INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2020 through March 11, 20202 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Wyoming Valley Alcohol and Drug Services, 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 an annual licensing renewal inspection conducted on March 10, 2020 through March 11, 2020, the project failed to ensure that each counselor with a Bachelor's Degree obtained at least one year of clinical experience (a minimum of 1820 hours) in a health or human services agency in six of seven applicable personnel records reviewed.
Employee # 5 was hired on December 30, 2020 and was a current employee at the time of the inspection. Employee #5 has a qualifying Bachelor's Degree; however, the employee was missing 10 of the 12 months of clinical experience required to qualify as a counselor.
Employee # 6 was hired on October 18, 2019 and was a current employee at the time of the inspection. Employee #6 has a qualifying Bachelor's Degree; however, the employee was missing 3 of the 12 months of clinical experience required to qualify as a counselor.
Employee # 7 was hired on September 9, 2019 and was a current employee at the time of the inspection. Employee #7 has a qualifying Bachelor's Degree; however, the employee was missing 6 of the 12 months of clinical experience required to qualify as a counselor.
Employee # 8 was hired on September10, 2019 and was a current employee at the time of the inspection. Employee #8 has a qualifying Bachelor's Degree; however, the employee was missing 6 of the 12 months of clinical experience required to qualify as a counselor.
Employee # 9 was hired on December 16, 2019 and was a current employee at the time of the inspection. Employee #9 has a qualifying Bachelor's Degree; however, the employee was missing 5 of the 12 months of clinical experience required to qualify as a counselor.
Employee # 10 was hired on December 30, 2019 and was a current employee at the time of the inspection. Employee #10 has a qualifying Bachelor's Degree; however, the employee was missing 2 of the 12 months of clinical experience required to qualify as a counselor.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Prior to hiring any potential employees for the position of counselor the Clinical Supervisor and CEO will ensure they all applicants meet the minimum qualifications for the position as set forth in the regulations. The Clinical Supervisor and CEO will ensure that the months/years of experience are documented on the the resume and meets the necessary one year of clinical experience standard prior to employee starting in counseling position. All of these employees will be re-classified as counselor assistants and proper training/documentation will occur as specified by DDAP regulations. They will be Supervised by either a established counselor, Clinical Supervisor or CEO until they can be classified as Counselors. This will begin immediately. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on an annual licensing renewal inspection conducted on March 10, 2020 through March 11, 2020, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information that included the purpose of disclosure in six out of fourteen client records reviewed.
Client # 3 was admitted on December 19, 2019 and was discharged on February 19. 2020. The record contained an informed and voluntary consent form, signed and dated on January 4, 2020, to an external service provider; however, the purpose of disclosure was not documented.
Client # 4 was admitted on January 15, 2020 and was active at the time of the inspection. The record contained an informed and voluntary consent form, signed and dated on December 30, 2019 to an external service provider; however, the purpose of disclosure was not documented.
Client # 5 was admitted on February 7, 2020 and was active at the time of the inspection. The record contained an informed and voluntary consent form, signed and dated on February 5, 2020, to the funding source; however, the purpose of disclosure was not documented.
Client # 6 was admitted on February 5, 2020 and was active at the time of the inspection. The record contained an informed and voluntary consent form, signed and dated on February 3, 2020, to a client-specific personal contact; however, the purpose of disclosure was not documented.
Client # 10 was admitted on January 11, 2020 and was discharged on February 19, 2020. The record contained an informed and voluntary consent form, signed and dated on January 8, 2020, to a probation officer; however, the purpose of disclosure was not documented.
Client # 12 was admitted on July 29,2019 and was active at the time of the inspection. The record contained five informed and voluntary consent forms, signed and dated on July 8, 2019, to the funding source, other external service providers and a probation officer; however, the purpose of disclosure was not documented.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Staff will be heavily trained on confidentiality and consent forms. This will be done through staff meetings. These are held bi-weekly. In addition, Clinical Supervisor will meet with each employee to discuss the need to fill out correctly. Weekly chart reviews will be done by the Clinical Supervisor to ensure compliance with confidentiality regulations.We have already begun the training this past Friday. We expect the training to be completed by the end of April 2020. This will be done by the Clinical Supervisor. |
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.
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Observations
Based on an annual licensing renewal inspection conducted on March 10, 2020 through March 11, 2020, the project failed to ensure that treatment and rehabilitation plans were reviewed and updated every 30 days in four out of seven records reviewed.
Client # 3 was admitted on December 19, 2019 and was discharged on February 19. 2020. A comprehensive treatment plan was completed on December 19, 2019. A treatment plan update was due no later than January 19, 2020; however, there was no update documented in the record at the time of the inspection.
Client # 4 was admitted on January 15, 2020 and was active at the time of the inspection. A comprehensive treatment plan was completed on January 15, 2020. A treatment plan update was due no later than February 15, 2020; however, there was no update documented in the record at the time of the inspection.
Client # 5 was admitted on February 7, 2020 and was active at the time of the inspection. A comprehensive treatment plan was completed on February 7, 2020. A treatment plan update was due no later than March 7, 2020; however, there was no update documented in the record at the time of the inspection.
Client #7 was admitted on February 3, 2020 and was discharged on March 10, 2020. A comprehensive treatment plan was completed on February 3, 2020. A treatment plan update was due no later than March 3, 2020; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Charts are now being reviewed more frequently by the Clinical Supervisor. We did make a change in regards to our Supervisor hence the issue. Charts are checked weekly to ensure all treatment plans are updated every 30 days. This is also discussed through staff meetings, emails, and one on one Supervision. This ensures they are done in a timely manner. |
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.
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Observations
Based on an annual licensing renewal inspection conducted on March 10, 2020 through March 11, 2020, the project failed to ensure that clients received counseling on a regularly scheduled basis, by not providing the required two individual sessions per week for clients #'s 1, 2, 3, 4, 5, 6, and 7.
Client #1 was admitted on December 14, 2019 and was active at the time of the inspection. There was no documentation for one of the two individual sessions required the weeks of December 15, 2019 through December 21, 2019, December 29, 2019 through January 4, 2020, January 5, 2020 through January 11, 2020 and January 12, 2020 through January 18, 2020. Additionally, there was no documentation of the two individual sessions required the week of December 22, 2019 through December 28, 2019.
Client #2 was admitted on February 5, 2020 and was active at the time of the inspection. There was no documentation for one of the two individual sessions required the week of February 23, 2020 through February 29, 2020. Additionally, there is no documentation of the two individual session required the weeks of February 9, 2020 through February 15, 2020 and February 16, 2020 through February 22, 2020.
Client #3 was admitted on December 19, 2019 and discharged on February 19, 2020. There was no documentation for one of the two individual sessions required the weeks of December 29, 2019 through January 4, 2020 and January 26, 2020 through February 1, 2020. Additionally, there is no documentation of the two individual session required the weeks of December 22, 2019 through December 28, 2019, January 5, 2020 through January 11, 2020, January 12, 2020 through January 18, 2020 and January 19, 2020 through January 25, 2020.
Client #4 was admitted on January 15, 2020 and was active at the time of the inspection. There was no documentation for one of the two individual sessions required the weeks of January 19, 2020 through January 25, 2020, February 9, 2020 through February 15, 2020 and February 16, 2020 through February 22, 2020. Additionally, there is no documentation of the two individual session required the weeks of January 26, 2020 through February 1, 2020, February 2, 2020 through February 8, 2020, February 23, 2020 through February 29, 2020 and March 1, 2020 through March 7, 2020.
Client #5 was admitted on February 7, 2020 and was active at the time of the inspection. There was no documentation for one of the two individual sessions required the weeks of February 9, 2020 through February 15, 2020 and February 16, 2020 through February 22, 2020. Additionally, there is no documentation of the two individual session required the weeks of February 23, 2020 through February 29, 2020 and March 1, 2020 through March 7, 2020.
Client #6 was admitted on February 5, 2020 and was active at the time of the inspection. There was no documentation for one of the two individual sessions required the weeks of February 9, 2020 through February 15, 2020, February 16, 2020 through February 22, 2020 and March 1, 2020 through March 7, 2020. Additionally, there is no documentation of the two individual session required the week of February 23, 2020 through February 29.
Client #7 was admitted on February 3, 2020 and discharged on March 10, 2020. There was no documentation for one of the two individual sessions required the week of February 9, 2020 through February 15, 2020. Additionally, there is no documentation of the two individual session required the weeks of February 16, 2020 through February 22, 2020, February 23, 2020 through February 29, 2020 and March 1, 2020 through March 7, 2020.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
This has been addressed at this past Friday's staff meeting by the Clinical Supervisor. Each clinician will have blocked off time to see their clients twice weekly. This will be checked several times a week by the Clinical Supervisor. The sessions will be documented in their charts by the clinician. If the client does not show or reschedules, that will be documented in the chart as well. Any missed appointments/reschedules will be scheduled again ASAP. This has already been relayed to the counselors and will begin this week. Again, this will be monitored several times a week through the Clinical Supervisor. |
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 an annual licensing renewal inspection conducted on March 10, 2020 through March 11, 2020, the project failed to ensure that treatment and rehabilitation plans were reviewed and updated every 60 days in four out of seven records reviewed.
Client #8 was admitted on December 9, 2020 and was discharged on March 4, 2020. A comprehensive treatment plan was completed on December 9, 2019. A treatment plan update was due no later than February 9, 2020; however, there was no update documented in the record at the time of the inspection.
Client #11 was admitted on November 8, 2019 and was discharged on March 6, 2020. A comprehensive treatment plan was completed on November 12, 2019. A treatment plan update was due no later than January 12, 2020; however, there was no update documented in the record at the time of the inspection.
Client #13 was admitted on September 25, 2019 and was discharged on January 2, 2020. A comprehensive treatment plan was completed on September 25, 2019. A treatment plan update was due no later than November 25, 2019; however, there was no update documented in the record at the time of the inspection.
Client #14 was admitted on October 25, 2019 and was discharged on January 20, 2020. A comprehensive treatment plan was completed on October 25, 2019. A treatment plan update was due no later than December 25, 2019; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
This has been discussed with staff by the Clinical Supervisor through staff meetings, emails, and Supervision. In addition, charts are now being checked weekly by the Supervisor to ensure paperwork is up to date and necessary forms and plans are present. |
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 an annual licensing renewal inspection conducted on March 10, 2020 through March 11, 2020, the project failed to document post discharge follow-ups in four out of seven records reviewed.
Client #9 was admitted on October 4, 2019 and was discharged on December 5, 2019. There was no post discharge follow-up documented in the client ' s record.
Client #10 was admitted on January 11, 2020 and was discharged on February 19, 2020. There was no post discharge follow-up documented in the client ' s record.
Client #13 was admitted on September 25, 2019 and was discharged on January 2, 2020. There was no post discharge follow-up documented in the client ' s record.
Client #14 was admitted on October 25, 2019 and was discharged on January 20, 2020. There was no post discharge follow-up documented in the client ' s record.
These findings were reviewed with project staff during the licensing process
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Plan of Correction
Follow up should be occurring. However, due to a change in Supervisors it was missed. It has been rectified as all counselors are made aware of this regulation by email, staff meetings (held every two weeks) and chart checks. Charts are checked weekly by the Clinical Supervisor weekly to ensure all regulations and paperwork is properly completed. Counselors are consistently reminded that follow up needs to occur. |