INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 2018 through September 13, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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704.11(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
The facility failed to ensure that employee #5, a counselor, had an individual training plan documented in the employee's personnel/training record for the current training year.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Assurance will develop a training plan for Employee #5.
Moving forward, all part time employees will be given a comprehensive training plan with a list of recommended training.
Training Plans are currently issued at the beginning of the calendar year as well as on the date of hire.
The Director of Quality Assurance will complete bi-annual audits in the employees' personnel records to ensure each employee has an individual training plan. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to ensure that employee #5, a counselor, had an annual written individual performance evaluation for the period reviewed. The last documented performance evaluation was dated June 14, 2016.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
All employees must have annual written individual performance evaluations.
It is StR Addiction Counseling's policy to complete a written performance evaluation for each employee.
The Clinical Director will complete a performance evaluation for employee #5 by 11/1/18
Moving forward the Director of Quality Assurance will complete quarterly audits in personnel records to ensure Performance Evaluations are completed. If an evaluation is not completed, the Director of Quality Assurance will instruct the appropriate supervisor to complete one. |
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
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in eight of ten client records reviewed. Additionally, the facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in two of ten client records reviewed.
Client #1 was admitted in the partial program on April 20, 2018 and was discharged on June 11, 2018. Consent to release information forms to the funding source and 2 probation officers, all signed and dated by client, allowed for the release of aftercare recommendations, discharge summary, medical records, labs and/or legal status, which exceeded 255.5.
Client #2 was admitted into the partial program on July 5, 2018 and was discharged on August 19, 2018. Consent to release information forms to 2 funding sources and a probation officer, all signed and dated by client, allowed for the release of aftercare recommendations, discharge summary, medical records, labs and/or legal status, which exceeded 255.5.
Client #3 was admitted into the partial program on June 21, 2018 and was discharged on August 6, 2018. There was evidence of disclosures to the funding source and to another treatment provider during the client's treatment episode; however, there were no consent to release information forms signed by the client documented in the record prior to the disclosures.
Client #4 was admitted into the partial program on July 20, 2018 and was discharged on August 15, 2018. There was a consent to release information form to the funding source, signed and dated by the client, that allowed for the release of aftercare recommendations, discharge summary, medical records, and labs, which exceeded 255.5.
Client #5 was admitted into the partial program on August 20, 2018 and was still active at the time of the inspection. Consent to release information forms to the funding source and a probation officer, both signed and dated by client, allowed for the release of aftercare recommendations, discharge summary, medical records, labs and/or legal status, which exceeded 255.5. Additionally, there was evidence of a disclosure to another treatment provider during the client's treatment episode; however, there were no consent to release information forms signed by the client documented in the record prior to the disclosures.
Client #6 was admitted into the outpatient program on June 11, 2018 and was still active at the time of the inspection. Consent to release information forms to the funding source and 2 probation officers, all signed and dated by client, allowed for the release of aftercare recommendations, discharge summary, medical records, labs and/or legal status, which exceeded 255.5.
Client #7 was admitted into the outpatient program on August 19, 2018 and was still active at the time of the inspection. Consent to release information forms to 2 funding sources and a probation officer, all signed and dated by client, allowed for the release of aftercare recommendations, discharge summary, medical records, labs and/or legal status, which exceeded 255.5.
Client #8 was admitted into the outpatient program on August 15, 2018 and was discharged on August 31, 2018. There was a consent to release information form to the funding source, signed and dated by the client, that allowed for the release of aftercare recommendations, discharge summary, medical records, and labs, which exceeded 255.5.
Client #10 was admitted into the outpatient program on December 14, 2017 and was discharged on June 30, 2018. There was a consent to release information form to the funding source, signed and dated by the client, that allowed for the release of aftercare recommendations, discharge summary, medical records, and labs, which exceeded 255.5.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Quality Assurance and Care Manager have been scheduled for the Confidentiality training conducted by BCDAC on 10/4/18. At this training the two employees will review Pa Coded 255.5 and confidentiality procedures specifically.
The consent to release information will be changed so that only the 4 criteria dictated in Pa Code 255.5 can be authorized to be released. There will no longer be any additional information or a narrative section for an employee or client to add requests to release information.
Moving forward, the Director of Quality Assurance will complete Monthly checks of the consents to release information forms to ensure there is a client and witness signature.
Clients #1, #2, #3, #4, #6, #7, #8, #9, #10 are no longer clients at StR Addiction Counseling.
Client #5 is still a current client and will have their current consents to release information that exceed what is allowed by 255.5 revoked. New consents to release information that comply with 255.5 will be signed and placed in the Client's file. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
The facility failed to provide treatment plan updates within the regulatory timeframe in two of five client records reviewed.
Client #2 was admitted into the partial program on July 5, 2018 and was discharged on August 19, 2018. The comprehensive treatment plan was completed on July 18, 2018 and an update was due no later than August 18, 2018. However, the update was not completed prior to discharge.
Client #3 was admitted into the partial program on June June 21, 2018 and was discharged on August 6, 2018. The comprehensive treatment plan was completed on June 26, 2018 and an update was due no later than July 26, 2018. However, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is StR Addiction Counseling's policy to complete treatment plan updates every 30 days.
Moving forward the Director of Quality Assurance will audit treatment plans every 30 days to ensure updates are documented appropriately.
If a Treatment Plan update is not completed within 30 days, the Director of Quality Assurance will report the finding to the Clinical Director. The Clinical Director will instruct the corresponding clinician to complete the treatment plan update and complete 1:1 supervision intent on reviewing and training to the Treatment Plan Policy. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
The facility failed to document individual counseling at least two times per week for partial hospitalization clients in four of five client records reviewed.
Client #2 was admitted July 5, 2018 and was discharged on August 19, 2018.
Client #3 was admitted on June 21, 2018 and was discharged on August 6, 2018.
Client #4 was admitted on July 20, 2018 and was discharged on August 15, 2018.
Client #5 was admitted on Augst 20, 2018 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is StR Addiction Counseling's policy to provide 2 individual counseling sessions every week to clients enrolled in the Partial Hospitalization Program.
Moving forward the Clinical Director will complete bi-weekly audits of client records to ensure 2 individual counseling sessions are provided each week for the clients at the PHP Level of Care.
If the Clinical Director observes a client at the PHP LOC as not receiving the mandated 2 individual sessions a week, they will meet with the responsible counselor to review the policy and complete the sessions as required. |