INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 10, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Engagement, LLC 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 and personnel records, the facility failed to document the completion of 25 clock hours of annual training for one applicable counselor.
Employee #2 was hired as a counselor on June 15, 2021 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from June 15, 2022 through June 15, 2023. Employee # 2's record only documented ten hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A staff meeting occurred on 10/23/2023 the findings were reviewed with all staff. Employee #2 was present. the required training hours for their position was reviewed, along with the documentation for said training hours. A Mid year review will occur with all staff to ensure there is good progress in obtaining the needed training hours for all staff. The mid year review will be conducted approximately on 4/01/2024 and the clinical Supervisor is responsible for Oversight. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on the physical plant inspection, the facility failed to ensure that the fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguishers located in the lobby, group room, and two offices did not have updated inspection tags.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The fire Extinguishers in the group room and counselor office, which were improperly tagged were taken to the inspection company and the inspection tags were corrected, to include the month they were inspected. The other two fire extinguishers were removed from the premise, since they are not required for the agency's needs. The facility director will verify property tagging occurs and no improperly tagged fire extinguishers are left in the building at any time. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including the project may not discriminate in the provision of services on the basis of marital status, ethnicity, handicap or religion in seven out of seven records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An agency staff meeting occurred on 10/23/2023. The client rights documentation was updated to include wording that the project may not discriminate in the provision of services on the basis of marital status, ethnicity, handicap or religion. All current client's were provided the updated correct client rights policy. All future clients will also be provided the updated client rights. This will be verified and monitored by the facility director. Random chart reviews will occur quarterly to verify that correct client rights policy notification is used. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document that a comprehensive treatment plan was developed with the client in five out of seven records reviewed.
Client #1 was admitted on June 14, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on June 15, 2023; however, did not have documentation it was developed with the client. The client did not sign the document until October 3, 2023.
Client #2 was admitted on June 21, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on June 26, 2023; however, did not have documentation it was developed with the client. The client did not sign the document until October 3, 2023.
Client #3 was admitted on July 8, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on July 9, 2023; however, did not have documentation it was developed with the client. The client did not sign the document until October 3, 2023.
Client #4 was admitted on July 27, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on August 25, 2023; however, did not have documentation it was developed with the client. The client did not sign the document until October 3, 2023.
Client #5 was admitted on November 25, 2022 and was discharged on August 22, 2023. A comprehensive treatment plan was completed on December 13, 2022; however, did not have documentation it was developed with the client. The client did not sign the document until February 15, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff training occurred on 10/23/2023. The need to have a client sign the treatment plan at the time is developed was reviewed. Addiotnally documentation will be placed in the client chart the day the treatment plan is developed and will include any issues that occur with having the client sign the treatment plan. The facility director will verify there is a client signature when reviewing charts, minimally, on a quarterly basis. |
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 treatment plan updates within the regulatory timeframe in two out of six records reviewed.
Client #5 was admitted on November 25, 2022 and discharged on August 22, 2023. A treatment plan update was completed on January 24, 2023 and the next update was due no later than March 24, 2023; however, there was no documentation that one was completed.
Client #6 was admitted on January 19, 2023 and was discharged on September 8, 2023. A treatment plan update was completed on June 1, 2023 and the next update was due no later than August 1, 2023; however, it was not completed until August 3, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff training occurred on 10/23/2023 in brain storming steps to be taken to identify any treatment plan reviews needing to be completed in the 60 day time frame from the previous treatment plan. Staff related successful steps that have aided them in timely completion of the treatment plan reviews. A quarterly review of charts will occur to ensure completion of the treatment plan reviews. The quarterly review will begin 10/27/2023 and the facility director/clinical Supervisor is responsible for Oversight. |
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 ensure that the clients received counseling services according to their individual treatment plan in six out of seven applicable records reviewed.
Client #1 was admitted on June 14, 2023 and was still active at the time of the inspection. The treatment plan dated June 15, 2023, indicated group therapy three times a week. The client only received one group therapy session for the week of August 7, 2023.
Client #2 was admitted on June 21, 2023 and was still active at the time of the inspection. The treatment plan dated June 26, 2023, indicated group therapy three times a week. The client only received two group therapy sessions the week of July 31, 2023.
Client #3 was admitted on July 8, 2023 and was still active at the time of the inspection. The treatment plan dated July 9, 2023, indicated group therapy three times a week. The client only received two group therapy sessions for the week of July 31, 2023.
Client #4 was admitted on July 27, 2023 and was still active at the time of the inspection. The treatment plan dated August 25, 2023, indicated group therapy three times a week and one individual therapy session a week. The client did not receive two group therapy sessions the week of September 4, 2023, and there was no documentation that the client received any individual therapy sessions.
Client #5 was admitted on November 25, 2022 and discharged on August 22, 2023. The treatment plan dated January 24, 2023, indicated group therapy two times a week. There is no documentation that the client received any group therapy sessions the week of July 10, 2023.
Client # 6 was admitted on January 19, 2023 and discharged on September 8, 2023. The treatment plan dated June 1, 2023, indicated group therapy two times a week. There is no documentation that the client received any group therapy the week of July 17, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff training occurred on 10/23/2023, in situations that a client misses scheduled treatment sessions a no show/cancelation note will be placed in the client chart to show that the recommended frequency of services were offered to the client, but the client did not participate in the recommended frequency of services. This will be monitored by the facility/clinical supervisor when quarterly chart reviews occur. the first one will be 10/27/2023. |
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 provide a complete client record, which is to include follow-up information in one out of one applicable discharged record reviewed.
Client #7 was admitted on February 14, 2023 and discharged on April 10, 2023. A follow up was due per the facility ' s policy and procedures manual at 60 days after discharge; however, there is no documentation that one occurred.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Training occurred with agency staff on 10/23/2023 regarding the time frame of follow up with clients who have been discharged from services. An end of the month review will occur to verify needed follow up contacts have been made. This will be done on a monthly basis as part of the staff meetings that occur weekly. The monthly reviews will begin 10/27/2023, which will be conducted by agency staff with the facility director / clinical supervisor overseeing the process. |