INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13, 2022, 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 document the completion of 25 clock hours of annual training required for counselors in one of one applicable record reviewed.
Employee # 2 was hired by the facility on November 28, 2012 and has been in the position of counselor since January 1, 2014. The facility's training year that was reviewed was from January 2021 through December 2021. Employee #2's personnel record only documented 24 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/6/22 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 10/13.
Clinical Director will meet with this Employee quarterly, for the rest of 2022 and again in 2023, to ensure progress in reaching annual training requirements. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records and discussion with the facility director, the facility failed to follow their written procedures for the management of treatment and rehabilitation services, pertaining to case consultations occurring at day 30, for two of seven client records and failed to follow their policy related to ACA discharges of calling the Emergency Contact within twelve hours in one of two applicable records.
Client #1 was admitted on December 28, 2021 and discharged Against Clinical Advice (ACA) on January 5, 2022. There was no documentation in the client record that the emergency contact was called.
Client #3 was admitted on April 19, 2022 and was discharged on May 19, 2022. There was no documentation of a case consultation in the client record.
Client #5 was admitted on August 14, 2022 and was active at the time of the inspection. There was no documentation of a case consultation in the client record.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
In a Clinical Staff Meeting on 10/6/22, the facility's policy around Case Consultations was reviewed. Copies of the facility's policy on this treatment activity as well as DDAP's correlating licensure standard, were given to all clinicians. The rationale was explained. Clinical team members discussed how to be more diligent in meeting this standard and it was determined that Case Consultation notes will be entered following bi-weekly clinical meetings if a case is discussed, when there is a crisis intervention for a client, or while planning aftercare which requires discussion about the client by the team. Clinical Director will review all charts to assure there is a case consultation in there prior to the client discharging.
With our new EMR system, there is an Emergency Contact formed that is required to review and complete when a client is discharging. This was implemented in February 2022 and was reviewed by the Clinical Director with the clinical team in a Staff Meeting on 10/6/22. The importance and purpose of notifying an Emergency Contact PRIOR to a client discharging was discussed, and at a very least, contacting the EC within 12 hours of discharge was reviewed. This occurred on 10/6/22. Clinical Director will audit all ACA discharges over the next 6 months to ensure Emergency Contact has been notified appropriately. |
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
Based on a review of personnel records, the facility failed to ensure that personnel records contained a reviewed and signed annual written staff performance evaluation in two of three applicable records.
Employee # 1 was hired as the Project and Facility Director on July 22, 2015 and is current in that position. The most recent annual written staff performance evaluation in the personnel record was reviewed and signed by the employee on June 1, 2021.
Employee # 2 was hired by the facility on November 28, 2012 and has been in the position of counselor since January 1, 2014. The most recent annual written staff performance evaluation in the personnel record was reviewed and signed by the employee on June 3, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with CEO on 10/4/22 to discuss this. It was determined that all annual reviews for employees will be scheduled out at the time of their previous review, by the Clinical Director. When the CEO is on site quarterly, he will review employee records to verify compliance with this POC.
These late annual reviewed will be completed by 10/30/22. Employee #1's review/performace eval will be conducted by the CEO. Employee #2's review/performance eval will be completed by the Clinical Director. |
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 seven client records, the facility failed to include documentation of all the required client rights, including that the project may not discriminate in the provision of services on the basis of ethnicity, marital status, sexual orientation, handicap or religion, in six records reviewed.
Client #2 was admitted on February 22, 2022 and was discharged on March 14, 2022.
Client #3 was admitted on April 19, 2022 and was discharged on May 19, 2022.
Client #4 was admitted on April 26, 2022 and was discharged on May 1, 2022.
Client #5 was admitted on August 14, 2022 and was active at the time of the inspection.
Client #6 was admitted on August 19, 2022 and was active at the time of the inspection.
Client #7 was admitted on August 29, 2022 and was 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
On 10/14/2022, Clinical Director edited the Client Rights and Responsibilities template form to include protection against discrimination on the basis of ethnicity, marital status, sexual orientation, handicap or religion, in addition to other attributes already identified. This has now permanently been corrected for all incoming clients. All active clients were informed of this right and the change in the form on 10/14/22. Their Primary Counselors reviewed this change with them each on 10/14/22. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of seven client records, the facility failed to include documentation of all the required client rights, including that clients have the right to appeal a decision limiting access to their records to the director, in six records reviewed.
Client #2 was admitted on February 22, 2022 and was discharged on March 14, 2022.
Client #3 was admitted on April 19, 2022 and was discharged on May 19, 2022.
Client #4 was admitted on April 26, 2022 and was discharged on May 1, 2022.
Client #5 was admitted on August 14, 2022 and was active at the time of the inspection.
Client #6 was admitted on August 19, 2022 and was active at the time of the inspection.
Client #7 was admitted on August 29, 2022 and was 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
On 10/14/2022, Clinical Director edited the Client Rights and Responsibilities template form to include the right for all clients to appeal a decision limiting access to their records, to the Director. This has now permanently been corrected for all incoming clients. All active clients were informed of this right and the change in the form on 10/14/22. Their Primary Counselors reviewed this change with them each on 10/14/22. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of seven client records, the facility failed to include documentation of all the required client rights, including that clients have the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records, in six records reviewed.
Client #2 was admitted on February 22, 2022 and was discharged on March 14, 2022.
Client #3 was admitted on April 19, 2022 and was discharged on May 19, 2022.
Client #4 was admitted on April 26, 2022 and was discharged on May 1, 2022.
Client #5 was admitted on August 14, 2022 and was active at the time of the inspection.
Client #6 was admitted on August 19, 2022 and was active at the time of the inspection.
Client #7 was admitted on August 29, 2022 and was 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
On 10/14/2022, Clinical Director edited the Client Rights and Responsibilities template form to include the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records. This has now permanently been corrected for all incoming clients. All active clients were informed of this right and the change in the form on 10/14/22. Their Primary Counselors reviewed this change with them each on 10/14/22.
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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 seven client records, the facility failed to include documentation of all the required client rights, including that clients have the right to submit rebuttal data or memoranda to their own records, in six records reviewed.
Client #2 was admitted on February 22, 2022 and was discharged on March 14, 2022.
Client #3 was admitted on April 19, 2022 and was discharged on May 19, 2022.
Client #4 was admitted on April 26, 2022 and was discharged on May 1, 2022.
Client #5 was admitted on August 14, 2022 and was active at the time of the inspection.
Client #6 was admitted on August 19, 2022 and was active at the time of the inspection.
Client #7 was admitted on August 29, 2022 and was 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
On 10/14/2022, Clinical Director edited the Client Rights and Responsibilities template form to include the right to submit rebuttal data or memoranda to their own records. This has now permanently been corrected for all incoming clients. All active clients were informed of this right and the change in the form on 10/14/22. Their Primary Counselors reviewed this change with them each on 10/14/22. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to document, in the client's complete record, verification that any work done by the client at the project is an integral part of his/her treatment and rehabilitation plan in four of seven client records reviewed.
Client #2 was admitted on February 22, 2022 and was discharged on March 14, 2022.
Client #3 was admitted on April 19, 2022 and was discharged on May 19, 2022.
Client #4 was admitted on April 26, 2022 and was discharged on May 1, 2022.
Client #5 was admitted on August 14, 2022 and was 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
In a Clinical Staff Meeting on 10/6/22, the importance of incorporating "work" or domestication therapies and activities into client treatment plans, and the rationale behind this, were reviewed with all Clinical Team members. Clinical Director will review all Master Treatment plans to assure these activities are incorporated into all client's individualized treatment experience. |