INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6-7, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clearbrook Treatment Centers, LLC. d/b/a Huntingdon Creek Recovery Center, was found to be not 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records conducted on November 6, 2017, the facility failed to ensure that a counselor assistant received the semi-annual performance evaluation.
Employee #5 was hired as a counselor assistant on June 1, 2016. A semi-annual performance evaluation would have been due by December 31, 2016 but was not documented at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical Director completed semi-annual performance review for employee #5 on 11/6/17. Moving forward, all semi-annual reviews will be completed for counselor assistants after 6 months in the position. The human resource director will monitor and ensure that all employee performance reviews are present in the employee personnel record. At this time, the facility is in full compliance with this standard since 11/6/17. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records conducted on November 6, 2017, the facility failed to ensure that a counselor assistant received the required 40 training hours during the first year of employment.
Employee #5 was hired as a counselor assistant on June 1, 2016. Training files were reviewed for the period from June 1, 2016 to June 1, 2017. During this time employee #5 received only 5 documented hours of training.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Human Resource Director will develop a spreadsheet in an excel document by 11/27/17. In this spreadsheet, the Human Resource Director will keep track of all employees, the number of training hours needed for the year, and number of hours completed. Human Resource Director and Clinical Director will periodically check this spreadsheet to ensure staff are attending required trainings. Clinical Director will also remind staff and counsel staff on training needs throughout the training year, and document any non-compliance issues in their employee record. |
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of administrative documents and a conversation with the facility staff, the facility failed to maintain a ratio of one primary care staff for every seven clients in the detoxification activity.
According to the detoxification census submitted by the facility, there were eight (8) clients in the detox unit from 5 pm on October 14, 2017 until 2 am on October 15, 2017. During this time there was only one (1) primary care staff on duty on the detox unit.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical Director, Nurse Manager, and Admissions Director have developed a system as of 10/15/17. Each day, we communicate the number of clients in detox versus the number of scheduled admissions. This will prevent future errors with the FTE standard. In addition, the nurse manager has set up a system for nursing coverage for emergency admissions. The FTE and census will be monitored throughout the year by the Director of Compliance. The facility is currently in compliance with this standard since 10/15/17. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of administrative materials the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
Fire drills were submitted for the following months: October 2016 thru September 2107.
All submitted fire drills indicated that the drills were conducted during the first or second shift.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The facility director met with the maintenance director on 11/8/17 to train him on the importance of fire drill compliance. The maintenance manager has conducted a fire drill on 11/16/17 at 6:30am. This is during 3rd shift hours. Another 3rd shift fire drill is scheduled for May, 2018. The maintenance manager will ensure this fire drill is conducted during sleeping hours. The facility director will oversee that the facility remains in compliance with this standard. As of 11/16/17, the facility has been in compliance with this standard. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Fourteen client records were reviewed on November 7, 2017. The facility failed to document a valid consent to release information form in client records #1-14. All client records contained a form called "Consent to Disclose Records" which was utilized by the facility to inform client's that "medical procedures performed and medications administered" may be disclosed to the "Court of Common Pleas" to obtain payment for services.
This information exceeds what is permitted by 4 Pa. Code 255.5
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The form called "Consent to Disclose Records" will be removed from electronic chart system by the Compliance Director on 11/22/17. All admission staff responsible for building the chart have been informed that this form will no longer be a part of the client record. Weekly chart monitoring is done by the case manager to ensure that this form is no longer used. The facility will be in full compliance on 11/22/17. |
709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project 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 and kept on file.
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Observations
Fourteen client records were reviewed on November 7, 2017. The facility failed to document written acknowledgement by the client that they were notified of all of their rights in fourteen of fourteen client records.
There was no documentation that the client was informed that the project, facility or clinical director would document the reason for removal from the client's record of any material deemed detrimental to the client in client records # 1-14.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Director will pull all existing "Client's Rights" forms from the Patient Handbook by 11/27/17. The Compliance Director will then add a new "Clients Rights" document with the language being pulled directly from the Department of Drug and Alcohol Programs website. Moving forward, each client will receive the "Clients Rights" document upon admission into the facility. The tech supervisor was informed that the "clients Rights" document has changed and will be responsible for ensuring that all Patient Handbooks contain the correct document moving forward. None of the clients listed in the deficiency are currently active clients so we were unable to give them updated copies. The facility will be in full compliance as of 11/27/17. |