INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 7, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, STR Addiction Counseling, 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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704.6(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 files, the facility failed to ensure that one applicable clinical supervisor had completed a core curriculum in clinical supervision, which is a qualification for the position.
Employee # 2 was promoted to the position of clinical supervisor on October 16, 2022 and is current in that position. Employee # 2 did not complete a core curriculum until July 21, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward, the HR Administrator and the Director of Quality Assurance will monitor and audit any promotion or hire of a Clinical Supervisor. HR Administrator and Director of Quality Assurance will work the individual to ensure they have completed the core curriculum within 6 months or hire/promotion.
Employee #2 has already completed both parts of the Clinical Supervision training. |
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.
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Observations
Based on a review of personnel records, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.
Employee # 4 was promoted to the position of counselor on May 29, 2023 and was current in that position at the time of the inspection. At the time of promotion, the employee had a qualifying bachelor ' s degree but not the required one year of clinical experience for a bachelor ' s level counselor.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Moving forward, the Director of Quality Assurance and the HR Administrator will work together to ensure that all Counselors will meet the qualifications prior to hire. The HR Administrator was trained on the qualifications on 9/21/23.The HR Administrator will review each applicant prior to hire to ensure they meet the qualifications.
Employee #4 will continue with documented regular supervison with the Executive Director. Employee will be in a Counselor Assistant role, supervised by the Executive Director for one year. After the year they will be eligible for the counselor role. |
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
Based on a review of fourteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in three records reviewed.
Client # 4 was admitted to the Partial level of care on April 24, 2023 and was discharged on May 17, 2023. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
Client # 8 was admitted to the Outpatient level of care on April 1, 2023 and was discharged on July 8, 2023. There was evidence of a disclosure to a family member during a family counseling session on April 10, 2023; however, the informed and voluntary consent form to the family member was not signed by the client until May 16, 2023.
Client # 10 was admitted to the Outpatient level of care on May 18, 2023 and was discharged on July 17, 2023. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff were retrained on 9/21/23 on policy and procedures relating to the release of information. Staff was reminded that they are not to release information unless a consent is fully complete.
The Care Manager will audit consents and disclosure on a weekly basis to ensure compliance. The Director of Quality Assurance will audit consents and disclosure monthly to ensure compliance.
Client #4, 8, 10 were all discharged at the time of survey.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of fourteen client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on consent to release information forms in one client record reviewed.
Client # 12 was admitted to the Outpatient level of care on July 24, 2023 and was active at the time of the inspection. The release of information form to the funding source was signed and dated by the client on July 24, 2023; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff were retrained on 9/21/23 on proper completion of a consent form.
The Care Manager will audit consents on a weekly basis to ensure compliance. The Director of Quality Assurance will audit consents monthly to ensure compliance. The Director of Quality Assurance will conduct quarterly trainings on the necessary elements of a consent form.
Client #12 completed a new consent for the funding source on 9/21/23. |
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
Based on a review of fourteen client records, the facility failed to ensure that informed and voluntary consent to release information forms included the specific information to be disclosed in one record reviewed.
Client # 13 was admitted to the Outpatient level of care on July 18, 2023 and was active at the time of the inspection. The record contained a consent to release information form to a member of their support system signed by the client on August 4, 2023, that was missing the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff were retrained on 9/21/23 on proper completion of a consent form.
The Care Manager will audit consents on a weekly basis to ensure compliance. The Director of Quality Assurance will audit consents monthly to ensure compliance. The Director of Quality Assurance will conduct quarterly trainings on the necessary elements of a consent form.
Client #13 completed a new consent for the support system on 9/21/23. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on a review of seven client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a case consultation note within the first two weeks, then monthly, per the facility's policy, in two of six applicable records reviewed.
Client # 3 was admitted on November 21, 2022 and was discharged on December 13, 2022. The client record did not contain documentation of case consultation notes.
Client # 7 was admitted on August 21, 2023 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Team will be retrained on case consultation notes and deadlines on 9/26/23.
Moving forward, the Lead Clincian will work with the team bi-weekly to ensure compliance with the documentation time frames. The Director of Quality Assurance will audit compliance with these requirements monthly.
Client #3 was discharged.
Client #7 case consult was completed on 9/14/23 |
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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in two of five applicable records reviewed.
Client # 8 was admitted from a higher level of on April 1, 2023 and was discharged on July 8, 2023. A treatment plan update was completed on April 5, 2023, and the next treatment plan update was due no later than June 5, 2023; however, no treatment plan updates were completed prior to the client ' s discharge.
Client # 11 was admitted on November 29, 2022 and was discharged on April 11, 2023. A treatment plan update was completed on January 24, 2023, and the next treatment plan update was due no later than March 24, 2023; however, no treatment plan updates were completed prior to the client ' s discharge.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Clinical Team will be retrained on treatment plan guidelines and deadlines on 9/26/23.
Moving forward, the Lead Clincian will work with the team bi-weekly to ensure compliance with the documentation time frames. The Director of Quality Assurance will audit compliance with these requirements monthly.
Client #8 and 11 were discharged at the time of insepction.
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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 seven client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation note within the first two weeks, then monthly, per the facility's policy, in four of seven applicable records reviewed.
Client # 9 was admitted on December 13, 2022 and was discharged on March 5, 2023. The client record did not contain documentation of case consultation notes.
Client # 11 was admitted on November 29, 2022 and was discharged on April 11, 2023. The client record did not contain documentation of case consultation notes after December 30, 2022.
Client # 12 was admitted on July 24, 2023 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.
Client # 14 was admitted on June 7, 2023 and was active at the time of the inspection. The client record contained documentation of a case consultation note on June 23, 2023, and the next case consultation note was due to be completed by July 23, 2023; however, the next case consultation note was not documented until August 28, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Team will be retrained on case consultation notes and deadlines on 9/26/23.
Moving forward, the Lead Clincian will work with the team bi-weekly to ensure compliance with the documentation time frames. The Director of Quality Assurance will audit compliance with these requirements monthly.
Client #11 was discharged at time of inspection.
Client #12 case consult was completed on 9/7/23.
Client #14 has been discharged. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project including a discharge summary within seven days of discharge per the facility ' s policy, in three of four applicable records reviewed.
Client # 8 was admitted on April 1, 2023 and was discharged on July 8, 2023. The discharge summary was not completed until July 27, 2023.
Client # 9 was admitted on December 13, 2022 and was discharged on March 5, 2023. The client record did not contain documentation of a completed discharge summary.
Client # 11 was admitted on November 29, 2022 and was discharged on April 11, 2023. The client record did not contain documentation of a completed discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Team will be retrained on discharge summaries and deadlines on 9/26/23.
Moving forward, the Lead Clincian will work with the team bi-weekly to ensure compliance with the documentation time frames. The Director of Quality Assurance will audit compliance with these requirements monthly.
Client #9 and #11 discharge summaries will be completed by 9/26/23. |