INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Little Creek Lodge, 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2022 through December 31, 2022 training year in one of two applicable personnel records reviewed.
Employee # 2 was hired as a lead counselor on January 1, 2014. The personnel record documented 8 hours of training received during the training year reviewed.
This is a repeat citation from the September 13, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/5/23 in a Clinical Staff meeting, Clinical Director reviewed the licensure training requirements for all Clinicians. Required training hours for Counselors and Counselor Assistance were reviewed and the licensing regulation was copied and given out to all of them.
Following the training, Clinical Director met with Employee #2 privately, and reviewed his Personal Training Plan with him, as well as his personal training log to show him. Acceptable training websites and resources such as DDAP's TMS site, TrainPA, and BHTEN's DBHIDS. Training posting location in Staff Office was also reviewed with him so that he has ample support and access to resources in order to obtain training requirement. He verbalized understanding of everything reviewed on 10/5. Writer made clear that this is the 2nd training year in a row that this has happened and put him on a performance improvement plan.
Clinical Director will meet with this Employee quarterly, for the rest of 2023 and again in 2024, to ensure progress in reaching annual training requirements. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's October 2022 through August 2023 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The fire drill logs, for every monthly drill conducted during the reviewed period, documented that the front door was utilized as the exit route and no other alternative exit routes were used.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In a Leadership Team Meeting on 9/20/2023, Project Director shared with Operations Manager the protocols and requirements around conducting monthly fire drills, specifically the requirement to use different exits. He expressed an understanding of this and plans to implement this effective October 2023 when that fire drill is conducted.
In our quarterly Leadership Team Meetings, the Fire Drill Logs will be reviewed and the rotation of exits requirement will be confirmed. |
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 release of information forms in two of seven client records reviewed.
Client # 4 was admitted on April 22, 2023 and was discharged on April 30, 2023. A release of information form to an outside individual was signed by the client on April 22, 2023, but the release form did not include the purpose of the disclosure. Additionally, a release of information form to a family member was signed by the client on April 29, 2023, but the release form did not include the purpose of the disclosure.
Client # 7 was admitted on December 1, 2022 and was discharged on January 3, 2023. The release of information form to another treatment provider was signed by the client on December 30, 2022, but the release form did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During routine chart audits in August 2023, it was determined that some residential care workers and nurses were not properly completing ROI forms in client charts. Specifically, this appeared to be happening during the initial intake process. On 8/17/23, a training was held for all residential care workers and nurses to go over the role and proper completion of ROI's, and the purpose of each section on the ROI. Routine chart audits will occur on a monthly basis and this will continue to be reviewed. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in seven of seven client records reviewed.
In every client record reviewed, there was no documentation that a copy of any of the release of information forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the annual on-site inspection, it was identified that the new ROI forms in our EMR did not include an option for clients to verify that they were offered a copy of the consent form they signed. A checkbox option was added onto the ROI forms for clients to check or not, verifying that they have been offered a copy. This change to the ROI form was made on 10/2/23. Routine chart audits will continue to occur on a monthly basis by the Clinical Director to make sure these boxes are being utilized. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that the project may not discriminate in the provision of services on the basis of age, creed, color, or national origin in seven of seven client records reviewed.
Every client record reviewed had client rights acknowledgment form; however, each client form was missing this specific client right.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
When the Client Rights and Responsibilities stock form in our EMR was edited after last inspection to add missing wording, somehow new language was added but then language that should have been there, was removed. The DDAP regulation on Client Rights and Responsibilities was referenced and the wording on non discrimination was copied and pasted verbatim into the form on our EMR on 10/2/2023. Routine chart audits will continue to occur on a monthly basis by our Clinical Director and this will be reviewed. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to inspect their own records and that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and that reasons for removing sections shall be documented in the record in seven of seven client records reviewed.
Every client record reviewed had client rights acknowledgment form; however, each client form was missing this specific client right.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The wording from the DDAP regulation regarding clients' right to inspect their own records, was reviewed and copied and pasted, verbatim, into the Client Rights and Responsibilities form in our EMR on 10/2/23. Routine monthly chart audits will continue to occur by our Clinical Director and this will be checked. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in seven of seven client records reviewed.
Every client record reviewed had client rights acknowledgment form; however, each client form was missing this specific client right.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The language from the DDAP regulation regarding clients having the right to submit rebuttal data on their own records was copied and pasted from the regulation into the Client Rights and Responsibilities form in our EMR. This was edited on 10/2/23. Routine monthly chart audits will continue to occur and this will be checked. |
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 notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client record reviewed.
Client # 4 was admitted on April 22, 2023 and was administratively discharged on April 30, 2023. The client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project on April 29, 2023; however, the written notice did not include the reason for termination.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The form that clients sign indicating they have been made aware that they are being therapeutically discharged, was edited to add a reason. Prior, that section did not exist. Now, that form cannot be completed without a reason given. This was changed on 10/2/23. The form cannot be completed without this section being complete and the use of this form will be reviewed for all clients that have been therapeutically discharged, by the Clinical Director. |