INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 22, 2022 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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704.11(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
Based on a review of personnel records, the facility failed to ensure that each employee had a written, annual individual training plan, with input from the employee and supervisor, documented in two of eight personnel records reviewed.
Employee #1 was hired as the project director/facility director on July 10, 2019. The individual training plan was signed and dated by the employee on April 25, 2022, but the plan was not signed by the supervisor and there was no additional documentation indicating the plan was developed with input from the supervisor.
Employee #7 was hired as a counselor on July 11, 2022. The individual training plan was signed and dated by the employee on July 14, 2022, but the plan was not signed by the supervisor and there was no additional documentation indicating the plan was developed with input from the supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward, the HR Administrator will be in charge of ensuring that all training plans are signed off on by both the employee and supervisor. The HR Administrator will audit the training plans monthly to ensure compliance. The Director of Quality Assurance will audit training plans on a quarterly basis to ensure compliance.
Employee #1 training plan was signed by the supervisor on 10/4/22.
Employee #7 training plan was signed by the supervisor on 10/4/22.
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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 client records, the facility failed to document the specific information to be disclosed on a consent to release information form in one of fourteen client records reviewed.
Client #6 was admitted on September 7, 2021 and was discharged on November 15, 2021. A release of information form to the emergency contact was signed and dated by the client on September 7, 2022; however, the form did not include the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were retrained on the required elements of consents on 9/30/22. They were reminded that they must fill out the specific information to disclose when completing consents with clients. Moving forward, the Care Manager will audit consents on a weekly basis. The Director of Quality Assurance will audit consents on monthly basis.
Client #6 was discharged at the time of inspection. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a consent to release information form in one of fourteen client records reviewed.
Client #14 was admitted to the partial hospitalization level of care on July 19, 2022 and was discharged to the outpatient level of care on August 30, 2022. The release of information form to an emergency contact was signed by the client on July 19, 2022, but the release form failed to include the purpose of the disclosure.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were retrained on the required elements of consents on 9/30/22. They were reminded that they must fill out the purpose of disclosure when completing consents with clients. Moving forward, the Care Manager will audit consents on a weekly basis. The Director of Quality Assurance will audit consents on monthly basis.
Client #14 was discharged at the time of inspection. |
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
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 30 days in one of one applicable client record reviewed.
Client #9 was admitted on August 10, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on August 16, 2022 and the first update was due no later than September 16, 2022; however, the update was not completed at the time of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical staff were retrained on timeframes for completions of treatment plans and updates on 10/4/22. The Director of Quality Assurance will audit the treatment plans on a monthly basis. Information gathered from audits will be used to support and train staff.
Client #9 is no longer in services. |