INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on June 11, 2019. Based on the findings of the on-site inspection, Colonial Park Intensive Outpatient Program, LLC was found to not 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
During a review of staff records on June 11, 2019, the facility failed to have a written individual training plan for each employee, appropriate to that employee's skill level.
Employee #2 was hired as a counselor on May 29, 2019. Employee #2 did not have a written individual training plan.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor met with employee #2 to provide individual training plan document. Document was completed by employee 6/13/2019. It will be the responsibility of the Clinical Supervisor to ensure all new employees receive an individualized training plan upon hire. New employees will have one week to complete the form and have it reviewed by the clinical supervisor. This will be added to Clinical Supervisor job description 7/8/2019. |
704.11(f)(1) LICENSURE Counselor's Trng Req
704.11. Staff development program.
(f) Training requirements for counselors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
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Observations
During a review of records on June 11, 2019, the facility failed to select subject areas for training according to the training plan for each individual.
Staff #2 was initially hired on August 16, 2018 and promoted to his/her current position as a counselor on May 29, 2019. Staff #2 did not have a training plan nor selected training areas for an individual training plan.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor met with employee #2 to provide individual training plan document. Document was completed by employee and reviewed by the clinical supervisor 6/13/2019. It will be the responsibility of the Clinical Supervisor to ensure all new employees receive an individualized training plan upon hire. New employees will have one week to complete the form and have it reviewed by the clinical supervisor. This will be added to Clinical Supervisor job description 7/8/2019. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
During a review of staff records on June 11, 2019, the facility failed to instruct staff in the use of the fire extinguisher upon employment.
Staff #2 was hired as a counselor on May 29, 2019 and was never trained in the use of a fire extinguisher.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Staff #2 was trained in the use of the fire extinguisher and completed the paperwork associated with fire safety on 06/12/19. Clinical Supervisor will ensure that all new staff members will complete their fire safety training upon orientation. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
During a review of the policy and procedure manual on June 11, 2019, the facility failed to make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders.
The facility did complete an annual report during the inspection but did not share it with the public via website or paper.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The administrative staff will ensure that an annual report is completed every year by 06/11 and made public using their website and other means of media. This will be included in the administration's job description starting 07/02/19. Annual Report will be place on the Colonial Park Intensive Outpatient website 07/15/2019. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
During a review of personnel policies and procedures on June 11, 2019, the facility failed to have the project director prepare annually, update and sign a written manual delineating project policies and procedures.
The project director had not updated and signed the policy and procedure manual since June 28, 2017.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Director met with owner to discuss the requirement of updating the policy and procedures manual annually. Clinical Director and appropriate staff will meet to review personnel policies and procedures manual 7/1/2019 and sign the annual update. It will be responsibility of the Clinical Director moving forward to set up meeting with appropriate staff to update the policy and procedures manual annually. This meeting will occur by 1/10 each year. It will be added to the job description of the Clinical Director 7/8/2019. |
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.
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Observations
During a review of client records on June 11, 2019, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information in seven out of seven client records.
The facility's consent to release form in all seven records stated, "I understand that I may revoke this authorization at any time upon written notice to Colonial Park Intensive Outpatient Program, LLC".
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Verbiage was added 6/30/2019 to the informed and voluntary consent form to reflect the following "I understand that I may revoke this authorization at any time upon written or verbal notice to Colonial Park Intensive Outpatient Program, LLC." All current clients will sign new consent to release forms with updated verbiage during their next individual sessions with their therapist. Each individual therapist will be responsible for ensuring each active client on their caseload signs new forms. All current clients will have signed off on the new forms by 7/30/2019. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
During a review of client records on June 11, 2019, the project failed to disclose only what is permitted by 4 PA Code 255.5.
Client #3 was admitted on March 18, 2019 and was still active at the time of the inspection. A voluntary consent to release information to a probation officer dated March 18, 2019 gave permission to disclose the following: treatment plans, psychological assessments, psychiatric history and assessment, results of physical exam, medical history and current status, biopsychsocial assessment, laboratory test results, employment information, legal status, family information, aftercare recommendations, discharge planning and discharge summary. Client #3 also had a voluntary consent to release to a probation officer dated June 5, 2019 which gave consent for the following: biopsychsocial assessment, legal status, aftercare recommendations, discharge planning and discharge summary.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Director will re-train staff on the proper completion of consent forms. This re-training will be done during weekly individual supervision. Re-training will be completed by 7/31/2019. Review of consents will also be added to the monthly chart auditing which will be conducted by Clinical Director. |
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
Upon review of client records on June 11, 2019, the facility failed to document treatment and rehabilitation plans were reviewed and updated at least every sixty days in five out of seven client records.
Client # 1 was admitted on January 21, 2019 and was still active at the time of the inspection. Client #1 had a comprehensive treatment plan dated February 1, 2019 and then did not have a review and update until June 4, 2019.
Client #2 was admitted on January 26, 2019 and was still active at the time of the inspection. Client #2 had a comprehensive treatment plan dated February 19, 2019 and then did not have a review and update until June 4, 2019.
Client #3 was admitted on March 18, 2019 and was still active at the time of the inspection. Client #3 had a comprehensive treatment plan on March 27, 2019 and did not have a review and update until June 5, 2019.
Client #5 was admitted on April 8, 2018 and was discharged on November 28, 2018. Client #5 had document treatment and rehabilitation plans dated June 22, 2018 and July 3, 2019. Client #5 had no further document treatment and rehabilitation plans before being discharged November 28, 2018.
Client #7 was admitted on March 2, 2018 and was discharged on October 7, 2018. Client #7 had treatment and rehabilitation plans dated May 25, 2018 and July 5, 2018. Client #7 had no further treatment and rehabilitation plans documented before being discharged October 7, 2018.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All staff at the office will be re-trained by the Clinical Director regarding the need to update the treatment plan at least every sixty days. Staff connected to clients identified in citation will also have this need incorporated in individual supervision with the Clinical Supervisor to ensure it is clarified and staff become compliant with treatment plan updates. Clinical Supervisor will be responsible for monthly chart audits. |