INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 13, 2009 licensure renewal inspection. The follow-up inspection was conducted on July 13, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 August 28, 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
At time of the plan of correction follow-up inspection on 7/13/09, it was not possible for the licensing specialist to determine if the facility followed the original plan of correction and was in compliance due to the fact that the training year is still in progress. The facility must resubmit the original plan of correction.
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Plan of Correction
All training files shall 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. The Director of Administrative Services shall monitor training files on a quarterly basis.
A memo has been sent to clinical staff asking them to be pro-active in their staff development in regards to training hours. |
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 manual, in three of four client records.
The findings include:
Four client records were reviewed on July 13, 2009. Treatment plans were required to be documented within 14 days of admission in four client records. The facility did not document a treatment plan within 14 days in client records # 1, 2 and 3.
Client record # 1 documented an admission date of 5/11/09. The treatment plan was documented on 5/26/09.
Client record # 2 documented an admission date of 5/11/09. The treatment plan was not documented at the time of inspection.
Client record # 3 documented an admission date of 5/11/09. The treatment plan was not documented at the time of inspection.
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Plan of Correction
1. Clinical staff shall receive an internal training session that includes the following:
a. Review of Division of Drug & Alcohol Program licensure regulation 709.52(a).
b. Application of 709.52(a) to the issuing and documentation of the client treatment plan within 14 days of admission.
2. Clinical Supervisor will monitor counselor case files for compliance with the Division of Drug and Alcohol Program Licensure standards and ADAPPT Policy as part of an ongoing monthly continuous quality improvement chart audit.
3.All clinical staff shall be held accountable to compliance with the Division of Drug and Alcohol Program Licensure standards and ADAPPT Policy for documentation of treatment plans within 14 days of admission
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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:
Four client records were reviewed on July 13, 2009. Progress notes were reviewed in four client records. The facility did not document group progress notes after each significant client contact in client records # 1, 2, 3 and 4.
Progress notes did not include a comment relative to each client's response or participation in the group session.
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Plan of Correction
1. Internal training for clinical staff shall be presented by the Clinical Supervisor that includes:
a.)Review of the Division of Drug and Alcohol Program licesnure regulation 709.53(a).
b.) Application of 709.53(a) to documentation of group therapy with a group progress note that includes D.A.P. format for individual sessions and individual clients.
c.)Examples shall be provided that model the composition of a group note that complies with the Division of Drug and AlcoholProgram Standards.
2. Clinical Supervisor will monitor counselor case files bi-weekly for ompliance with the Division of Drug and Alcohol Program Licensure Standards.
3.Clinical staff shall be held accountable for compliance with the Division of Drug and Alcohol Program Licensure Standards related to documentation of group notes. |