INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 23, 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. Satellite Hazelton 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 as 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 three out of five 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 #4 was hired on April 21, 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.
Employee #5 was hired on August 16, 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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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.
These findings were reviewed with facility staff during the licensing process.
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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 Staff during emergencies.
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..
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The executive director will make the facility's annual report available to the public by publishing it on the second Thursday of January each year (1/11/2024, 1/9/2025, 1/8/2026, 1/7/2029, etc.) 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.
Including this policy in ABT, Inc.'s Policy and Procedure manual it will be reviewed every November as a reminder to publish our annual report.
Responsible for these actions: Executive Director
Time frame: 11/15/2023
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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
on a review of the facility's policy and procedures 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 Executive Director will prepare, annually update and sign a written manual delineating project policies and procedures on the second Thursday of January each year (1/11/2024, 1/9/2025, 1/8/2026, 1/7/2029, etc.). As for this year (2023), the manual was signed on 11/15/2023.
ABT, Inc.'s policy and procedures manual has been updated to include policies and procedures for the Intake, Evaluation, and Referral activity and all parts of the partial and outpatient service activities.
Responsible for these actions: Executive Director and Clinical Supervisor
Time frame: 11/15/2023
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709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
Based on a review of personnel records, the facility failed to verify qualifying professional credentials as Employee #3 hired as the clinical supervisor on May 6, 2023 personnel record contained a resume with inaccurate job history as determined by previous DDAP inspections.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Going forward, the Project Director will review all new hire documents. Employee #3 has updated her resume to reflect an accurate job history.
Responsible for these actions: Project Director
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 hired as the clinical supervisor on May 6, 2023. The employee record failed to contain a written job description.
These findings were discussed with facility staff during the inspection process
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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 which now includes a written job description.
Responsible for these actions: Clinical Director
Time frame: 11/15/2023
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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 client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #5 was admitted on June 12, 2023, and was discharged on August 10, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #5 was met with on December 9th, 2023, and a new release was completed to allow billing. The billing release is part of the initial intake package and is usually completed with every client upon intake. During staff training on December 11th, 2023, the contents of the intake packet were reviewed, and staff was asked to monitor that all forms are completed during intake. Moving forward, the Chief Operations Manager will review charts after intake to ensure all releases were completed properly.
Responsible for these actions: Chief Operations Manager and Counselors
Time frame: 11/15/2023 |
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 seven 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 all seven client records reviewed.
Client #1 was admitted on October 2, 2023 and still active at the time of the inspection
Client #2 was admitted on August 11, 2023 and was still active at the time of the inspection.
Client #3 was admitted on October 18, 2023 and was still active at the time of the inspection
Client #4 was admitted August 17, 2023 and was still active at the time of the inspection
Client #5 was admitted on June 12, 2023 and was discharge on August 10, 2023.
Client #6 was admitted on September 12, 2021 and was discharged on March 10, 2023.
Client #7 was admitted on October 20, 2022 and was discharged on September 20, 2023.
These findings were discussed with facility staff during the inspection 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 sessions. 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 seven 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 all seven records reviewed.
Client #1 was admitted on October 2, 2023 and still active at the time of the inspection
Client #2 was admitted on August 11, 2023 and was still active at the time of the inspection.
Client #3 was admitted on October 18, 2023 and was still active at the time of the inspection
Client #4 was admitted August 17, 2023 and was still active at the time of the inspection
Client #5 was admitted on June 12, 2023 and was discharge on August 10, 2023.
Client #6 was admitted on September 12, 2021 and was discharged on March 10, 2023.
Client #7 was admitted on October 20, 2022 and was discharged on September 20, 2023.
These findings were discussed with facility staff during the inspection 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 ensure 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 seven outpatient client records, the facility failed to ensure that the individual treatment and rehabilitation plan included proposed type of support services in all seven records reviewed.
Client #1 was admitted on October 2, 2023 and still active at the time of the inspection.
Client #2 was admitted on August 11, 2023 and was still active at the time of the inspection.
Client #3 was admitted on October 18, 2023 and was still active at the time of the inspection.
Client #4 was admitted August 17, 2023 and was still active at the time of the inspection.
Client #5 was admitted on June 12, 2023 and was discharge on August 10, 2023.
Client #6 was admitted on September 12, 2021 and was discharged on March 10, 2023.
Client #7 was admitted on October 20, 2022 and was discharged on September 20, 2023.
These findings were discussed with facility staff during the inspection 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 individual treatment and rehabilitation plan to include CRS's, Self-help groups, sponsors, recovery coaches, spouses, mentoring/peer support, pastor, family, etc.
Responsible for these actions: Clinical Director and Counselors
Time frame: 11/15/2023
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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 a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of four records reviewed.
Client #2 was admitted on August 11, 2023 and was still active at the time of the inspection. A treatment plan update was completed on May 8, 2023 and the next update was due no later than July 8, 2023; however, the next update was completed on October 6, 2023.
Client #4 was admitted on August 17, 2023, and was still active at the time of the inspection. A treatment plan update was completed on August 17, 2023, and the next update was due no later than October 17, 2023; however no update was documented at the time of the inspection.
Client #6 was admitted on September 12, 2021 and discharged on March 10, 2023. A treatment plan update was completed on October 13, 2022 and the next update was due no later than December 13, 2022; however, it was completed on February 13, 2023
Client #7 was admitted on October 20, 2022 and discharged on September 20, 2023. A treatment plan update was completed on December 6, 2022 and the next update was due no later than February 6, 2023; however, it was completed on May 17, 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 for ensuring 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 ensure the above is being performed and completed.
Time frame: Immediate action |
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.
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Observations
Based on three of three applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur 7 days after discharge.
Client # 5 was admitted June 12, 2023 2023 and was discharged on August 10, 2023.There was no follow-up information available in the client record.
Client #6 was admitted on September 12, 2021 and was discharged on March 10, 2023. There was no follow-up information available in the client record.
Client#7 was admitted on October 20, 2022 and was discharged on September 20, 2023. There was no follow up information available in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Completing a follow-up seven days after discharge on all closed charts is standard procedure. On December 11, 2023, a staff training was held to review this process. All staff are aware and going forward the Chief Operations Manager will review charts to ensure the follow-up has been completed.
Responsible for these actions: Chief Operations Manager
Time frame: 11/15/2023
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