INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19, 2021 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on one of four employee personnel records reviewed, employee # 4 did not meet the qualification requirements of at least 2 years of clinical experience with an associate degree.
Employee # 4 was hired as a counselor on August 9, 2021 and was still in this position at the time of the inspection. Based on a review of employee # 4's resume and application, they did not have at least 2 years of clinical experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance to 704.7(b), any further employees hired on as staff will have the correct clinical experience and degree as DDAP regulations follows.
Employee #4 will have two years as of August 9, 2023 and then will be properly promoted to counselor status.
The Clinical Director and Executive Director are the individuals responsible for hiring and will make sure there is proper documentation of clinical experience for any degree moving forward including proper supervision.
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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 four of seven client records reviewed, the facility failed to provide documentation of treatment and rehabilitation plans being reviewed and updated at least every 60 days in client record # 2, 3, 5, and 6.
Client # 2 was admitted on August 12, 2021 and was still active at the time of the inspection. A treatment plan was developed on August 12, 2021. The next treatment plan update was due to occur on October 12, 2021 however, there was no other treatment plan update in the client record.
Client # 3 was admitted on July 12, 2021 and was still active at the time of the inspection. A treatment plan was developed on August 12, 2021. The next treatment plan update occurred on September 10, 2021. The next treatment plan update was due to occur on November 10, 2021 however, there was no other treatment plan update in the client record.
Client # 5 was admitted on June 30, 2021 and was discharged on September 30, 2021. A treatment plan was developed on June 30, 2021. The next treatment plan update was due to occur on August 30, 2021 however, there was no other treatment plan update in the client record.
Client # 6 was admitted on May 28, 2021 and was discharged on September 23, 2021. A treatment plan was developed on May 28, 2021. The next treatment plan update was due to occur on July 28, 2021 however, there was no other treatment plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
According to PA Code 709.92 (b): Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. In four of the charts upon review there was failure to do so.
Counselors are responsible to assure that they update the client's treatment plan on or before 60 days. Clinical Director will do every month checks on treatment plans as well as have counselors submit the treatment plans and case consults to Clinical Director when they are due to adhere to the 60 day rule. There are no reasons for the treatment plans to be updated unless discussed with Clinical Director.
Responsible for these actions: Counselors on the individuals case as well as Clinical Director to assure above is being performed and completed.
Corrective action to be effect as of: 12/20/2021 |
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.
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Observations
Based on seven of seven client records reviewed, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in client records # 1, 2, 3, 4, 5, 6, and 7.
Client # 1 was admitted on September 9, 2021 and was still active at the time of the inspection. A treatment plan developed on September 9, 2021 indicated a 6.5 weekly type and frequency of services. A treatment plan update on November 8, 2021 indicated a 4.5 weekly type and frequency of services. The record of service and progress notes indicate the following:
September 9-23 -0 individuals and 3 group sessions
September 23-October 7 -2 individual and 3 group sessions
October 7-21 -0 individual and 6 group sessions
October 21-November 4 -1 individual and 5 group session
Client # 2 was admitted on August 12, 2021 and was still active at the time of the inspection. A treatment plan developed on August 12, 2021 indicated a 9.0 weekly type and frequency of services. The record of service and progress notes indicate the following:
August 12-19 -0 individual sessions and 0 group sessions
August 19-26 -1 individual sessions and 0 group sessions
August 26-September 2 -0 individuals and 0 group sessions
September 2-9 -0 individual and 0 group sessions
September 9-16 -1 individual session and 0 group sessions
September 16-23 -1 individual session and 0 group sessions
September 23-30 -1 individual session and 0 group sessions
September 30-October 7 -1 individual and 0 group sessions
October 7-14 -0 individual and 0 group session
October 14-21 -0 individual and 0 group session
October 21-28 -1 individual and 0 group session
October 28-November 4 -1 individual and 0 group session
November 4-11 -0 individual and 0 group session
November 11-18 -0 individual and 0 group session
Client # 3 was admitted on July 12, 2021 and was still active at the time of the inspection. A treatment plan developed on July12, 2021 indicated a 4.5 weekly type and frequency of services. A treatment plan update on September 10, 2021 indicated a 2.5 weekly type and frequency of services. The record of service and progress notes indicate the following:
July 12-26 -0 individual sessions and 0 group sessions
July 26-August 9 -1 individual sessions and 1 group sessions
August 9-23 -0 individual sessions and 0 group sessions
August 23-September 6 -2 individuals and 0 group sessions
September 6-20 -0 individual and 3 group sessions
September 20-October 4 -1 individual session and 3 group sessions
October 4-18 -1 individual and 2 group session
October 14-21 -0 individual and 0 group session
October 18-November 1 -1 individual and 1 group session
November 4-11 -0 individual and 0 group session
November 1-15 -0 individual and 1 group session
Client # 4 was admitted on August 18, 2021 and was still active at the time of the inspection. A treatment plan developed on August 18, 2021 indicated a 9.0 weekly type and frequency of services. A treatment plan update on October 15, 2021 indicated a 6.5 weekly type and frequency of services. The record of service and progress notes indicate the following:
August 18-25 -0 individual sessions and 0 group sessions
August 25-September 1 -1 individuals and 1 group sessions
September 1-8 -0 individual and 1 group sessions
September 8-15 -1 individual and 2 group sessions
September 15-22 -2 individual and 1 group sessions
September 22-29 -1 individual and 0 group sessions
September 29-October 6 -0 individual session and 2 group sessions
October 6-13 -1 individual and 2 group session
October 15-29 -1 individual and 4 group session
October 29-November 12 -0 individual and 2 group session
Client # 5 was admitted on June 30, 2021 and was discharged September 30, 2021. A treatment plan developed on June 30, 2021 indicated a 5.0 weekly type and frequency of services. The record of service and progress notes indicate the following:
June 30-July 20 -0 individuals and 0 group sessions
July 21-August 2 -0 individuals and 0 group sessions
Client # 6 was admitted on May 28, 2021 and was discharged September 23, 2021. A treatment plan developed on May 28, 2021 indicated a 4.5 weekly type and frequency of services. The record of service and progress notes indicate the following:
May 28-June 11 -0 individuals and 0 group sessions
June 11-25 -0 individuals and 2 group sessions
June 25-July 9 - 0 individuals and 0 group sessions
July 9-September 2 - 0 individuals and 0 group sessions
Client # 7 was admitted on February 3, 2021 and was discharged August 3, 2021. A treatment plan developed on February 3, 2021 indicated a 7.0 weekly type and frequency of services. A treatment plan update on April 19, 2021 indicated a 4.5 weekly type and frequency of services. A treatment plan update on June 2, 2021 indicated a 4.25 weekly type and frequency of services. The record of service and progress notes indicate the following:
February 3-10 -1 individual sessions and 1 group sessions
February 10-17 -0 individuals and 1 group sessions
February 17-24 -1 individual and 1 group sessions
February 24-March 3 -1 individual and 1 group sessions
March 3-March 10 -1 individual and 1 group sessions
March 10-17 -0 individual and 1 group sessions
March 17-24 -0 individual and 1 group sessions
March 24-31 -0 individual and 1 group sessions
March 31-April 7 -1 individual and 0 group sessions
April 7-14 -0 individual and 0 group sessions
April 14-21 -1 individual and 0 group sessions
April 19-April 28 -0 individual and 0 group sessions
April 28-May 12 -1 individual and 0 group sessions
May 12-26 -1 individual and 0 group sessions
May 26-June 9 -1 individual and 0 group sessions
June 2-July 2 -1 individual and 6 group sessions
July 2-August 2 -2 individual and 6 group sessions
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
According to PA Code 709.92 (c), clients need to be following their treatment plan requirements as it is stated on their individual treatment plans. When a client does not follow the treatment plan it is to be documented on the record of service as well as noted in the client's file of the non-compliance.
Regarding client charts within A Better Today moving forward, all client charts will note the non-compliance on what the facility calls a "blue note" (equivalent to a case management note) by documenting the missing sessions, whether group and/or individual sessions (no shows, cancels, and reschedules). Also, for documentation purposes the record of service form that is in each client's file will have the written recording of stated no shows, cancels, and/or reschedules.
It is very important for a client to following their treatment plan to obtain the best possible care. Continued conversations with the client and if they have oversight is pivotal.
Documentation on the "blue note" will indicate those conversations as well within their individual session notes. If a client is struggling to make the treatment that is required of them, case consultation will be done between Clinical Director and counselor with the client to see if the treatment plan needs to be changed.
Responsible for these actions: Counselors on the individuals case as well as Clinical Director to assure above is being performed and completed.
Corrective action to be affect as of: 12/20/2021
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on four of seven client records reviewed, the facility failed to provide a complete client record to include the documentation of services on the record of service in client records # 1, 3, 4, and 7.
Client # 1 was admitted on September 9, 2021 and was still active at the time of the inspection. Progress notes dated September 16, and October 1, 2021 but were not documented on the record of service. Also, Progress notes that are group notes were documented as individual sessions on the record of service for October 28, 29, November 4, and 5, 2021.
Client # 3 was admitted on July 12, 2021 and was still active at the time of the inspection. Progress notes dated July 27, August 3, 5, 2021 were not documented on the record of service. Also, Progress notes that are group notes were documented as individual sessions on the record of service for November 5, 17, 2021.
Client # 4 was admitted on August 18, 2021 and was still active at the time of the inspection. Progress notes dated September 2, 10, and 22, 2021 were not documented on the record of service.
Client # 7 was admitted on February 3, 2021 and was discharged on August 3, 2021. Progress notes dated July 27 and 13, 2021 indicated individual sessions but the record of service indicates no show.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include a record of service documenting all services provided to the client, the Clinical Director has put together a meeting with all clinical staff to discuss documentation within the chart and what needs to be done moving forward.
All client charts moving forward will be documented correctly. Showed appointments/no shows/reschedules/cancellations to be noted on the record of service for group and individual sessions, especially for showed progress notes that are in the chart.
Documentation has to be clearly documented as such if the session was a group or individual session. Record of service and notes per client deficiencies with be documented/re-done to adhere to corrections.
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