 2010
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Plan of Correction
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility's policies and procedures manual and an interview with the clinical supervisor, the facility failed to prepare and annually update a written manual delineating project policies and procedures.
The findings include:
The facility's policies and procedures manual was reviewed on July 12 and 13, 2010. The manual contained contained conflicting policies and procedures due to outdated policies that were never removed when the new policies were implemented.
The clinical supervisor confirmed that the policies and procedures manual had not been updated.
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Plan of Correction
The Project Director and Clinical Supervisor will review the current Policy and Procedure Manual and remove all outdated materials and ensure that the newest policies are in the manual. The Clinical Supervisor, under the direction of the Project Director will be responsible for keeping the manual up to date. This will be done over the next 3 months to be completed no later than the 31st of October 2010. |
709.92(a) 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:
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Observations
Based on a review of facility policy and client records, the facility failed to complete individual treatment plans within the time frame specified in the policy in three of five client records.
The findings include:
Five client records were reviewed on July 16, 2010. Five client records were required to have an individual treatment plan. According to facility policy, the individual treatment plan is due to be completed by the second treatment session. The individual treatment plan was developed late, as per facility policy in three client records.
Client #1 was admitted on 2/22/10. Client #1 attended his second treatment session on 3/1/10. Client #1 also attended a treatment session on 3/8/10 and 3/15/10. The individual treatment plan for client #1 was dated 3/22/10, which was the client's fifth treatment session.
Client #4 was admitted on 2/27/10. Client #4 attended her second treatment session on 3/13/10. The individual treatment plan for client #4 was dated 3/20/10, which was the client's third treatment session.
Client #5 was admitted on 2/20/10. Client #5 attended his second treatment session on 3/6/10. The individual treatment plan for client #5 was dated 5/1/10.
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Plan of Correction
The Clinical Supervisor is scheduled to meet with one staff on August 12 and the second staff at the end of August to review the standards and the time requirements for all of our paperwork. The requirements that treatment goals be developed by the second visit and updated every 2 months from that date will be reviewed. The Clinical Supervisor will review this standard and charting at supervision meetings and will review records via our electronic medical records monthly for compliance. The Clinical Supervisor will record any problems and how each problem will be addressed. |
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 facility policy and client records, the facility failed to document case consultation notes in three of five client records.
The findings include:
Five client records were reviewed on July 16, 2010. According to the facility's policy and procedure manual, case consultations are due to be completed every 90 days. Only four of the client records were required to have a case consultation.
Client #1 was admitted on 2/22/10. A case consultation was due by 5/22/10, but was not documented until 6/21/10; however, the only person in attendance was the therapist, which does not constitute a case consultation.
Client #2 was admitted on 3/16/10. A case consultation was due by 6/16/10, but was not documented until 6/23/10.
Client #3 was admitted on 3/29/10. A case consultation was due by 6/29/10. As of 7/16/10, there was no case consultation documented in client record #3.
Client #5 was admitted on 2/20/10. A case consultation was due by 520/10. As of 6/12/10, the date of the client's discharge, there was no case consultation documented in client record #5.
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Plan of Correction
The Clinical Supervisor has scheduled a meeting on August 12 and the end of August to review paperwork requirements and the date sensitivity of each document. This will be reinforced at supervision meetings. The Clinical Supervisor will review this requiement on our electronic medical record to ensure that the Case Consultations are being done within the 90 day requirement. Any problems with this standard will be documented and addressed at monthly supervision meetings. |