INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 7, 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.
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to hire a counselor who meets the qualification of a counselor.
Findings:
Five personnel records were reviewed on July 6, 2009. Qualifications for the counselor positions was required in two personnel records. An employee with a Bachelor's 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.
|
Plan of Correction
The Clinical Supervisor completed a new Personnel Action Form which was signed on 7-13-09 to reflect the correct job title. The therapsit signed the job description on 7-20-09. The Project Director will sign them as well by 7-30-09. She is aware of the 40 hours of training required and of the weekly supervision meetings. The corrected job description will be placed in the personnel file. This documentation will be available for review after 7-30-2009 at the Hanover Office, Human Resourse 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.
|
Observations
Based on the review of CPR/First Aid cards and interview with 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 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. The facility did not have trained staff who were CPR certified.
|
Plan of Correction
CPR and First Aid is now being mandated for all Drug and ALohol Therapists. The Clinical Supervisor will be conveyeing the staff meeting on 8-6-09. We have scheduled a CPR/FIrst Aid training on 8-13-09. The Clinical Supervisor will monitor attendance at this training. If clinicials are not able to sign up, the Clinical Supervisor will direct staff to the American Red Cross for training. The clinical Supervisor will continue to monitor this requirement through quarterly reviews of the Training Manual. Documentation of compliance will be housed in the Training Manual. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
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 a clinical 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.
|
Plan of Correction
On 8-6-09, the Clinical Supervisor will have a staff meeting to review findings and compliance expectations. The Clinical Supervisor will hand out an example that meets standards for compliance for the psychosocial evaluation. Expectations are that charts wil include all points offered in the example. Compliance will consist of weekly chart reviews. Charts that do not meet expectations will be docuemented on a Supervision Documentation form and returned to the therapist for review. The chart will be reviewed again at the next weekly visit. The Intake Packet is being updated by the Clinical Supervisor and will be ready for distribution on 8-30-09. Changes are being made to prompt the clinicial to provide more interpretive data. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
|
Observations
Based on the review of client records, the facility failed to document short and long-term goals in two of four client records.
Findings:
Four client records were reviewed on July 7, 2009. Short and long-term goals were required in two client records. The facility documented short and long-term goals without measurable action steps in client records #2 and 4.
|
Plan of Correction
On 8-6-09, the Clinical Supervisor will meet with staff to review findings and compliance expectation. We will review the required parts of short and long term goals, that action steps need to be clearly measurable. Charts will be reviewed weekly to ensure compliance and documented on a Supervision Documentation form. If a chart does not meet expectations and goals are not measurable, the chart will be returned with action needed. Charts will be reviewed to document compliance at the next weekly meeting. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on the review of client records, the facility failed to document type and frequency of treatment services in two of four client records.
Findings:
Four client records were reviewed on July 7, 2009. Type and frequency of treatment services were required in two client records. Documentation of type and frequency was not documented in records #2 and 4.
|
Plan of Correction
By 8-6-09, the Clinical supervisor will have reviewed the expectations that all blanks be filled in. The Type and Frequency of Treatment Services will be pointed out with the expectation that each time goals are done, this section is completed in its entirety. Weekly chart reviews and treatment team meetings will review this requirement to ensure compliance. |
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.
|
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 four client records. Support services were not documented in records #1, 2 and 4.
|
Plan of Correction
By 8-6-09, the expectations that all sections of the chart are completed will be addressed by the Clinical Supervisor. Compliance will be evidenced by weekly chart reviews, if a chart is out of compliance a Supervison Documentation form will be sent to the therapsit for correction. The chart will be reviwed again at the next weekly visit. |
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.
|
Observations
Based on a review of client records, the facility failed to document a complete treatment plan updates three of four client records.
Findings:
Four client records were reviewed on July 7, 2009. Treatment plans updates were required in four client records. In client records #1, 2 and 3 treatment plan updates did not include the client's progress in relationship to the stated goals of the treatment plan, but rather stated generalized comments that were not specific to the client's progress in treatment.
|
Plan of Correction
During our discussion of cmpliance with paperwork, the CLinical Supervisor will address the expectation that progress in treatment in relationship to the stated goals is a required part of the goal review forms. Compliancw will be done at weekly chart ereviews with non compliance documented by the Supervisions Documentation form. The chart will be reviewed at the next weekly visit. |
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.
|
Observations
Based on a review of client records, the facility failed to document complete case consultations notes in two of four client records.
Findings:
Four client records were reviewed on July 7, 2009. 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 #1 was admitted on 1/2/09 and as of the date of survey no case consultation completed. Client record #2 was admitted on 12/10/08 and as of the date of survey no case consultation have been documented.
|
Plan of Correction
During the staff meeting on 8-6-09, the Case Consultation time line will be reviewed by the Clinical Supervisor. Compliance will be done through weekly chart reviews, and in treatment team meetings. If a case is not in compliance, it will be documented through Supervision Doumentation form. The chart will then be reviewed at the next weekly chart review. |