INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 6, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Adams Hanover Counseling Services 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 4, 2009.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to hire a counselor who met qualification in one of five records.
Findings:
Five personnel records were reviewed on July 6, 2009. Qualification for the counselor positions was required in two personnel records. PA State standards states that an employee with a Bachelor Degree must have at least 1 year of clinical experience in a health or human service agency. Employee #5 did not have the required experience and does not meet the qualification for the counselor position.
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Plan of Correction
The Clinical Supervisor completed a new Personnel Action Form which was signed on 07-13-09 to reflect the correct job title. The therapsit signed the job description on 7-24-09. She is aware of the 40 hours of training required and weekly supervision requirements. The job description will be signed by the Project Director by 7-30-2009. The documentation will be placed in the personnel file and is available for review at the Hanover Office, Human Resource Department. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of CPR/First Aid documentation provided by the facility and an interview with the Clinical supervisor, the facility failed to have sufficient number of staff persons who are CPR certified on site during the project's hours of operation.
Findings
Based on the a review of CPR/First Aid cards and an interview with the Clinical Supervisor it was determined that the facility was unable to provide CPR coverage during their hours of operation.
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Plan of Correction
CPR and First Aid is now being mandated for all Drug and Alcohol Therapsits. Staff meeting to discuss this requirement at this cite is scheduled for 8-6-09. The CPR and First Aid class is being offered on 8-13-09. The Clinical Supervisor will monitor compliance through attendance at that training and through quarterly review of the Training Manual and in monthly staff meetings. Any therapist unable to attend the training on 8-13-09 will have to arrange the class through the American Red Cross direct. |
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, the facility failed to ensure and document that counselors completed at least 25 hours of training for the training year 2007/2008 in one of five records.
Findings:
Five personnel records were reviewed on July 7, 2009. Twenty-five hours of annual training was required in one personnel record. This was not documented in personnel record #5, only had 21 hours of training for the training year 2007/2008.
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Plan of Correction
In reviewing the Training Manual for this therapist, this therapist has completed 30 hours of training for the training year 10-1-08 through 9-30-09, with supporting documentation that has been recorded correctly. The Clinical Supervisor will monitor training hours through a quarterly review of the Training Manual and in staff meetings. Documentation of this review will be documented on a Supervison Documentation form that will be housed at the site. |
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 complete psychosocial evaluations in four of four client records.
Findings:
Four client records were reviewed on July 7, 2009. Psychosocial evaluations were required in four client records. The counselors did not document an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor's conclusion/impressions of the client in client records #1, 2, 3 and 4.
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Plan of Correction
On 8-6-09, the Clinical Supervisor will be meeting with staff to review findings and compliance expectations. Expectations are that charts will include all points offered in theregulations and the example. Comopliance will consist of weekly chart reviews. If a chart is out of compliance, the therapsit is notified using a Supervision Documentation forms. The chart will then be reviewed again at the next weekly visit to ensure compliance. Also, by 8-28-09, the final version of our Intake packet will be distributed. The changes made will be in promting more discriptive information. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services in three of four client records reviewed.
Findings:
Four client records were reviewed on July 7, 2009. Support services were required in three client records. Support services were not documented in records #1, 3 and 4.
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Plan of Correction
At the staff meeting on 8-6-09, the Clinical Supervisor will address the lack of support service documentation. Compliance will be evidenced by weekly chart reviews, and if a problem is identified, a Spervision Documentation form will be completed with the expectations of complettion. The chart will then be reviewed at the next visit to document compliance. |
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 on a review of client records, the facility failed to document complete case consultations notes in one of three client records.
Findings:
Four client records were reviewed. Case consultations were required in three client records. Per the facility's policy and procedure case consultation notes will be documented every 90 days after admission. Client record #4 was admitted on 10/28/08 and was discharged on 3/27/09; no case consultation was documented in the record.
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Plan of Correction
On 8-6-09, a staff meeting will be held by the Clinical Supervisor to addrss findings and compliance expectations. As part of the meeting, we will review time lines for Case Consultations. Compliance will be evidenced by weekly chart reviews, and if a chart is out of compliance, a Supervision Documentation form will be used to notify the therapist that an action is required. The chart will then be reviewed the following visit for compliance. |