INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 19, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, A Better Today Inc. 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records and a discussion with facility staff, the facility failed to ensure clinical supervisors participated in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position.
Employee #2 was hired as the clinical supervisor on June 19, 2023. No documentation of monthly meetings were documented in the personnel record.
Employee #3 was promoted to clinical supervisor on May 6, 2023. No documentation of monthly meetings were documented in the personnel record.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
In accordance with 704.6, any further clinical supervisors hired on as staff will have the correct clinical experience and degree as DDAP regulations.
(e)The Executive Director will participate in documented monthly meetings with the clinical supervisor to discuss their duties and performances for the first 6 months of their employment. The frequency of meetings after that will be, at minimum, every 6 months and based on the clinical supervisor's skill level.
The Executive Director and Chief Operations Manager are the individuals responsible for hiring and will make sure there is proper documentation of clinical experience moving forward, including proper documented supervision.
Time Frame: Immediate action
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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.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee in the required time frame, appropriate to that employee's skill level in two out of six employee records reviewed.
Employee #3 was hired on September 1, 2021 as a counselor assistant and was promoted to a clinical supervisor on May 6, 2023. There is no training plan for her current position.
Employee #5 was hired on August 14, 2023 as a counselor assistant and was still in the position as of the date of the inspection. The plan is dated October 2, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A written individual training plan for each employee, appropriate to that employee's skill level, will be developed annually with input from the Clinical Supervisor and the employee.
The Clinical Supervisor will participate in documented weekly, or monthly meetings with all employees to discuss individual training plans based on the employee's previous education, experience, current job functions, and job performance, including employee #5.
The clinical supervisor will review employee charts on a bi-weekly basis to ensure a written individual training plan for each employee will be completed in accordance with the regulation, within 30 days.
The Executive Director will provide monthly reviews for Employee #3 and all Clinical Supervisors.
Responsible for these actions: Executive Director and Clinical Supervisor
Time frame: 11/15/2023
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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 form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #6 was hired as a counselor on September 27, 2022 and was due to have the communicable disease trainings no later than September 27, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will review staff charts monthly to inform counselors of the training attained and the required training needed for the year to ensure compliance to training requirements for the following year (2024).
Employee #6 will complete HIV/AIDS training and the TB/STD training on the next available date it is offered.
Responsible for these actions: Clinical Director and employee #6.
Time frame: Immediate action
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705.27 (4) (ii) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(ii) Assignments of staff during emergencies.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to provide a written procedure for staff and clients to follow in case of an emergency that includes the assignments of staff during emergencies.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facilities Policy and Procedure manual has been updated to include a written procedure for staff and clients to follow in case of an emergency, including the assignments of Staffs during emergencies.
Responsible for these actions: Clinical Director
Time frame: Immediate action
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from November, 2022 - October 2023, the facility failed to prepare alternative exit route to be used during fire drills, as all drills utilized the same exit route.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facilities Fire Policy has been updated to include alternate exit routes to be used during fire drills so all drills do not utilize the same exit route.
Responsible for these actions: Clinical Director
Time frame: Immediate action
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a discussion with facility staff, the governing body failed to make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director will make the facilities annual report available to the public by publishing it annually in the local newspaper which will include, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable
Responsible for these actions: Executive Director
Time frame: January 2024
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to ensure that the project director annually prepare, update, and sign a written manual delineating project policies and procedures.
In addition, an incomplete policy and procedures manual was provided during the inspection. No policies and procedures were provided for the Intake, Evaluation and Referral activity. For the partial and outpatient service activities, parts of the policy and procedures were not included in the documentation submitted during the inspection process.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will review the Policy and Procedure Manual by December 29, 2023, to ensure all policies and procedures are included in the manual. Once it is assured that the manual is completed, the Project Director will sign off on it for the 2023 year. Going forward, the director will update if needed and then sign off yearly to ensure the policy and procedure manual is kept up to date.
Responsible for these actions: Project Director
Time frame: 12/29/2023
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709.26 (b) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(1) Application or resume for employment.
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Observations
Based on a review of personnel records, the facility failed to verify qualifying professional credentials as Employee #3 promoted to clinical supervisor on May 6, 2023, personnel record contained a resume with inaccurate job history as determined by previous DDAP inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3 will update resume to reflect accurate job history which will include promotions, description of job duties, and accurate job history timeline.
The Clinical Supervisor will review resumes to ensure the information is accurate.
Responsible for these actions: Clinical Supervisor and employee #3.
Time frame: Immediate action
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709.26 (c) LICENSURE Personnel management.
§ 709.26. Personnel management.
(c) There shall be written job descriptions for project positions.
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Observations
Based on a review of personnel records, the facility failed to ensure that personnel records included a written job description for project positions.
Employee #3 was promoted to clinical supervisor on May 6, 2023. The employee record failed to contain a written job description.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will review employee charts monthly to ensure that personnel records include a written job description for project positions for new hires and employee promotions. ABT has updated employee #3 record that now includes a written job description.
Responsible for these actions: Clinical Director
Time frame: 11/15/2023
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709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of outpatient client records, the facility failed to ensure that the individual treatment and rehabilitation plan included short and/or long-term goals for treatment formulated by both staff and client in five out of five applicable client records reviewed.
Client #1 was admitted on May 5, 2023 and was still active at the time of the inspection.
Client #3 was admitted on April 25, 2023 and was still active at the time of the inspection.
Client #4 was admitted on January 31, 2023 and was still active at the time of the inspection.
Client #5 was admitted on March 7, 2023 and discharged on June 27, 2023.
Client #6 was admitted on March 28, 2023 and discharged on May 6, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The treatment plan was revised to meet the ASAM criteria. Counselors will be trained in weekly meetings on developing stronger documentation. Counselors will continue to develop the treatment plan with clients during their individual session. All treatment plans will be reviewed during weekly census meetings with the clinical supervisor and counselors.
Short and long-term goals will be discussed. The counselor will also include how they can implement themselves in helping the client achieve these goals.
Treatment modalities used will be documented along with the time frame the client has set to achieve their goals.
Responsible for these actions: Clinical Supervisor and Counselors
Time frame: Immediate action
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of outpatient client records, the facility failed to ensure that the individual treatment and rehabilitation plan included type and frequency of treatment and rehabilitation services in five out of five applicable records reviewed.
Client #1 was admitted on May 5, 2023 and was still active at the time of the inspection.
Client #3 was admitted on April 25, 2023 and was still active at the time of the inspection.
Client #4 was admitted on January 31, 2023 and was still active at the time of the inspection.
Client #5 was admitted on March 7, 2023 and discharged on June 27, 2023.
Client #6 was admitted on March 28, 2023 and discharged on May 6, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of December 1, 2023, all treatment plans will include the type and frequency of treatment specified by group and individual sessions. Staff was met with to go over this requirement, and to assure it was understood. Going forward, charts will be reviewed by the clinical director to assure the type and frequency of treatment are included in all treatment plans.
Responsible for these actions: Clinical Director and Counselors
Time frame: 12/1/2023
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of outpatient client records, the facility failed to ensure that the individual treatment and rehabilitation plan included proposed type of support services in five out of five applicable client records reviewed.
Client #1 was admitted on May 5, 2023 and was still active at the time of the inspection.
Client #3 was admitted on April 25, 2023 and was still active at the time of the inspection.
Client #4 was admitted on January 31, 2023 and was still active at the time of the inspection.
Client #5 was admitted on March 7, 2023 and discharged on June 27, 2023.
Client #6 was admitted on March 28, 2023 and discharged on May 6, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A Better Today, Inc is implementing a "Coordination of Care Policy" where a counselor contacts other support services that the client has signed releases for. This will occur every 60 days when the counselor and client discuss the treatment plan update.
ABT has updated the current the individual treatment and rehabilitation plan to include CRS's, Self-help groups, sponsor, recovery coach, spouse, mentoring/peer support, pastor, family, etc.
Responsible for these actions: Clinical Director and Counselors
Time frame: 11/15/2023 |
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 a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of six applicable records reviewed.
Client #1 was admitted on May 5, 2023 and was still active at the time of the inspection. A treatment plan update was completed on July 5, 2023 and an update was due no later than September 5, 2023; however, it was not completed until September 6, 2023.
Client #4 was admitted on January 31, 2023, 2023 and was still active at the time of the inspection. A treatment plan update was completed on May 31, 2023 and the next update was due no later than July 30, 2023; however, it was not completed until August 1, 2023
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
According to PA Code 709.92(b): Treatment and rehabilitation plan shall be reviewed and updated at least every 60 days. In two of the charts, upon review, there was a failure to do so.
Counselors are responsible to ensure they update the client's treatment plan on or before 60 days. The Clinical Supervisor will do monthly checks on treatment plans as well as have counselors submit the treatment plans and case consults to the Clinical Supervisor when they are due to adhere to the 60-day rule.
Responsible for these actions: Clinical Supervisor and Counselor to assure above is being performed and completed.
Time frame: Immediate action
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