INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 1-2, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clearbrook Treatment Centers, LLC d/b/a Huntington Creek Recovery Center 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to document that the facility director met both the education and experiential qualifications for the position.
Employee #1 was hired on April 1, 2022 as Project Director and was still in the position at the time of the inspection. No degree or transcript was provided for review.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #1 has requested a copy of his transcript and expects to receive this by 03/31/23.
Going forward, Acadia and/or HCRC Human Resources will ensure that an employee's educational credentials (i.e., degree or transcript) are on file prior to the start of employment. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide direct observation by a trained counselor or clinical supervisor for the first 3 months of employment or for the next 9 months, under close supervision.
Employee #7 was hired on March 21, 2022 and was still employed at the time of the inspection. He had no documentation of direct or close supervision.
Employee #8 was hired on October 16, 2018 as a driver and was promoted to counselor assistant on September 1, 2022 and was still employed at the time of the inspection. He had no documentation of direct or close supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #7 will have close supervision with documentation from a trained counselor or clinical supervisor for nine months, as of 03/21/2022. The expected completion date will be 12/21/22.
Employee #8 will have close supervision with documentation from a trained counselor or clinical supervisor for nine months, as of 09/01/2022. The expected completion date will be 06/01/2023.
Going forward, the Clinical Director and/or Clinical Supervisor will ensure that the program adheres to the supervision requirements as stated in §704.9. For example, a current employee is expected to be promoted to counselor assistant this month. Close supervision will be provided and documented for a period of nine months. |
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 records.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in one out of seven client records reviewed.
Client #6 was admitted on July 15, 2022 and discharged on August 12, 2022. A release of information form for a family member dated July 15, 2022 did not have documentation that the client was offered a copy of the consent form.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Client #6 was discharged on 07/15/22.
Going forward, the following steps will occur to prevent this deficiency from recurring:
1) The Clinical Director or designee will review charts on a weekly basis to ensure that consents are completed, timely, and that a copy was offered to the client and documented in the chart. Any deficiencies will be addressed with the responsible employee for correction immediately. The Clinical Director or designee will then review to ensure that the correction was made.
2) The Clinical Director and/or Director of Nursing will provide training to any/all staff responsible for completing client consents; including when and how to complete a consent, offering a copy to the client, documenting that a copy was offered, and retaining a copy in the client's record. This training will be completed by 12/31/22. Documentation of completion of the training will be provided to both HR and Q&PI. |
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 the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client record.
Client #12 was admitted on March 13, 2022 and discharged on March 20, 2022.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #12 was discharged on 03/20/22.
Going forward, the following steps will occur to prevent this deficiency from recurring:
1) The Clinical Director or designee will review charts on a weekly basis to ensure that all clients involuntarily terminated from treatment receive written notification of the termination and that this is documented in the chart. Any deficiencies will be addressed with the responsible employee for correction immediately. The Clinical Director or designee will then review to ensure that the correction was made.
2) The Clinical Director will provide training to any/all staff responsible for completing notifications of termination; including when and how to complete the notification, documenting that the notification was completed and provided to the client, and retaining a copy in the client's record. This training will be completed by 12/31/22. Documentation of completion of the training will be provided to both HR and Q&PI. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a psychosocial evaluation in two out of five records reviewed.
Client #9 was admitted on October 12, 2022 and discharged on October 17, 2022.
Client #12 was admitted on March 13, 2022 and discharged on March 20, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff responsible for completing psychosocial evaluations will receive a refresher training from the Clinical Director or Clinical Supervisor.
The Clinical Director or designee will review charts on a weekly basis to ensure that psychosocial evaluations are present and timely. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of four discharged records reviewed.
Client #10 was admitted on September 2, 2022 and discharged on September 6, 2022.
Client #11 was admitted on August 9, 2022 and discharged on August 13, 2022.
Client #12 was admitted on March 13, 2022 and discharged on March 20, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #10, #11, and #12 were discharged from the facility.
Going forward, the following steps will occur to prevent this deficiency from recurring:
1) The Clinical Director or designee will review charts on a weekly basis to ensure that all clients who consented to participate in post-discharge follow-up have received 30-, 60-, 90-, and 180-day follow-up according to facility policy and that this is documented in the chart. Any deficiencies will be addressed with the responsible employee for correction immediately. The Clinical Director or designee will then review to ensure that the correction was made.
2) The Clinical Director will provide training to all staff responsible for completing post-discharge follow-up; including the consent form to participate in follow-up, contacts at 30, 60, 90, and 180 days, documentation of client's current status and changes to the client's continuing care goals.
This training will be completed by 01/15/23. Documentation of completion of the training will be provided to both HR and Q&PI. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to verify the individual's identity, including name, address, date of birth, emergency contact and other identifying information in three out of five records reviewed.
Patient #8 was admitted on October 29, 2022 and was still active at the time of the inspection. There was no proof of verification of the individual's identity, including name, address, date of birth, and other identifying information.
Patient #10 was admitted on September 2, 2022 and was discharged September 6, 2022. There was no proof of verification of the individual's identity, including name, address, date of birth, and other identifying information.
Patient #11 was admitted on August 9, 2022 and was discharged August 13, 2022. There was emergency contact listed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All direct care staff will be trained by the Clinical Director and/or Director of Nursing on the process of obtaining current patient ID (including name, address, date of birth, etc.), identifying at least one emergency contact, and ensuring that information is documented in the patient's chart.
The Clinical Director or designee will review charts on a weekly basis to ensure that the above-mentioned items are present and timely. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed written consent prior to administering an agent in one out of five applicable records.
Patient #8 was admitted on October 29, 2022 and was still active at the time of the inpspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Nursing and/or Clinical Director will provide training to all staff on obtaining the proper consents for an agent to be administered for maintenance or detoxification treatment prior to administration.
The Clinical Director or designee will review charts on a weekly basis to ensure that the consents are present and timely. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of residential client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of three discharged records reviewed.
Client #5 was admitted on July 31, 2022 and was discharged on August 28, 2022.
Client #6 was admitted on July 15, 2022 and was discharged on August 12, 2022.
Client #7 was admitted on June 14, 2022 and was discharged on June 23, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff responsible for completing post-discharge follow-up will receive a training from the Clinical Director or Clinical Supervisor.
The Clinical Director or designee will review charts of discharged patients to ensure that follow-up is completed, timely, and documented in the patient's chart. |