INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 23, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, STR Addiction Counseling, 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that two applicable employees received a minimum of 6 hours of HIV/AIDS and 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum within the regulatory timeframe.
Employee # 4 was hired as a counselor assistant on June 22, 2022 and was promoted to the position of counselor on May 29, 2024. Employee # 4 was due to have the communicable disease trainings no later than June 22, 2023; however, the HIV/AIDS training was not completed until March 11, 2024 and the TB/STD training was not completed until March 28, 2024.
Employee # 5 was hired as a counselor on April 10, 2023 and was current in that position at the time of the inspection. Employee # 5 was due to have the communicable disease trainings no later than April 10, 2024; however, 6 hours of HIV/AIDS training was not documented as completed as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 has completed the required trainings.
Employee #5 completed their HIV/AIDs training on 6/12/2024.
Moving forward, the HR Generalist will audit staff files on a monthly basis to ensure compliance with DDAP standards. The Director of Quality Assurance will audit the staff files on a quarterly basis to ensure compliance.
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705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection on July 23, 2024, the facility failed to ensure interior exits were lit at all times.
The light in the vestibule connecting the main office suite to an emergency exit on the rear side of the building was not lit and the area was dark when the doors were closed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director installed a light switch guard on the light switch on 7/31/24.
The Facility Director will regularly audit to make sure the light is in good repair and the bulb has not died. |
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.
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Observations
Based on a review of ten client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in two records reviewed.
Client # 3 was admitted to the partial hospitalization level of care on September 28, 2023 and transferred to a lower level of care on November 16, 2023. There was evidence of a disclosure to a family member during a family counseling session on November 2, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client # 13 was admitted to the outpatient level of care on June 24, 2024 and was active at the time of the inspection. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
This is a repeat citation from the September 7, 2023 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Client #3 and Client #13 are no longer in services.
Staff was retrained on completing releases of information and confidentiality on 8/2/24.
Director of Quality Assurance and Executive Director will work together to regularly audit client charts. Staff will be reminded of confidentiality and release requirements on a regular basis. |
709.93(a)(8) LICENSURE Client records
709.93. 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) Case consultation notes.
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Observations
Based on a review of seven client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation note within the first twenty days, then every thirty days, per the facility's policy, in four of seven applicable records reviewed.
Client # 9 was transferred to the outpatient activity from a higher level of care on April 18, 2024 and was discharged on June 24, 2024. The client record did not contain documentation of case consultation notes.
Client # 10 was transferred to the outpatient activity from a higher level of care on December 18, 2023 and was discharged on January 18, 2024. The client record did not contain documentation of case consultation notes after November 7, 2023.
Client # 11 was admitted on December 4, 2023 and was discharged on January 19, 2024. The case consultation note was due to be completed by December 24, 2023; however, it was not documented as completed until January 16, 2024.
Client # 13 was admitted on June 24, 2024 and was active at the time of the inspection. The case consultation note was due to be completed by July 15, 2024; however, the record did not contain documentation of case consultation notes as of the date of the inspection.
This is a repeat citation from the September 7, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #9, 10, 11 and 13 are no longer in services.
Staff was retrained on case consultation policy and timeframes for completion on 8/2.
Director of Quality Assurance will audit client charts on a monthly basis for compliance with documentation timeframes. Staff will be given extra training as needed on documentation. |