INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 1, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CDS Group, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of six personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee # 6 was hired as a counselor assistant on September 23, 2024. Employee # 6 had a Bachelor ' s degree at the time of hire and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for the first 6 months of employment. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision in each week reviewed.
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."
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Quality Assurance, HR Manager and Director of Clinical Services met and reviewed the necessary items to be included in supervision notes on 11/11/24.
Moving forward,the Director of Clinical Services will include direct observation notes in the supervison notes.
The HR Manager will audit these supervisions as necessary when a Counselor Assistant is employed. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of six personnel records, the facility failed to ensure that one employee had a written individual training plan that was developed annually.
Employee # 2 was hired as the Facility Director on January 22, 2024 and was current in that position at the time of the inspection. Employee # 2's initial annual individual training plan was not developed until October 7, 2024.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The HR Manager will work with the facility director to ensure that any employees hired develop and sign off on their training plan within the first weeks of employment.
The HR Manager will audit employee files on a quarterly basis to ensure that that all training plans are completed in a timely manner. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on a review of fourteen client records, the facility failed to ensure that consent to release information forms included the dated signature of the client in one record reviewed.
Client # 12 was admitted to the Outpatient level of care on May 24, 2024 and was active at the time of the inspection. The record contained a consent to release information form to an outside agency dated July 8, 2024, but did not contain the client ' s signature.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Client #12 was no longer in services at the time of inspection
Director of Quality Assurance and Executive Director reviewed consent forms with the team on 11/11/2024.
The Director of Quality Assurance and Executive Director will work together to audit charts and ensure proper completion of the release of information. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four of four applicable records reviewed.
Client # 1 was admitted on May 9, 2024 and was discharged on July 19, 2024. The individual treatment and rehabilitation plan was completed on June 10, 2024, and the treatment plan update was due no later than July 9, 2024; however, no treatment plan update was completed prior to discharge.
Client # 4 was admitted on March 25, 2024 and was discharged on May 23, 2024. The individual treatment and rehabilitation plan was completed on April 3, 2024, and the treatment plan update was due no later than May 2, 2024; however, no treatment plan update was completed prior to discharge.
Client # 5 was admitted on August 29, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 12, 2024, and the treatment plan update was due no later than October 11, 2024; however, no treatment plan update was completed prior to the date of the inspection.
Client # 6 was admitted on August 21, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 9, 2024, and the treatment plan update was due no later than October 8, 2024; however, no treatment plan update was completed prior to the date of the inspection.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Client #1, and #4 were discharged at the time of inspection.
Client #6 will meet with staff before 11/15/24 to update their treatment plan.
Executive Director will meet with clinical staff on 11/14/24 to review timeframes on treatment plan completion and updates.
Director of Quality Assurance and Executive Director will audit charts on a monthly basis to ensure compliance with treatment plan updates. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
|
Observations
Based on a review of client records, the facility failed to provide individual counseling sessions two times weekly for clients in the partial hospitalization activity in five of seven records reviewed.
Client # 1 was admitted on May 9, 2024 and was discharged on July 19, 2024. The record contained documentation of only one individual counseling session for the weeks of May 20, 2024, May 27, 2024, June 10, 2024, June 17, 2024, and June 24, 2024.
Client # 2 was admitted on April 10, 2024 and was discharged on May 9, 2024. The record contained documentation of only one individual counseling session for the week of April 29, 2024.
Client # 3 was admitted on September 9, 2024 and was discharged on October 3, 2024. The record contained documentation of only one individual counseling session for the week of September 23, 2024.
Client # 5 was admitted on August 29, 2024 and was active at the time of the inspection. The record contained documentation of only one individual counseling session for the weeks of September 23, 2024, September 30, 2024, and October 14, 2024.
Client # 6 was admitted on August 21, 2024 and was active at the time of the inspection. The record contained documentation of only one individual counseling session for the weeks of September 23, 2024 and October 14, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Client #1, #2, and #3 were discharged at the time of inspection
Client #5 and #6 will be monitored to ensure that they are seen two times a week for the rest of their treatment stay.
Executive Director will meet with clinical staff on 11/14/24 to review timeframes and requirements for indivdual sessions and missed session notes.
Office Manager will audit sessions on a weekly basis to ensure that clients are seen as required.
Director of Quality Assurance and Executive Director will audit charts on a monthly basis to ensure compliance with indviduals. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
|
Observations
Based on a review of 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 notes, in three of seven applicable records reviewed. The facility policy manual indicates that case consultation notes will be completed within 20 days of admission, and every 30 days thereafter.
Client # 1 was admitted on May 9, 2024 and was discharged on July 19, 2024. The record did not contain documentation of case consultation notes.
Client # 3 was admitted on September 9, 2024 and was discharged on October 3, 2024. The record did not contain documentation of case consultation notes.
Client # 6 was admitted on August 21, 2024 and was active at the time of the inspection. The record did not contain documentation of case consultation notes.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Client #1 and #3 was discharged at the time of inspection.
Client #6 has had a case consultation completed on 10/16/24. And will ensure that more are completed as required by policy.
Executive Director will meet with clinical staff on 11/14/24 to review timeframes on case consultation.
Director of Quality Assurance and Executive Director will audit charts on a monthly basis to ensure compliance with case consultation notes. |
709.83(a)(11) LICENSURE Client records
709.83. 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.
|
Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in three of three applicable records reviewed.
Client # 1 was admitted on May 9, 2024 and was discharged on July 19, 2024. The record did not contain documentation of follow-up information.
Client # 2 was admitted on April 10, 2024 and was discharged on May 9, 2024. The record did not contain documentation of follow-up information.
Client # 4 was admitted on March 25, 2024 and was discharged on May 23, 2024. The record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clients were discharged at the time of service. The Care Manager will reach out to the clients and do a follow up with them prior to 11/15/24.
Executive Director will meet with the Care Manager on 11/14/24 to discuss the frequency of follow up calls
Director of Quality Assurance and Executive Director will audit charts on a monthly basis to ensure compliance with follow up calls. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation in three of seven applicable records reviewed. The facility policy states that new admissions are to have a psychosocial evaluation completed within 14 business days of admission.
Client # 10 was admitted on March 28, 2024 and was discharged on June 10, 2024. The psychosocial evaluation was not completed until September 2, 2024.
Client # 11 was admitted on May 28, 2024 and was discharged on August 29, 2024. The psychosocial evaluation was not completed until June 27, 2024.
Client # 14 was admitted on August 27, 2024 and was discharged on September 13, 2024. The psychosocial evaluation was not completed until September 18, 2024.
These finding were discussed with facility staff during the licensing process.
|
Plan of Correction
Executive Director will meet with clinical staff on 11/14/24 to review timeframes on psychosocial assessments.
Director of Quality Assurance and Executive Director will audit charts on a monthly basis to ensure compliance with psychosocial assessments. |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three of three applicable records reviewed.
Client # 9 was admitted on February 1, 2024 and was discharged on September 15, 2024. The individual treatment and rehabilitation plan was completed on March 26, 2024, and the treatment plan update was due no later than May 24, 2024; however, no treatment plan update was completed prior to discharge.
Client # 12 was admitted on May 24, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 31, 2024, and the treatment plan update was due no later than July 29, 2024; however, no treatment plan update was completed prior to the inspection.
Client # 13 was admitted on July 29, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 31, 2024, and the treatment plan update was due no later than September 28, 2024; however, no treatment plan update was completed prior to the date of the inspection.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Executive Director will meet with clinical staff on 11/14/24 to review timeframes on treatment plan completion and updates.
Moving forward, Director of Quality Assurance and Executive Director will audit charts on a monthly basis to ensure compliance with treatment plan updates. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in six of seven records reviewed.
Client # 8 was admitted on July 8, 2024 and was discharged on August 5, 2024. The treatment plan completed on July 9, 2024, indicated that the client was to receive one individual session per week; however, the record did not contain documentation that any individual sessions offered the week of July 29, 2024.
Client # 9 was admitted on February 1, 2024 and was discharged on September 15, 2024. The treatment plan completed on March 26, 2024, indicated that the client was to receive one individual session per week; however, the record did not contain documentation that any individual sessions offered between July 25, 2024 and August 14, 2024.
Client # 11 was admitted on May 28, 2024 and was discharged on August 29, 2024. The treatment plan completed on June 10, 2024, indicated that the client was to receive one individual session per week; however, the record did not contain documentation that any individual sessions were offered the weeks of July 1, 2024 and July 22, 2024.
Client # 12 was admitted on May 24, 2024 and was active at the time of the inspection. The treatment plan completed on May 31, 2024, indicated that the client was to receive two individual sessions per week; however, the record contained documentation of only one individual counseling session for the weeks of June 10, 2024, June 17, 2024, July 15, 2024, August 5, 2024, September 9, 2024, September 16, 2024, September 23, 2024, and September 30, 2024.
Client # 13 was admitted on July 29, 2024 and was active at the time of the inspection. The treatment plan completed on July 31, 2024, indicated that the client was to receive two individual sessions per week; however, the record contained documentation of only one individual counseling session for the weeks of August 19, 2024, September 16, 2024, September 23, 2024, September 30, 2024, and October 7, 2024.
Client # 14 was admitted on August 27, 2024 and was active at the time of the inspection. The treatment plan completed on September 11, 2024, indicated that the client was to receive one individual session per week; however, the record did not contain documentation that any individual sessions were offered the week of October 21, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Client #8, #9, #11 were discharged at the time of inspection
Client #12, #13 and #14 will be monitored to ensure that they are seen at the required frequency for the rest of their treatment stay.
Executive Director will meet with clinical staff on 11/14/24 to review timeframes and requirements for indivdual sessions and missed session notes.
Office Manager will audit sessions on a weekly basis to ensure that clients are seen as required.
Director of Quality Assurance and Executive Director will audit charts on a monthly basis to ensure compliance with indviduals. |
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.
|
Observations
Based on a review of 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 notes, in five of seven applicable records reviewed. The facility policy manual indicates that case consultation notes will be completed within 20 days of admission, and every 30 days thereafter.
Client # 8 was admitted on July 8, 2024 and was discharged on August 5, 2024. The record did not contain documentation of case consultation notes.
Client # 9 was admitted on February 1, 2024 and was discharged on September 15, 2024. The first case consultation note was not documented until April 12, 2024.
Client # 11 was admitted on May 28, 2024 and was discharged on August 29, 2024. The record did not contain documentation of case consultation notes.
Client # 12 was admitted on May 24, 2024 and was active at the time of the inspection. The first case consultation note was not documented until September 17, 2024. No subsequent case consultation notes were completed.
Client # 14 was admitted on August 27, 2024 and was active at the time of the inspection. The first case consultation note was not documented until September 26, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Client #8, #9, #11 were discharged at the time of inspection.
Client #12 and #14 will have updated case consultations prior to 11/15/24.
Executive Director will meet with clinical staff on 11/14/24 to review timeframes on case consultation.
Director of Quality Assurance and Executive Director will audit charts on a monthly basis to ensure compliance with case consultation notes. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in one of one applicable record reviewed.
Client # 11 was admitted on May 28, 2024 and was discharged on August 29, 2024. The client record did not contain documentation of a completed aftercare plan.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clien #11 was discharged at the time of inspection.
Executive Director will meet with clinical staff on 11/14/24 to review expectations on aftercare plans.
Director of Quality Assurance and Executive Director will audit charts on a monthly basis to ensure compliance with aftercare plans. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in two of three applicable records reviewed.
Client # 8 was admitted on July 8, 2024 and was discharged on August 5, 2024. The record did not contain documentation of follow-up information.
Client # 10 was admitted on March 28, 2024 and was discharged on June 10, 2024. The record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clients were discharged at the time of service. The Care Manager will reach out to the clients and do a follow up with them prior to 11/15/24.
Executive Director will meet with the Care Manager on 11/14/24 to discuss the frequency of follow up calls
Director of Quality Assurance and Executive Director will audit charts on a monthly basis to ensure compliance with follow up calls. |