INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, McDerrmott Counseling, LLCS 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 one personnel record and discussion with facility staff, employee #1 started as the sole proprietor on August 1, 2010 and was still active in that role at the time of the inspection. Employee #1 only completed four hours of the required twenty five hours of training for the 2020 training year.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
McDermott Counseling was scheduled for annual continuing education through PENN STATE HERSHEY MEDICAL CENTER March 2020-Conference was abruptly cancelled when the pandemic was announced. Pamela McDermott currently attending 2021 online conference -rescheduled from 2020. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of eight client records, the facility failed to document written acknowledgment by clients that they have been notified of their client rights in three client records.
Client #1 completed an evaluation on July 23, 2020 and the client record did not contain written acknowledgment by the client that they had been notified of their client rights.
Client #2 completed an evaluation on March 2, 2021 and the client record did not contain written acknowledgment by the client that they had been notified of their client rights.
Client #3 completed an evaluation on February 28, 2021 and the client record did not contain written acknowledgment by the client that they had been notified of their client rights.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from the January 14, 2020 inspection.
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Plan of Correction
McDermott Counseling will review protocol of written documentation. Patient rights form was developed in 2010.Form will be evident in all charts. Patient rights form will be reviewed and signed by all patients. Form will more systematically included in all admission/intake packets. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of three client records, the facility failed to include documentation of consent to treatment for all three client records reviewed.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from the January 14, 2020 inspection.
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Plan of Correction
McDermott Counseling developed the consent to treatment form in 2010-majority of patients are only seen for intake .Agency protocol will revise admission packet that all patients review and sign treatment consent. Patient seen for intake will also receive consent to treatment form. |
709.44(a)(1)(i) LICENSURE Medical History
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(1) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of three client records, the facility failed to document and complete a medical history for all three client records reviewed.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from the January 14, 2020 inspection.
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Plan of Correction
McDermott Counseling as reviewed during inspection process will develop a medical history of all patients. Patient seen for intake/referral or continued care will complete a medical history. |
709.44(a)(1)(ii) LICENSURE Drug/Alcohol history
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(1) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of three client records, the facility failed to document and complete a drug/alcohol history for all three client records reviewed.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from the January 14, 2020 inspection.
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Plan of Correction
McDermott Counseling will develop a substance use history for all patients. All patients whether admitted for continued care or seen for evaluation only-will have documented drug and alcohol history in chart. |
709.44(a)(1)(iii) LICENSURE Personal history
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(1) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of three client records, the facility failed to document and complete a personnel history for all three client records reviewed.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from the January 14, 2020 inspection.
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Plan of Correction
McDermott Counseling will develop a psychsocial evaluation for all patients-whether they meet criteria for short term education/treatment or require an evaluation and do not need to reschedule.Every chart will reflect documentation of a psychsocial history. |
709.44(a)(3) LICENSURE Psychosocial evaluation
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(3) Psychosocial evaluation.
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Observations
Based on a review of three client records, the facility failed to document and complete a psychosocial evaluation for all three client records reviewed.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from the January 14, 2020 inspection.
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Plan of Correction
Each chart will implement a revised psychosocial evaluation. McDermott Counseling has a modified template of psychosocial evaluation since 2010-very comprehensive evaluation congruent with continued care treatment needs. An evaluation that is better described as a summary- focused on short term care counseling/education is the immediate goal |