INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection buprenorphine monitoring inspection conducted on November 27 & 28, 2023 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 dba Huntingdon 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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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of ten personnel records, the facility failed to ensure that two counselor assistants were counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #8 was hired on December 11, 2022 as a counselor assistant. Employee #8 has a high school diploma and may counsel clients only under direct observation of a trained counselor or clinical supervisor for the first 3 months of employment and close supervision of a trained counselor or clinical supervisor for the first 6 months of employment. Employee #8 did not receive formal case review during supervisions occurring on March 7, 17, 23, 29, April 5, 13, 20, 28, May 3, 12, 23, 30, June 6, 19, 27, July 6, 14, 21, 27, August 4, 10, 31, September 7, 13, 28, and October 5, 2023. Employee #8 did not have documented one hour a week of direct observation from December 2022- March 2023. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Based on a review of the supervision notes there is no documented formal case review or direct observation for the first six months of employment.
Employee #10 was hired on September 1, 2022 as a counselor assistant. Employee # 10 has a high school diploma may counsel clients only direct observation of a trained counselor clinical supervisor for the first 3 months of employment and close supervision of a trained counselor or clinical supervisor for the first 6 months of employment. Employee #10 did not receive formal case review during supervisions occurring on March 7, 16, 17, 23, 29, April 5, 12, 20, 25, May 3, 11, 18, 26, June 5, 13, 21, 28, July 5, 14, 21, 27, August 4,10,18, 25 and September 1, 2023. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Based on a review of the supervision notes there is no documented formal case review or direct observation for the first six months of employment.
This is a repeat citation from the November 2, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CA Supervision Note Form is being revised to ensure that the CA is receiving the correct supervision and to improve the process supervision documentation process the addition of prompts for important elements, including but not limited to:
1) hire date
2) credentials
3) whether the supervision is direct observation or close supervision required based on DDAP regulations
4) start date and projected end date of direct observation and/or close supervision
The Director of Clinical Services or designee will ensure that the direct observation and/or close supervision occurs as required for each particular CA via:
1) sitting in on a random sample of supervised activities
2) weekly review of documentation of services provided with signatures of both the CA and the counselor.
The CA will not be promoted to counselor until all required direct observation and/or close supervision occurs and is confirmed by the Director of Clinical Services or the Manager of Clinical Services.
The expected completion date of implementation of the new form and process will be 01/08/2024. |
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 the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of nine client records reviewed.
Client #2 was admitted on November 26, 2023 in the detoxification activity and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source and emergency contact dated November 26, 2023 were offered to the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Q&PI will review and revise the form for ease and accuracy regarding ensuring that the client is offered a copy of the consent. The facility management team met and decided that the primary person completing the paper consents with a client will be responsible for reviewing the consent for completion before scanning the consent to the EHR.
In addition, the Director of Clinical Services or designee will add this item to the regular department chart audits.
The expected completion date of implementing the new form and process will be 01/08/2024. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of patient records, the facility failed to verify the individual has reached 18 years of age prior to administration of an agent in one out one applicable record reviewed.
Patient #1 was admitted on November 20, 2023 to the detoxification activity and was still active at the time of the inspection. There was no documentation that the facility obtained verification of the patient's age prior to administering an agent.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Q&PI will revise the existing policy to reflect the various forms of acceptable proof of ID (including photo and age). Facility staff and the access center will be educated on these various forms of IDs, so the client has them upon admission. Staff will document a note regarding all requests for ID, attempts to assist the client, and the outcome of the attempts.
The expected completion date of the revised policy and implementation of the revised process will be 01/19/2024. |
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 client records, the facility failed to provide a complete client record, which is to include follow-up information in four out of four discharged records reviewed.
Client #6 was admitted on February 10, 2023 and discharged on March 2, 2023. There was no documentation that a follow up occurred in the client file.
Client #7 was admitted on September 12, 2023 and discharged on October 9, 2023. There was no documentation that a follow up occurred in the client file.
Client #8 was admitted on September 23, 2023 and discharged on October 20, 2023. There was no documentation that a follow up occurred in the client file.
Client #9 was admitted on September 22, 2023 and discharged on October 2, 2023. There was no documentation that a follow up occurred in the client file.
This is a repeat citation from the November 2, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The follow-up phone calls for are made by the access center. The Admissions Supervisor or designee will check for completion of this call on a weekly basis.
1) If the access center completed the call, this information will be documented in the client's EHR by the Admissions Supervisor or designee.
2) If the call was not completed by the access center, the Admissions Supervisor or designee will make the call to the client and will document that attempt and outcome in the revised Aftercare Follow-Up Note in the EHR.
In addition to Acadia's quarterly chart audits, the Clinical Director or designee will conduct weekly chart audits of discharged clients to ensure completion of the follow-up calls.
The Director of Q&PI and the Clinical Director will jointly monitor that the plan of correction is being followed.
The expected completion date of the revised form and implementation of the process will be 01/08/2024. |