INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 3, 2014 through December 4, 2014 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:
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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 a review of the Staffing Requirements Facility Summary Report (SRFSR), as well as a review of personnel records, the Project failed to ensure that each counselor completed at least 25 clock hours of annual training in one of seven personnel records reviewed.
The findings include:
The SRFSR was reveiwed on November 14, 2014 and re-reviewed with facility staff on December 3, 2014 and five personnel records requiring documentation of 25 clock hours of annual training were reviewed on December 3, 2014. The Project failed to provide documentation of 25 clock hours of annual training in the personnel record of Employee #7.
Employee #7 was hired as a counselor on April 12, 2011. Based on the SRFSR and the personnel record, Employee #7 only had 19 hours of documented training for the project's July 1, 2013 through June 30, 2014 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We currently use a spreadsheet to track training hours for each clinician, but failed to make appropriate use of this tool. The Assistant Administrator will give the training hour spreadsheet to the Clinical Supervisor on a quarterly basis beginning 1/2/15 so that she can address the training plan during the weekly scheduled supervision sessions. The Assistant Administrator will also email each clinician on a quarterly basis to let them know how many hours they have and how many they still need before the end of the fiscal year. Program Director will be responsible for ensuring compliance with this Plan of Correction. |
709.81(b)(2)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project, which is to include project policies, hours of operation, fee schedule, and services provided by the project in one of one records reviewed.
The findings include:
Twelve client records were reviewed on December 3, 2014 through December 4, 2014. Only one record was reviewed pertaining to partial hospitalization and it required documentation of client orientation. The facility failed to provide documentation of the client's orientation in client record # 2.
Client #2 was admitted to partial hospitalization treatment on January 13, 2014 and remained in partial hospitalization until march 13, 2014, at which time the client was transferred to the outpatient level of care. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided during the client orientation phase.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Assistant Administrator has created a new document to hand to each client at intake for immediate implementation. The document lists our policies, hours, fee schedule, and services provided. The client will sign stating they have been informed of these policies and will be offered a copy. All staff will be informed of the new form and its inclusion in the intake process during the 1/20/15 staff meeting. Program Director will be responsible for ensuring implementation of this Plan of Correction. Regarding the chart identified in the citation, Client #2 was discharged from the Program on 12/12/14 and so we were not able to work with the client to update/correct the deficiency in this particular case. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project, which is to include project policies, hours of operation, fee schedule, and services provided by the project in twelve of twelve records reviewed.
The findings include:
Twelve client records requiring documentation of the client's orientation to the project upon admission were reviewed on December 3, 2014 through December 4, 2014. The facility failed to provide documentation of the client's orientation in client record #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12.
Client #1 was admitted to treatment on April 4, 2013 and was still active at time of the on-site inspection. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided during the client orientation phase.
Client #2 was admitted to treatment on January 13, 2014 and was still active at time of the on-site inspection. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided during the client orientation phase.
Client #3 was admitted to treatment on March 24, 2014 and was still active at time of the on-site inspection. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided during the client orientation phase.
Client #4 was admitted to treatment on January 17, 2014 and was still active at time of the on-site inspection. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided during the client orientation phase.
Client #5 was admitted to treatment on December 9, 2013 and was still active at time of the on-site inspection. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided during the client orientation phase.
Client #6 was admitted to treatment on August 26, 2013 and was still active at time of the on-site inspection. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided during the client orientation phase.
Client #7 was admitted to treatment on March 28, 2013 and was discharged on August 5, 2014. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided during the client orientation phase.
Client #8 was admitted to treatment on December 27, 2013 and was discharged on April 11, 2014. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided during the client orientation phase.
Client #9 was admitted to treatment on February 17, 2014 and was discharged on June 10, 2014. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided during the client orientation phase.
Client #10 was admitted to treatment on January 6, 2014 and was discharged on June 9, 2014. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided during the client orientation phase.
Client #11 was admitted to treatment on March 21, 2014 and was discharged on November 11, 2014. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided during the client orientation phase.
Client #12 was admitted to treatment on December 16, 2013 and was discharged on June 27, 2014. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided during the client orientation phase.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Assistant Administrator has created a new document to hand to each client at intake for immediate implementation. The document lists our policies, hours, fee schedule, and services provided. The client will sign stating they have been informed of these policies and will be offered a copy. All staff will be informed of the new form and its inclusion in the intake process during the 1/20/15 staff meeting. Program Director will be responsible for ensuring implementation of this Plan of Correction. Regarding the charts/clients identified in the citation, one was discharged 12/12/14, one was discharged 12/13/14, six were already discharged at the time of the review, and three of the clients were open but not active (that is, they had not been seen for a period of time despite attempts to contact, and are consequently being discharged). One remaining open and active client (#4) received the required orientation on 1/5/15 and documentation has been included in the client record. |
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 document a treatment plan update at least every 60 days in four of twelve client records reviewed.
The findings include:
Twelve client records requiring a the treatment and rehabilitation plan to be reviewed and updated at least every 60 days were reviewed on December 3, 2014 through December 4, 2014. The facility failed to document a treatment plan update in client records #6, 8, 9, and 11.
Client #6 was admitted to treatment on August 26, 2013 and was still active at the time of the on-site inspection. The date of the last treatment plan update was documented on July 21, 2014. The facility failed to document a treatment plan update since July 21, 2014.
Client #8 was admitted to treatment on December 27,2013 and was discharged on April 11, 2014. The client has an initial treatment plan dated December 27, 2014; however, at the time of the inspection, the facility failed to document a master treatment plan for this client, so it was unable to be determined when a treatment plan update should have been completed. date of the last treatment plan update was documented on July 21, 2014. The facility failed to document a treatment plan update since July 21, 2014.
Client #9 was admitted to treatment on February 17, 2014 and was discharged on June 10, 2014. The date of the last treatment plan update was documented on March 17, 2014. The facility failed to document a treatment plan update since March 17, 2014.
Client #11 was admitted to treatment on March 21, 2014 and was discharged on November 4, 2014. The date of the client's master treatment plan was April 30, 2014. The facility failed to document a treatment plan update since developing the master treatment plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Assistant Administrator has developed a Treatment Spreadsheet to track when treatment plans are due. Each Monday beginning 1/12/15 front office support staff (R. Nice) will give a copy to each clinician highlighting the treatment plans due the next week. This will give the counselors a list of the clients they need to schedule to see during the next week, and will work more like the Electronic Medical Record software we are hoping to purchase soon, which will give reminders to each clinician of what is currently due each time they log into the program. This Plan of Correction will be reviewed with all staff at the 1/20/15 staff meeting. Clinical Supervisor will review the spreadsheets with each counselor during weekly individual clinical supervision sessions. Program Director will be responsible for ensuring implementation of this Plan of Correction. Regarding the client records identified in the citation, only one (#6) was open at the time of the review. However, the client is not active (that is, the client has not been seen in some time despite efforts to contact and re-engage) and will be discharged, consequently we were not able to do a new treatment plan with the client. However, a treatment plan review was completed by assigned clinician on 1/5/15. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in six of twelve records reviewed.
The findings included:
Twelve client records requiring the documentation of the provision of services in accordance with those specified in the treatment plan were reviewed on December 3, 2014 through December 4, 2014. The facility failed to provide counseling services as stated in the treatment and rehabilitation plan in client record #'s 3, 4, 5, 6, 8, and 12.
Client #3 was admitted to treatment on March 24, 2014 and was still an active client at time of the inspection. An individual treatment and rehabilitation plan was developed with the client on 03/24/2014 and the plan stated that the client would be provided individual sessions 1 time per month and group sessions 2 times per week. During the month of September 2014, the client only had one group session (09/18/14). During the month of October 2014, the client only had four group sessions (10/2/14, 10/7/14, 10/23/14, and 10/28/14). During the month of November 2014, the client only had one group session (11/11/14).
Client #4 was admitted to treatment on January 17, 2014 and was still an active client at time of the inspection. An individual treatment and rehabilitation plan was developed with the client on 01/17/2014 and the plan stated that the client would be provided individual sessions 2 times per month. During the month of February 2014, the client only had one individual session (02/17/14). During the month of March 2014, the client did not have any individual sessions. During the month of April, May, June, and July 2014, the client only had one individual session each month (04/07/14, 05/01/14, 06/26/14, and 07/23/14). During the month of August 2014, the client did not have any individual sessions.
Client #5 was admitted to treatment on December 9, 2013 and was still an active client at time of the inspection. An individual treatment and rehabilitation plan was developed with the client on 12/09/2013 and the plan stated that the client would be provided individual sessions 2 times per month and group sessions 3 times per week. During the month of February 2014, the client did not have any individual sessions and only had eight group sessions (02/04/14, 02/11/14, 02/13/14, 02/14/14, 02/18/14, 02/20/14, 02/21/14, and 02/25/14). During the month of March 2014, the client only had one individual session (03/13/14) and only had seven group sessions (03/04/14, 03/11/14, 03/13/14, 03/20/14, 03/21/14, 03/25/14, and 03/28/14). During the month of April 2014, the client only had one individual session (04/21/14) and three group sessions (04/01/14, 04/03/14, and 04/04/14). During the month of May 2014, the client did not have any individual sessions and only had four group sessions (05/23/14, 05/27/14, 05/29/14, and 05/30/14). During the month of July 2014, the client did not have any individual sessions and only had four group sessions (07/01/14, 07/03/14, 07/08/14, and 07/24/14). During the month of August 2014, the client did not have any individual sessions and only had two group sessions (08/12/14 and 08/28/14). During the month of September 2014, the client did not have any individual sessions and only had four group sessions (09/04/14, 09/22/14, 09/25/14, and 09/29/14). During the month of October, the client only had one individual session (10/10/14) and only had three group sessions (10/02/14, 10/10/14, and 10/06/14). During the month of November 2014, the client did not have any individual sessions and did not have any group sessions.
Client #6 was admitted to treatment on August 26, 2013 and was still an active client at time of the inspection. An individual treatment and rehabilitation plan was developed with the client on 08/26/2013 and the plan stated that the client would be provided individual sessions 1 time per week and 3 group sesssions per week. During the months of April 2014, May 2014, June 2014, July 2014, August 2014, September 2014, October 2014, and November 2014, the client did not have any individual sessions.
Client #8 was admitted to treatment on December 27, 2013 and was discharged on April 11, 2014. An individual treatment and rehabilitation plan was not completed by the facility for this client. Due to not having an individual treatment plan completed, there was no way to verify or confirm what services were to be provided to this client.
Client #12 was admitted to treatment on December 16, 2013 and was discharged on June 27, 2014. An individual treatment and rehabilitation plan was developed with the client on 12/16/2013 and the plan stated that the client would be provided individual sessions 2 times per month and group sessions 3 times per week. During the month of February 2014, the client only had seven group sessions (02/03/14, 02/06/14, 02/10/14, 02/13/14, 02/24/14, 02/25/14 and 02/27/14). During the month of March 2014, the client only had six group sessions (03/03/14, 03/04/14, 03/06/14, 03/14/14, 03/17/14, and 03/30/14). During the month of April 2014, the client did not have any individual sessions and did not have any group sessions. There was no other documentation providing an explanation. During the month of May 2014, the client did only had one individual session (05/30/14) and only had one group session (05/30/14). During the month of June 2014, the client did not have any individual sessions and did not have any group sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Primary issue resulting in this citation was our failure to document when clients did not show up for, or cancelled, scheduled appointments (whether for individual or group sessions). Beginning 1/2/15 all no-shows and cancellations will be documented with case notes. Clinicians will write a case note when a scheduled client doesn't show for her/his appointment. Front office staff will write a case note when a client calls to cancel, and will forward the case note form to the appropriated clinician for their review and completion. Under the "assessment" and "plan" part of the case note the clinician will make note of what they see happening with the client as it relates to their current treatment plan. At the time of the next treatment plan, the client's record of service will be analyzed to see if the treatment plan should be changed or if further attempts should be made to engage the client at the recommended level of care. Clinical Supervisor will review these attendance case notes during weekly individual clinical supervision sessions, and during weekly clinical staffings. This Plan of Correction was already reviewed with staff during a 12/23/14 staff meeting. Program Director will be responsible for ensuring implementation of the Plan of Correction. |
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 a review of client records, the facility failed to document a complete client record on an individual, which includes information relative to the client's involvement with the project, to include case consultations in six of twelve client records reviewed.
The findings include:
Twelve client records requiring a complete client record on an individual were reviewed on December 3, 2014 through December 4, 2014. The facility did not provide a complete client record for client #s1, 2, 4, 6, 9, and 11.
Client #1 was admitted to treatment on April 04, 2014 and was still active at the time of the on-site inspection. The last documented case consultation was dated 06/17/2014. The facility failed to include documentation of a case consultation in the client record as of 06/17/2014.
Client #2 was admitted to treatment on January 13, 2014 and was still active at the time of the on-site inspection. The last documented case consultation was dated 06/30/2014. The facility failed to include documentation of a case consultation in the client record as of 06/30/2014.
Client #4 was admitted to treatment on January 17, 2014 and was still active at the time of the on-site inspection. The last documented case consultation was dated 04/01/2014. The facility failed to include documentation of a case consultation in the client record as of 04/01/2014.
Client #6 was admitted to treatment on August 26, 2014 and was still active at the time of the on-site inspection. The last documented case consultation was dated 07/21/2014. The facility failed to include documentation of a case consultation in the client record as of 07/21/2014.
Client #9 was admitted to treatment on February 17, 2014 and was discharged on June 10, 2014. The facility failed to include documentation of a case consultation in the client record as of the date of the on-site inspection.
Client #11 was admitted to treatment on March 21, 2014 and was discharged on November 4, 2014. The last documented case consultation was dated 06/24/2014. The facility failed to include documentation of a case consultation in the client record as of 06/24/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Assistant Administrator has developed a Treatment Spreadsheet to track when clients are due for a case consultation. Weekly, beginning the week of 1/12/15 and prior to each Tuesday's case consultation staffing, front office staff (R. Nice and R. Candelario) will sort the Treatment Spreadsheet by "case consultation due date", will fill out client names needing case consults on blank case consult forms, and will pull those client charts and give them to each counselor prior to the weekly clinical staffing. This Plan of Correction was discussed with all staff at a 12/23/14 meeting. Program Director will ensure implementation of this Plan of Correction. Regarding the client records identified in the citation, only one (#4) is still open and active. A case consultation was completed and documented on 12/16/14. |