INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 28, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Treatment and Healing 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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704.9(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.
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Observations
Based upon review of personnel records, it was determined that the facility failed to provide close supervision to a counselor assistant with an associates degree by a trained counselor or clinical supervisor for at least the first 9 months of employment.
Employee #5 was hired on June 10, 2021 and was still employed at the time of the inspection. She was not provided close supervision the weeks of August 30, 2021 and September 13, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was noted that the assistant counselor did not have close clinical supervision on the "weeks of August 30, 2021 and September 13, 2021"
This omission was due to the fact that, the Clinical supervisor was on maternity leave and the Facilities director failed to Document in a timely manner the Group supervision for those two weeks. It is the responsibility of the Facilities director and the clinical supervisor to maintain clear and accurate records for all supervision. A review of the PNP and DDAP regulations was conducted on 10/25/21.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the policy and procedures manual and client rights documentation on September 28, 2021, the project failed to include all parts of the client rights regulation. The project failed to include that a client may not be discriminated against creed, sex, color, and national origin in seven out of seven records.
This is a repeat citation from the July 10, 2020 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was noted that the Director in the previous POC failed to clearly add "creed, sex, color, and national origin in seven out of seven records."In the client files and the PNP . This citation has been corrected in that corrections to both the policies and procedures manual and the Clients rights documentation in the active client charts are currently being updated , to state " the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion." In addition, all previous copies of the PNP have been destroyed and the new Corrections have been implemented company wide. All clinicians will ask all current clients to sign updated and corrected clients' rights. This was the responsibility of the Program director and the Facilities director. This policy is in full effect as of November 1 2021. |
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 three out of seven client records reviewed.
Client #1 was admitted on January 4, 2021 and was still active at the time of the inspection. A treatment plan was completed on January 4, 2021 and the next update was due no later than March 4, 2021; however, the next update was completed on September 15, 2021.
Client #2 was admitted on January 14, 2021 and was still active at the time of the inspection. A treatment plan update was completed on February 12, 2021 and the next update was due no later than April 12, 2021; however, the next update documented in the record was September 20, 2021.
Client #4 was admitted on July 30, 2020 and was discharged on March 30, 2021. A treatment plan was completed on July 31, 2020 and the next update was due no later than September 31, 2020; however, the next documented review was not until October 27, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In this citation the TPR was not performed in the required 60 day time frame. The director reeducated the staff on the requirements for TRP's . The new Facilities director has implemented a new policy in which the Director will oversee all chart audits monthly. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit and continuing through to discharge of a client. This Policy was implemented on November 1 2021. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete all admit and discharge file paperwork to comply with DDAP regulations. |
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 a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of three applicable discharged records reviewed.
Client #5 was admitted on January 19, 2018 and was discharged on April 14, 2021.
Client #6 was admitted on February 3, 2021 and was discharged on July 15, 2021
Client #7 was admitted on April 14, 20021 and was discharged on July 15, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was noted that the follow-up discharge information was not in the three filed audited. The PNP states that each client will have A completed aftercare plan , Discharge summary, Follow up , Phone call (7days) 30, 60 and 90 day letters .The follow up documents were not present in the discharged files . All staff will be reeducated on PNP for all aspects of the PNP. Including but not limited to Intake , clearances , proper completion of the client file and discharge and follow up procedures. It is the Clinical supervisors responsibility to Audit all files to determine if they are compliant to PNP and DDap regulations. The facility director will complete a follow up discharge audit of all discharged files. |