INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 27-28, 2017 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of 7 personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor during the first six months of employment in that position in 1 of 1 applicable record.
Employee # 2 was hired as a clinical supervisor on 4/9/17 and was still in the position as of the inspection. Monthly supervision notes were required for April 2017 through September 2017; however, there was no documentation of monthly supervision as of the date of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director will meet the Facility Director on 10/6/17. This meeting will be documented on a meeting agenda formed and signed by both the Clinical Director and Facility Director. The form will be added to the Clinical Director's personnel file. Moving forward, in the event that another or different Clinical Director is hired, the Facility Director will document monthly meetings with the Clinical Director for the first 6 months of employment in the new position. |
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 provide documentation of an individual training plan for the current training year, which was identified as 5/01/17-4/30/18, in 5 of 5 employees reviewed.
Employee # 1 was hired as the Project Director on 12/24/13 and was still in the position.
Employee # 2 was hired as a Clinical Supervisor on 4/9/17 and was still in the position.
Employee # 3 was hired as a counselor on 12/6/15 and was still in the position.
Employee # 4 was hired as a counselor on 5/30/17 and was still in the position.
Employee # 5 was hired as a counselor on 10/10/16 and was still in the position.
Employee # 6 was hired as a counselor on 6/12/17 and was still in the position.
Employee # 7 was hired as a counselor on 7/31/17 and was still in the position.
Employee # 8 was hired as a counselor assistant on 5/8/17 and was still in the position.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will change our facility training year to the calendar year. Each employee will meet with the Clinical Director and review the facility training plan and come up with a specific, individual training plan for their position and needs. This meeting will happen before 1/1/2018. The meeting will be documented by an updated training plan, signed off on by both the employee and Clinical Director. Moving forward, each employee will meet with the Clinical Director within their first two weeks of employment to review and change, as needed, their own individual training plan. This meeting will be documented by a training plan that is signed by both the employee and Clinical Director. |
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 the review of 14 client records, each client record reviewed had consent to release information forms that were missing required elements.
Client #1 was admitted on 8/15/17 and was still an active client at the time of the inspection. All the consent forms in the record were missing witness signatures.
Client # 2 was admitted on 8/22/17 and was still an active client at the time of the inspection. All the consent forms in the record were missing witness signatures.
Client # 3 was admitted on 8/30/17 and was still an active client at the time of the inspection. All the consent forms in the record were missing witness signatures.
Client # 4 was admitted on 7/26/17 and was discharged on 9/14/17. All the consent forms in the record were missing witness signatures.
Client # 5 was admitted on 5/25/17 and was discharged on 6/29/17. All the consent forms in the record were missing witness signatures. Additionally, there was a consent to release form signed and dated on 6/27/17 to an outside individual; however, the purpose for disclosure listed "other n/a".
Client # 6 was admitted on 5/8/17 and was discharged 7/25/17. All the consent forms in the record were missing witness signatures. Additionally, there was a consent to release form signed and dated on 7/20/17 to an outside individual; however, the purpose for disclosure listed "other n/a".
Client # 7 was admitted on 7/26/17 and was discharged on 8/31/17. All the consent forms in the record were missing witness signatures.
Client # 8 was admitted on 8/18/17 and was still an active client at the time of the inspection. All the consent forms in the record were missing witness signatures.
Client # 9 was admitted on 9/14/17 and was still an active client at the time of the inspection. All the consent forms in the record were missing witness signatures.
Client # 10 was admitted on 6/29/17 and was still an active client at the time of the inspection. All the consent forms in the record were missing witness signatures. Additionally, there was a consent to release form signed and dated on 6/7/17 to an outside individual; however, the purpose for disclosure listed "other n/a".
Client # 11 was admitted on 5/18/17 and was discharged on 7/18/17. All the consent forms in the record were missing witness signatures. Additionally, there was a consent to release form signed and dated on 4/8/17 to an outside individual; however, the purpose for disclosure listed "other n/a".
Client # 12 was admitted on 4/11/17 and was discharged on 6/10/17. All the consent forms in the record were missing witness signatures.
Client # 13 was admitted on 6/6/17 and was discharged 8/8/17. All the consent forms in the record were missing witness signatures.
Client # 14 was admitted on 2/20/17 and was discharged on 3/23/17. All the consent forms in the record were missing witness signatures. Additionally, there was a consent to release form signed and dated on 1/20/17 to an outside individual; however, the purpose for disclosure listed "other n/a".
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will work with the EMR to adjust the consent form to list and allow a witness to create a signature. The Clinical Director will also alter the form so as not to have a check box for "other n/a" All forms relative to consents to release information will have the ability to have a witness signature and no longer have an "other n/a" checkbox by 10/31/2017. The Clinical Director will send a memo to all staff (Care Managers and Clinicians) that are responsible to document release of information consents of the new policy to sign the form as a witness on 10/31/2017. The Project Director will audit a random sample of client records on 10/31/17 to ensure that all current records have a signed consent with a witness signature and all forms are without the "other n/a" check box. Moving forward, the Clinical Director will include and audit of consent forms, checking for witness signatures, into his quarterly records review.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to provide documentation that clients were notified, in writing, of the decision to involuntarily terminate the client's treatment at the project in 3 of 3 applicable records.
Client # 12 was admitted into the outpatient level of care on 4/11/17 and was administratively discharged on 6/10/17.
Client # 13 was admitted into the outpatient level of care on 6/6/17 and was administratively discharged 8/8/17.
Client # 14 was admitted into the outpatient level of care on 2/20/17 and was administratively discharged on 3/23/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will upload, sign and send the termination letter to each client that is involuntarily terminated from treatment. This process will happen immediately. The Facility Director reviewed the regulation, form, and protocol with the Clinical Director on 10/1/17. the Facility Director will ensure the Clinical Director's compliance by reviewing charts of clients' that were involuntarily discharged on a quarterly basis. |
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
Based on a review of client records, the facility did not provide individual counseling two times per week as required for the partial hospitalization activity in 3 of 7 records reviewed.
Client # 1 was admitted on 8/15/17 and was still active at the time of the inspection. Documentation of two individual sessions per week was not completed for the week of 9/4/17.
Client # 6 was admitted on 5/8/17 and was discharged on 7/25/17. Documentation of two individual sessions per week was not completed for the weeks of 6/5/17, 6/12/17, 6/19/17, 6/26/17, 7/3/17, and 7/10/17.
Client # 7 was admitted on 7/26/17 and was discharged on 8/31/17. Documentation of two individual sessions per week was not completed for the week of 7/31/2017.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director met with all Counselors on 10/4/17 to review the regulation relevant to the requirement of 2 individual sessions for each client that is at the PHP level of care. Moving forward, the Clinical Director will be sure to check the frequency of individual counseling during his monthly chart audits. |