INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clear Concepts 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:
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" submitted for the three facilities in the project and a review of current caseload assignments, the Project failed to provide for a full time clinical supervisor for every 8 Full Time Equivalent (FTE) counselors.The findings include:The "Staffing Requirements Facility Summary Reports" for the three facilities that make up the Project were reviewed March 19, 2014 and revealed that there are 9 FTE counselors working for the Project. The project does not have a clinical supervisor on staff.The findings were reviewed and confirmed with the Project Director on March 19, 2014.
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Plan of Correction
Our project is in full compliance
with this standard as of March 28,
2014. We failed to provide a full
time clinical supervisor as required
in the regulations for Clinical
Supervisor Qualifications. Our
project was unaware that we had 8
full time counselors employed. This
mistake was discovered during the
on-site licensure renewal inspection.
The proper steps were taken and our
project is in compliance with this
standard and we have hired a
Facility Director and Clinical
Supervisor. In the future the Project
Director will review the staff and
staff caseloads to ensure that the
proper staff is supervised and we are
in compliance with this standard. |
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 update treatment plans at least every 60 days in one out of three client records.The findings include:Five client records were reviewed on March 20, 2014. Three of those client records required documentation of a treatment plan update. One out of three client records did not include a treatment plan update documented within 60 days, specifically client record # 1.Client # 1 was admitted on November 6, 2013. The comprehensive treatment plan for client #1 was documented on November 6, 2013. A treatment plan update was due by January 6, 2014 but had not been updated until February 11, 2014. The findings were reviewed with the project director.
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Plan of Correction
Our facility will be in full
compliance with this standard
beginning immediately. This
standard and our agency policy
relative to this standard will be
reviewed with all counselors at our
next staff meeting on April 10, 2014.
The proper completion and
timetable of the treatment plan
update every 60 days will begin
immediately. This standard and
policy will also be reviewed with all
therapists by the Clinical Supervisor
in individual supervision to assure
compliance. |
709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to document a complete client record to include discharge summaries in one out of three client records.The findings include:Five client records were reviewed on March 20, 2014. Three of those records were for discharge clients and were required to include a discharge summary. The facility failed to document a discharge summary in one out of three client records, specifically #5. Additionally, the discharge summaries documented in records # 3 and 4 were undated. Client #5 was admitted on July 29, 2013 and discharged on January14, 2014. As of the date of inspection there was no documentation of a discharge summary for client #5. The findings were reviewed with quality the facility director during the exit interview.
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Plan of Correction
Our facility will be in full
compliance with this standard
beginning immediately. This
standard and our agency policy
relative to this standard will be
reviewed with all counselors at our
next staff meeting on April 10,
2014.The proper completion and
timing of completion of the
discharge summary will begin
immediately. This standard and
policy will also be reviewed with all
therapists by the Clinical Supervisor
in individual supervision to assure
compliance. In the future all
therapists will bring their closed
charts to supervision and the Clinical
Supervisor will verify that the
therapist has the completed
discharge summary and has it filed
in the chart. The primary therapist
for client #5 reviewed the client
chart and completed the discharge
summary as of April 18, 2014. |