INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8-9, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, Inc. 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 May 12, 2009.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to document the Department provided core curriculum in clinical supervision for supervisors who have not functioned for two years as supervisors in the provision of clinical services.
Findings:
Six personnel records were reviewed on April 9, 2009. A core curriculum in clinical supervision was required in one personnel record. The facility did not document the core curriculum in personnel record # 3.
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Plan of Correction
The Program Supervisor is scheduled to attend the core curriculum training May 4th-8th, in Harrisburg, Pa. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in three of eleven client records.
Findings:
The facility documented the release of client information that exceeds 4 Pa Code 255.5 regulations in client records # 1, 6 and 11.
Client record #1 documented the release of a psychological evaluation, psychiatric evaluation, treatment/aftercare plan, neurological evaluation, biopsychosocial evaluation, social work report, court records and medical history to U.S. Probation.
Client record #6 documented the release of a psychological evaluation, psychiatric evaluation, treatment/aftercare plan, neurological evaluation, biopsychosocial evaluation, social work report, court records and medical history to Adult Probation and Parole Services and also to an insurance company.
Client record #11 documented the release of a psychological evaluation, psychiatric evaluation, treatment/aftercare plan, neurological evaluation and ' anything requested ' to a government agency.
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Plan of Correction
Staff training held on April 20th; Confidentiality regulations were reviewed, and all charts purged of invalid consents.
The charts will be monitored in an ongoing fashion by the Program Supervisor, and Facility Manager. |
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 a review of client records, the facility failed to document treatment plans to include proposed types of supportive services in three of five client records.
Findings:
Eleven client records were reviewed on April 9, 2009. Treatment plans with proposed types of supportive services were required in five client records. The facility did not document treatment plans to include proposed types of supportive services in client records # 1, 2 and 4.
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Plan of Correction
Staff training held 4/20/09, to review Standard for treatment Plan.
Monitoring will be done during ongoing chart reviews, as well as group and individual supervision, by the Program Supervisor. |
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 document counseling services provided according to the individual treatment plan in three of six client records.
Findings:
Eleven client records were reviewed on April 9, 2009. Documentation of counseling services provided according to an individual treatment plan was reviewed in six client records. The facility did not document counseling services according to the treatment plan in client records # 2, 4 and 6.
Record # 2, treatment plan 11/20/08 and treatment plan update 1/21/09 state 1:1 counseling sessions two times weekly.
1:1 counseling sessions were documented only on December 3, 8, 10, 12, and January 7, 15, 21, 28, and February 4, 5, 11, 18 and 15.
Record # 4, treatment plan update 12/16/08 states 1:1 counseling sessions three times weekly.
1:1 counseling sessions were documented only on December 16, 23, 30, and January 20 and 27.
Record # 6, treatment plan 12/11/08 and treatment plan update 2/11/09 state 1:1 counseling sessions one times weekly.
1:1 counseling sessions were documented only on December 11, and February 11, 18, and 25.
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Plan of Correction
Staff training held 4-20-09 to clarify how " frequency of treatment" should be documented in the Treatment Plan. Program Coordinator will monitor during chart reviews, as well as during group and individual supervision. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of five client records.
Eleven client records were reviewed on April 9, 2009. Follow-up information was required in five client records. The facility did not document follow-up information within 30 days after discharge, as stated in the project's policy and procedures manual, in client records # 8 and 9.
Record # 8 was discharged 10/15/08, but follow-up information was not documented at time of inspection.
Record # 9 was discharged 12/22/08, but follow-up information was not documented at time of inspection.
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Plan of Correction
Staff training held 4-20-09 to discuss follow up procedured for Discharged Clients.
Within 7 days of d/c, HBHS staff will attemt to contact clients to ascertain need for any additional support or resources, providing referrals or further services as needed, or to verify client's connection to the referred next level of care.
This procedure will be monitored by the Program Supervisor. |