INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 12-14 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Adappt House 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 February 13, 2009.
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Plan of Correction
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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records, the facility failed to document semiannual performance evaluations for counselor assistants in one of one personnel record.
The findings include:
Six personnel records were reviewed on January 13, 2009. A semiannual performance evaluation was required in one personnel record. The facility did not document a semiannual performance evaluation in personnel record # 4.
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Plan of Correction
The Clinical Supervisor will ensure that the following procedure will be put into practice immediately: a written semiannual performance evaluation based upon measurable performance standards will occur during a counselor assistant's supervised period. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to document nine months of weekly close supervision notes for counselor assistants in two of two personnel records.
The findings include:
Six personnel records were reviewed on January 13, 2009. Nine months of weekly close supervision notes were required in two personnel records. The facility did not document weekly close supervision notes in personnel records # 4 and 5.
The last documented supervision note in personnel record # 4 was on 01/21/08, after only 16 documented supervision notes.
The last documented supervision note in personnel record # 5 was on 11/18/08, after only 14 documented supervision notes.
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Plan of Correction
The Clinical Supervisor will immediately schedule and document weekly supervision sessions with counselor assistants during the nine month close supervision period. |
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 a review of personnel records on January 13, 2009, the facility failed to document at least 25 clock hours of training for each counselor annually in one of one personnel records.
The findings include:
Six personnel records were reviewed on January 13, 2009. Twenty-five clock hours of training was required in one personnel record. The facility did not document 25 clock hours of training in personnel record # 6. Personnel record # 6 documented only 13 clock hours of training for the previous training year.
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Plan of Correction
All training files will be tracked by the Training Coordinator on a monthly basis to ensure that the appropriate number of training hours required by the standard are achieved.
A memo has been sent to clinical staff asking them to be pro-active in their staff development in regards to training hours. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of administrative documentation, the facility failed to document a fire drill during sleeping hours at least once every six months.
The findings include:
The facility's fire drill log was reviewed on January 14, 2008. The facility failed to document a fire drill during sleeping hours from June 1, 2008 through January 13, 2009.
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Plan of Correction
The Director of Security will ensure that unannounced fire drills will occur and be documented in the fire drill log at least every six months during sleeeping hours.
The Director of Security will track the fire drill log on a monthly basis in order to keep an up to date record of "evening fire drills". |
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 administrative documentation, the facility failed to document a written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
The findings include:
Administrative Documentation was reviewed on January 12, 2009. A written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage was required. The facility failed to document a written agreement for 24-hour emergency psychiatric and medical coverage.
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Plan of Correction
A current written provider agreement between ADAPPT and the Reading Hospital & Medical Center for 24-hour emergency, psychiatric, and medical coverage has been obtained and placed in the Policy & Procedure Manual. The Director of Administrative Services will ensure that all provider agreements will be maintained and updated within the appropriate timeframe. |
709.32(c)(7) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(7) Medication errors and drug reactions.
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Observations
Based on a review of client medication records, the facility failed to document missed dosages, refused dosages and medication errors.
The findings include:
Three client medication records were reviewed on January 14, 2009. Medication records were required to document missed medication, refused medication and medication errors. The facility failed to document missed medication, refused medication and medication errors in client records # 8 and 9.
Client record # 8 includes documentation of a prescription for Citalopram 20mg, 1 tablet at bedtime. The medication log indicates Citalopram 20mg, 1 tablet received: 01/05/2009 at 21:19 and 21:41.
Client record #9 Cephalexin 500mg, 1 capsule, 4 times daily. The medication log indicates Cephalexin 500mg, 1 capsule received: 01/09/2009 at 06:10, 12:20 and 21:30; 01/10/2009 at 06:27 and 21:16; 01/11/2009 at 06:12 and 21:17; and 01/12/2009 at 06:07, 12:06 and 21:26.
Client Record #9 includes documentation of a prescription for Fluoxetine 200mg, 2 tablets 1 time daily. The medication log indicates Fluoxetine 200mg, 2 tablets received: 01/10/2009 at 06:27 and 17:51.
Client Record #9 includes documentation of a prescription for Vistaril 50mg, 1 tablet in evening. The medication log did not document Vistaril 50mg, 1 tablet: 01/05/2009 and 01/06/2008.
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Plan of Correction
A written policy exists regarding medication control which includes administration of medication. In an effort to educate and re-enforce proper procedures related to this policy ADAPPT has implemented a monthly staff meeting led by Richard Levin, Director of Security, which will be dedicated to medication documentation. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document physical examinations within seven days of admission, as stated in their policy and procedures manual, in three of four client records.
The findings include:
Nine client records were reviewed on January 13, 2009. Physical examinations were required to be documented within seven days of admission in four client records. The facility failed to document physical examinations within seven days in client records # 1, 2 and 4.
Client record #1 documented an admission date of 11/24/08. The physical examination date was on 12/04/08.
Client record #2 documented an admission date of 11/24/08. The physical examination date was on 12/06/08.
Client record #3 documented an admission date of 11/24/08. The physical examination date was on 12/04/08.
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Plan of Correction
The contracted physician does on-site physical examinations once a week on a Thursday, unless a holiday falls on a Thursday, in which case he would not be in attendance at ADAPPT
The Director of Operations and the physician have agreed on an alternate plan to cover holiday weeks in order to comply with the seven day requirement for physical examinations.
This plan commenced on February 1, 2009.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 client records, the facility failed to document treatment plans within 14 days of admission, as stated in the facility policy and procedures manual, in two of four client records.
The findings include:
Nine client records were reviewed on January 13, 2009. Treatment plans were required to be documented within 14 days of admission in four client records. The facility failed to document a treatment plan within 14 days in client records # 1 and 4.
Client record # 1 documented an admission date of 11/24/08. The treatment plan was documented on 12/09/08.
Client record # 4 documented an admission date of 11/24/08. The treatment plan was documented on 12/11/08.
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Plan of Correction
A training is scheduled for February 2, 2009 to address the lack of compliance with this standard. The training will include a review of the Policy & Procedure Manual protocol and timeframe for the documentation of treatment plans. The Clinical Supervisor will ensure that all treatment plans are documented within the assigned 14 day timeframe. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document complete treatment plan updates in four of four client records.
The findings include:
Nine client records were reviewed on January 13, 2009. Treatment plan updates were required in four client records. The facility failed to document complete treatment plan updates in client records # 1, 2, 3, and 4. The treatment plan updates failed to include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
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Plan of Correction
The Clinical Supervicor will hold a training for all clinical staff on February 2, 2009 to review treatment and rehabilitation plan protocols and timeframes.
The Clinical Supervisor will review all client charts on a bi-weekly basis to ensure that they include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan, in addition to addressing other issues related to this standard.
ADAPPT Policy and Procedure Manual states that treatment and rehabilitation plans shall be reviewed and updated at least every 30 days |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on a review of client records the facility failed to document progress notes after each significant client contact in four of four client records.
The findings include:
Nine client records were reviewed on January 13, 2009. Progress notes were reviewed in four client records. The facility failed to document group progress notes after each significant client contact in client records # 1, 2, 3 and 4.
A single progress note was written for five group sessions in client records # 1 and 3. The progress notes contained only one comment relative to the client's response or participation for all five group sessions.
Additionally:
Client record # 1, no group progress notes documented for the period 12/01/05 - 12/05/08.
Client record # 2, no group progress notes documented in the client record.
Client record # 4, no group progress notes documented for the period 12/29/08 - 01/02/09.
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Plan of Correction
The Clinical Supervisor has presented and documented a training to all clinical staff on February 4, 2009 to address adherence to the standard related to Progress Notes. The Clinical Supervisor, by client chart review, will ensure that a note will be in the client's chart documenting the progress of the client after each significant contact, including group notes.
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