INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on July 26, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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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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 #4.
Employee # 4 was hired by the project on October 4, 2011 and became an drug and alcohol counselor on March 1, 2012. As of the date of inspection, there was no documentation to verify that employee #4 received emergency training.
The findings were confirmed during a conversation with 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, by office, in the event of an emergency. These responsibilities will be presented at the next staff meetings for each site. A signed copy of the responsibilities will be placed in each staff personnel file to review. The Clinical Supervisor will have this done by October 31, 2012.
For Employee #4 ? This employee is no longer with the agency effective August 17, 2012..
For all new hires, prior to the start of employment, a review of the emergency training form will be done by the Clinical Supervisor. A signed and dated copy will be put in the personnel file for review.
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705.28 (d) (8) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(8) Prohibit the use of elevators during a fire drill or a fire.
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Observations
Based on a physical plant inspection, the facility failed to prohibit the use of elevators during a fire drill or fire.
The findings include:
A physical plant inspection was conducted on July 30, 2012 at approximately 11:10 AM. At the time of the inspection it was observed that the facility lacked signage prohibiting the use of the elevator in the event of a fire at two of three levels, specifically the first and third floors.
The clinical supervisor confirmed the findings
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Plan of Correction
The Clinical Supervisor met with the Project Director on August 9 to review this citation. The Project Director contacted the landlord who has responded that the required signs will be posted by August 31, 2012 at the elevator on all 3 floors. The Clinical Supervisor will document compliance at a site visit by the end of September. The Clinical Supervisor will make sure that the signs remain in place on a monthly basis. |
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 of 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. |
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. Three out of four client records lacked documentation of a psychosocial evaluation that included a clinical assessment, specifically client records #1, 3, and 4.
Client #1 was admitted to treatment on May 24, 2012. The psychosocial evaluation was completed on May 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.
Client #3 was admitted to treatment on December 15, 2011 and discharged on April 9, 2012. The psychosocial evaluation was completed on December 15, 2011 and did not include a clinical assessment of the client ' s support systems, coping mechanisms, and negative factors that may affect treatment.
Client #4 was admitted to treatment on December 1, 2011 and discharged on April 3, 2012. The psychosocial evaluation was completed on December 1, 2011 and did not include a composite picture of the client or a clinical assessment of the negative factors that may affect treatment or the client's attitude towards treatment.
The findings were reviewed with the clinical supervisor.
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Plan of Correction
The Clinical Supervisor documented the finding to staff during the staff meeting on September 21, 2012. The Clinical Supervisor will do weekly case reviews starting September 28, 2012 to verify compliance with staff. If by November 28, 2012, staff are in compliance with standard, the Clinical Supervisor will do monthly chart audits thereafter.
The Compliance Officer has instructed the Clinical Supervisor that alterations to exiting clinical records can not be done. To preserve the record, a note will be added to the NOTE section of each client's EMR to correct charts #1, #3, and #4.
The Clinical Supervisor will also meet with the EMR (Electronic Medical Records) supervisor to review the assessment form to make changes that will prompt staff to provide the required information. This is to be completed by 10/15/2012.
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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 # 4.
Client #4 was admitted to treatment on December 1, 2011 and discharged on April 3, 2012. The treatment plan update was completed on February 9, 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 30 August 2012 to review this citation that progress on treatment goals must be documented at each treatment plan update. The Clinical Supervisor will start doing weekly chart reviews on September 28, 2012 to ensure compliance. If by 10/28/2012 staff are in compliance, then monthly chart audits will take place.
The Compliance Officer has advised the Clinical Supervisor that changing an existing EMR is not possible. A note in the EMR of Client #4 in the NOTE section will be added to address progress on treatment goals. This will be done by October 31, 2012.
Progress towards meeting this requirement will be documented during monthly staff meetings.
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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.
Two client records requiring documentation of case consultations were reviewed on July 27, 2012. Two of two client records did not have documentation of a case consultation, specifically #'s 3 and 4.
Client #3 was admitted to treatment on December 15, 2011 and discharged on April 9, 2012. A case consultation was due by March 1, 2012 for client #3. As of the date of inspection, there was no documentation of a case consultation for client #3.
Client #4 was admitted to treatment on December 1, 2011 and discharged on April 3, 2012. A case consultation was due by March 1, 2012 for client #4. As of the date of inspection, there was no documentation of a case consultation 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 documented the finding to staff during the staff meeting on August 30, 2012 that Case Consultations are required at 90 day intervals. The Clinical Supervisor will meet with staff monthly and will include completing Case Consultations that are coming due.
For Client #3, a late case consultation will be added to the client's EMR. Future case consultations as applicable will be completed within the original time line for this client.
The Clinical Supervisor will also do monthly case reviews starting in September 28, 2012 to verify compliance with staff.
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