INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 17-18, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Harbor Counseling 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 October 16, 2009.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on the review of personnel and training records, the facility failed to ensure that each counselor met the annual requirement of 25 training hours for the 2008-09 training year in two of four applicable records reviewed..
The findings included:
Seven employee records were reviewed during the onsite inspection. Four of these were records of counselors. All of these were required to have 25 hours of training documented for the 08-09 training year. Record # 5 had no training documented for the 08-09 training year. Record # 7 had only 20 hours of training documented for the 08-09 training year.
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Plan of Correction
Employee record #5 was of a part-time employee no longer employed by our agency. The insufficient number of training hours for the employee represented by record #7 (20 hours instead of the requisite 25) was a result of internal miscommunication about the trainings attended by the counselor (we had considered attendance at a planned training that in fact had been cancelled, and we failed to adjust the training plan). At a staff meeting on 9/22/09 this regulatory standard was reviewed with staff, and staff's collective responsibility for ensuring compliance was emphasized. However, Clinical Supervisor will be responsible for ongoing monitoring of the training plan for all staff and will have primary responsibility for ensuring compliance. |
709.81(b)(3)(i) LICENSURE Intake and admission
709.81. 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 the review of client records, the facility failed to document current medical histories in three of three client records reviewed.
The findings included:
Three records of clients documenting treatment at the partial hospitalization level of care were reviewed on 9/18/09. Each of the three records was required to have a complete medical history. In client record #1 the history was collected originally on 3/5/04 but the client was admitted on 3/19/09. No current medical history was documented for the 3/19/09 intake. In client record # 4 the history was collected on 12/12/05 but the client was admitted to treatment on 4/30/09. No current medical history was documented for the 4/30/09 intake. In client record # 8 the history was collected on 3/10/08 but the client was admitted to treatment on 4/23/09 . No current medical history was documented for the 4/23/09 admission.
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Plan of Correction
At a 9/22/09 staff meeting the regulatory standard, and requirements for satisfactory compliance, were reviewed and clarified. All clinical and support staff are now aware that any histories six months old or older may not be re-used or updated, but rather a new and current history must be gathered and documented. The three client records cited already have been updated with new and current histories documented, as required by the regulatory standard. Clinical Supervisor will be responsible for ongoing monitoring of client charts for compliance. |
709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to document current Drug and Alcohol histories in three of three client records reviewed.. .
The findings included:
Three records of three clients who attended the partial hospitalization level of care were reviewed during the onsite inspection. Each of the three records was required to have a current drug and alcohol history. In client record #1 the history was collected on 3/5/04 but the client was admitted on 3/19/09. No current Drug and Alcohol history was documented for this admission. In client record # 4 the history was collected on 12/12/05 but the client was admitted to treatment 4/30/09. No current Drug and Alcohol History was documented for this admission . In client record # 8 the history was collected on 3/10/08 but the client was admitted on 4/23/09. No current Drug and Alcohol history was documented for this admission.
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Plan of Correction
At a 9/22/09 staff meeting the regulatory standard, and requirements for satisfactory compliance, were reviewed and clarified. All clinical and support staff are now aware that any histories six months old or older may not be re-used or updated, but rather a new and current history must be gathered and documented. The three client records cited already have been updated with new and current histories documented, as required by the regulatory standard. Clinical Supervisor will be responsible for ongoing monitoring of client charts for compliance. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. 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 the review of client records, the facility failed to document current personal histories in three of three client records reviewed..
The findings included:
The records of three clients who attended the partial hospitalization level of care were reviewed during the onsite inspection. Each of the three records was required to have a current personal history. In record #1 the history was collected on 3/5/04 but the client was admitted on 3/19/09. No current personal history was documented for this admission. In record # 4 the history was collected on 12/12/05 but the client was admitted to treatment 4/30/09. No current personal History was documented for this admission . In record # 8 the history was collected on 3/10/08 but the client was admitted on 4/23/09. No current personal history was documented for this admission.
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Plan of Correction
At a 9/22/09 staff meeting the regulatory standard, and requirements for satisfactory compliance, were reviewed and clarified. All clinical and support staff are now aware that any histories six months old or older may not be re-used or updated, but rather a new and current history must be gathered and documented. The three client records cited already have been updated with new and current histories documented, as required by the regulatory standard. Clinical Supervisor will be responsible for ongoing monitoring of client charts for compliance. |
709.83(a)(8) LICENSURE Client records
709.83. 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) Record of services provided.
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Observations
Based on the review of client records, the facility failed to document complete records of service as required in two of three records reviewed.
The findings included:
Three client records were reviewed at this level of care. Each was required to have a complete record of services which documented the date of service, type of service , provider of service and duration of service. Records # 1 and 8 failed to document the type of service provided at each session with the client or the provider of the service.
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Plan of Correction
Internal procedures for documenting record of services has been changed in order to ensure that all of the information required for full compliance with the regulatory standard has been documented. At a staff meeting on 9/22/09 the regulatory standard and compliance requirements was reviewed with all staff, and the new internal procedures for documentation of record of services was reviewed. The three client records cited have already been updated to include fully compliant records of service. Business Manager and Clinical Supervisor will be responsible for ongoing monitoring of client charts to ensure compliance with the standard. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. 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 the review of client records, the facility failed to document current personal histories.
The findings included:
Seven records of clients who attended the outpatient level of care were reviewed during the onsite inspection. Each of the records was required to have a current personal history. In client record # 4 the history was collected on 12/12/05 but the client was admitted on 4/30/09. No current history was documented for this admission. In record # 8 the history was collected on 3/10/08 but the client was admitted on 4/23/09. No current history was documented for this admission. Client records # 3, 4, 5, 7 and 9 failed to include documentation of family interrelationships. Client record # 7 did not document complete responses on the psychosocial history form. The prompts given on the agency form were not followed and blank spaces were noted on the areas of the form designated for details in each required area of the history (educational, employment and sexual).
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Plan of Correction
At a 9/22/09 staff meeting the regulatory standard, and requirements for satisfactory compliance, were reviewed and clarified. All clinical and support staff are now aware that any histories six months old or older may not be re-used or updated, but rather a new and current history must be gathered and documented. Additionally, all clinical and support staff are now aware that all sections of the psychosocial histories are to be completed, all prompts to be followed, all areas of personal history to be documented. The seven client records cited already have been updated with new and current and complete histories documented, as required by the regulatory standard. Clinical Supervisor will be responsible for ongoing monitoring of client charts for compliance. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on the review of client records, the facility failed to document complete records of service as required in each record.
The findings included:
Seven client records were reviewed at this level of care. Each was required to have a complete record of services which documented the date of service, type of service , provider of service and duration of service. Client records # 4, 5, 6, 7, 8 and 9 failed to document the provider of the service at each session.
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Plan of Correction
Internal procedures for documenting record of services has been changed in order to ensure that all of the information required for full compliance with the regulatory standard has been documented. At a staff meeting on 9/22/09 the regulatory standard and compliance requirements were reviewed with all staff, and the new internal procedures for documentation of record of services was reviewed. The seven client records cited have already been updated to include fully compliant records of service. Business Manager and Clinical Supervisor will be responsible for ongoing monitoring of client charts to ensure compliance with the standard. |