INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 3, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Guidance 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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704.11(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 and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #4 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on March 22, 2021 and was still in this position at the time of the inspection. Employee # 4 was due to have the communicable disease trainings no later than March 22, 2022. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
(A) 5/10/22 All department staff met and reviewed the training requirements as they pertain to required trainings and timeframes for completion. Staff also reviewed the annual training plan requirements of 25 hours per year.
(B) 5/18/22 Employee #4 completed DDAP TB/STI training.
(C) 5/24/22 Training requirements were reviewed with agency Training and Development Coordinator. An indicator was added to the training management system to ensure that DDAP requirement are met by staff in the D&A program on an annual basis.
(D) Staff training hours and requirements will be reviewed by the Project Director on a quarterly basis.
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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 one of one applicable employee personnel records reviewed, the facility failed to provide documentation of at least 25 clock hours of annual training required for a counselor for the January-December 2021 training year.
Employee # 3 was hired as a counselor on September 1, 2018 and was still in this position at the time of the inspection. After a review of employee #3's personnel record, there was only 22.75 training hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
(A) 5/10/22 All department staff met and reviewed the training requirements as they pertain to required trainings and timeframes for completion. Staff also reviewed the annual training plan requirements of 25 hours per year.
(B) 5/24/22 Training requirements were reviewed with agency Training and Development Coordinator. An indicator was added to the training management system to ensure that DDAP requirements are met by staff in the D&A program on an annual basis.
(C) Staff training hours and requirements will be reviewed by the Project Director on a quarterly basis.
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709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
709.17(a)(3)
Based on a review of administrative information, client records, and personnel records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for an informed and voluntary consent form from the client for the disclosure of information were submitted and approved by the Department for the June 10, 2021, November 17, 2020, April 25, 2019, and June 13, 2018 annual licensing inspections.
Obtaining an informed and voluntary consent form from the client for the disclosure of information were again found to be a deficiency in the May 2022 licensing inspection.
Plans of correction for a complete client record to include case consultation in accordance with the facility policy and procedure manual were submitted and approved by the Department for the June 10, 2021, November 17, 2020 annual licensing inspections.
Case consultations were again found to be a deficiency in the May 3, 2022 licensing inspection.
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Plan of Correction
(A) The facility will ensure that the current plan of correction is followed by reviewing all charts on a weekly basis. This review will be done by the Project Director.
(B) The facility will ensure that the plan of correction is followed by meeting monthly with the Quality and Compliance Department in order to review and correct deficiencies.
(C) The current plan of correction will be reviewed by all department staff on a monthly basis to ensure adherence. |
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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent form from the client for the disclosure of information prior to the disclosure of information contained in the client record in client record # 7.
Client # 7 was admitted on July 22, 2021 and was discharged on April 27, 2022. A contact note with a probation officer occurred on July 23, 2021 however, an informed and voluntary consent from the client for the disclosure of information for the probation officer was not signed by the client until September 7, 2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 10, 2021, November 17, 2020, April 25, 2019, and June 13, 2018 annual licensing inspections.
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Plan of Correction
(A) 5/10/22 Clinicians, Executive Director, Quality Director, and Clinical Director met and reviewed, in detail consents for the D&A program. Instruction was provided on completion of consents in order to comply with PA Code.
(B) PA Code 255 was reviewed by Project Director with each clinician in individual supervision.
(C) Clinicians will be responsible for completing consents and obtaining a written signature during individual sessions with clients. Clinicians will be responsible for reviewing that consent with Project Director during weekly supervision and before information is disclosed to the person the consent names.
(D) 5/10/22 All department staff were retrained by Executive Director, Quality Director and Project Director on limiting consents to Treatment Plan summary only for drug and alcohol clients. The agency Treatment Plan Summary follows PA Code 255.5 in limiting information to: whether or not the client is in treatment, prognosis of the client, nature of the project, brief description of the progress of the client, and a short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
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709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information which is to include the name of the person, agency or organization to whom the disclosure is being made.
Client # 3 was admitted on February 4, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated February 4, 2022 did not provide the name of the person, agency or organization to whom the disclosure is being made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
(A) 5/10/22 Clinicians, Executive Director, Quality Director, and Clinical Director met and reviewed, in detail consents for the D&A program. Instruction was provided on completion of consents in order to comply with PA Code.
(B) PA Code 255 was reviewed by Project Director with each clinician in individual supervision. Specific emphasis was placed on identifying the name of the individual that information will be released to and including that information on the consent.
(C) 5/10/22 All department staff were retrained on limiting consents to Treatment Plan summary only for drug and alcohol clients. The agency Treatment Plan Summary follows PA Code 255.5 in limiting information to: Whether or not the client is in treatment, prognosis of the client, nature of the project, brief description of the progress of the client, and a short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
(D) Clinicians will be responsible for completing consents and obtaining a written signature during individual sessions with clients. Clinicians will be responsible for reviewing that consent with Project Director during weekly supervision and before information is disclosed to the person the consent names.
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709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on six of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information which is to include the specific information disclosed or keep information disclosed limited to 255.5 (b) for a government or funding agency.
Client # 1 was admitted on August 13, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated August 13, 2021 to a funding source allowed for the disclosure of "consultation".
Client # 2 was admitted on December 21, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 21, 2021 to a funding source only included "billing information" as the specific information to be disclosed. Also, an informed and voluntary consent from the client for the disclosure of information to a probation officer dated December 21, 2021 allowed for the release of "evaluation assessment, treatment plan-service plan, discharge summaries, substance use- treatment summary, substance use-ASAM summary".
Client # 3 was admitted on February 4, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a county agency and housing authority agency dated March 3, 2022 allowed for the release of "service summary-substance use, treatment summary- substance use-ASAM summary".
Client # 4 was admitted on March 15, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a funding source dated March 15, 2022 allowed for the release of "evaluation assessment, treatment plan-service plan, discharge summaries, substance use- treatment summary, substance use-ASAM summary". Also, an informed and voluntary consent from the client for the disclosure of information to a county agency dated March 15, 2022 allowed for the release of "discharge summaries, substance use- treatment summary".
Client # 6 was admitted on January 13, 2022 and was discharged on April 19, 2022. An informed and voluntary consent from the client for the disclosure of information dated January 13, 2022 to a funding source, employer, and an attorney allowed for the disclosure of "consultation".
Client # 7 was admitted on July 22, 2021 and was discharged on April 27, 2022. An informed and voluntary consent from the client for the disclosure of information to a probation officer dated September 7, 2021 allowed for the release of "evaluation assessment, treatment plan-service plan, discharge summaries, substance use- treatment summary, substance use-ASAM summary".
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
(A) 5/10/22 The quality director changed the consent form to only allow "treatment summary" to be included in the consent. The agency Treatment Plan Summary follows PA Code 255.5 in limiting information to: whether or not the client is in treatment, prognosis of the client, nature of the project, brief description of the progress of the client, and a short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
(B) 5/10/22 Clinicians, Executive Director, Quality Director, and Clinical Director met and reviewed, in detail consents for the D&A program. Instruction was provided on completion of consents in order to comply with PA Code.
(C) Clinicians will be responsible for completing consents and obtaining a written signature during individual sessions with clients. Clinicians will be responsible for reviewing that consent with Project Director during weekly supervision and before information is disclosed to the person the consent names.
(D) The quality department will audit client health records on a monthly basis for 6 months following the inspection.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on five of seven client records reviewed, the facility failed to provide a preliminary treatment plan in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a preliminary treatment plan be completed on the first appointment with the client.
Client # 1 was admitted on August 13, 2021 and was still active at the time of the inspection. There was no preliminary treatment available in the client record. The first treatment plan documented in the client record occurred on August 25, 2021.
Client # 2 was admitted on December 21, 2021 and was still active at the time of the inspection. There was no preliminary treatment available in the client record. The first treatment plan documented in the client record occurred on February 14, 2022.
Client # 3 was admitted on February 4, 2022 and was still active at the time of the inspection. There was no preliminary treatment available in the client record. The first treatment plan documented in the client record occurred on March 3, 2022.
Client # 5 was admitted on July 21, 2021 and was discharged on November 3, 2021. There was no preliminary treatment available in the client record. The first treatment plan documented in the client record occurred on August 5, 2021.
Client # 6 was admitted on January 13, 2022 and was discharged on April 19, 2022.
There was no preliminary treatment available in the client record. The first treatment plan documented in the client record occurred on January 21, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
(A) 5/10/22 Department staff were retrained on the necessity of developing a treatment plan during the initial evaluation with a client.
(B) 5/10/22 Department staff were retrained on the necessity of having a treatment plan update completed and documented every 60 days following the initial evaluation.
(C) 5/19/22 The quality and compliance director designed a dashboard within the electronic health record so that project director can access a report showing treatment plan due dates for each enrolled client.
(D) Treatment plans will be reviewed in weekly supervision of clinicians by Project Director.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on two of four applicable client records reviewed, the facility failed to provide documentation of treatment and rehabilitation plans being reviewed and updated at least every sixty days in client records # 1 and # 6.
Client # 1 was admitted on August 13, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on September 16, 2021. A treatment and rehabilitation plan update was due November 16, 2021 but did not occur until December 7, 2021.
Client # 6 was admitted on January 13, 2022 and was discharged on April 19, 2022. A treatment and rehabilitation plan was developed on January 21, 2022. A treatment and rehabilitation plan update was due March 22, 2022 however, there were no treatment and rehabilitation plan updates in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
(A) 5/10/22 Department staff were retrained on the necessity of developing a treatment plan during the initial evaluation with a client.
(B) 5/10/22 Department staff were retrained on the necessity of having a treatment plan update completed and documented every 60 days following the initial evaluation.
(C) 5/19/22 The quality and compliance director designed a dashboard within the electronic health record so that project director can access a report showing treatment plan due dates for each enrolled client.
(D) Treatment plans will be reviewed in weekly supervision of clinicians by the Project Director.
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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 three of five applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a case consultation to occur quarterly for the first year of services and then annually thereafter.
Client # 1 was admitted on August 13, 2021 and was still active at the time of the inspection. A case consultation was due to occur no later than November 13, 2021. A case consultation documented in the client record occurred on February 16, 2022.
Client # 2 was admitted on December 21, 2021 and was still active at the time of the inspection. A case consultation was due to occur no later than March 21, 2022. There was no case consultation documented in the client record.
Client # 5 was admitted on July 21, 2021 and was discharged on November 3, 2021. A case consultation was due to occur no later than October 21, 2022. There was no case consultation documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 10, 2021, November 17, 2020 annual licensing inspection.
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Plan of Correction
(A) 5/10/22 All staff were retrained on the need for quarterly reviews.
(B) 5/19/22 The quality director implemented a dashboard in the electronic health record to track quarterly reviews.
(C) Quarterly reviews will be reviewed in weekly supervision of clinicians by the Project Director.
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