INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 14, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Adams Hanover Counseling Services, 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 August 14, 2010.
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Plan of Correction
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility's policies and procedures manual and an interview with the clinical supervisor, the facility failed to prepare and annually update a written manual delineating project policies and procedures.
The findings include:
The facility's policies and procedures manual was reviewed on July 12 and 13, 2010. The manual contained contained conflicting policies and procedures due to outdated policies that were never removed when the new policies were implemented.
The clinical supervisor confirmed that the policies and procedures manual had not been updated.
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Plan of Correction
The Program Director and the Clinical Supervisor will review the current Policy and Procedure manual and remove all outdated materials and ensure that the newest policies are in the manual. The Clinical Supervisor, under the direction of the Porject Director, will be responsible for keeping the manual up to date. This will be done over the next 3 months to be completed no later than the 31st of October 2010. |
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 support services on the individual treatment plan in three of five client records.
The findings include:
Five client records were reviewed on July 14, 2010. Five client records were required to have individualized treatment plans with documented support services. Support services were not documented on the individual treatment plan in client records #2, 4 and 5.
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Plan of Correction
The Clinical Supervisor is scheduled to meet with staff at the end of August to review the required paperwork and the need to completely fill in a document. The Clinical Supervisor will be reviewing charts monthly via our electronic medical records to ensure that this requirement is in compliance. Any problems will be documented and addressed. These standards will be reinforced through monthly staff meetings. |
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 facility policy and client records, the facility failed to document case consultation notes in two of three client records.
The findings include:
Five client records were reviewed on July 14, 2010. According to the facility's policy and procedure manual, case consultations are due to be completed every 90 days. Only three client records were required to have a case consultation.
Client #1 was admitted on 12/10/09. A case consultation was due by 3/10/10. As of 5/6/10, the date the client was discharged, there was no case consultation documented in client record #1.
Client #5 was admitted on 3/9/10. A case consultation was due by 6/9/10. As of 7/14/10, there was no case consultation documented in client record #5.
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Plan of Correction
The Clinical Supervisor has scheduled a meeting with staff at the end of August to review paperwork requirments and the date sensitivity of each document. For Case Consults, this standard will be reviewed in supervision, and completed within the electronic medical records on or before the 3 month dead line. This standard can be tracked within the electronic medical record to ensure compliance and completion. Any problems will be documented and addressed at monthly staffings. |