INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 12, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Caron Outpatient Services LLC 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of four personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director.Employee # 1 was promoted to the position of Project Director on July 1, 2021 and has remained in that position. The facility's training year that was reviewed was from July 1, 2021 through June 30, 2022. Employee # 1's employee record only documented 1 hour of training for the period reviewed.This is a repeat citation from the February 1, 2022 annual licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 has completed 8 hours of training in the current training year which ends on June 30, 2023. Employee #1 is also scheduled to attend DDAP TB/STD for 4 hours in February which will bring his total training hours to 12 hours for the training year.
In addition, the Director of Training will monitor the completion of employee #1 training hours on a quarterly basis to ensure 12 hours are obtained this training year.
To ensure training hours are completed as required for future training years, the Training Administrator will distribute a training hours report on a quarterly basis to the Facility Director, Project Director and Compliance Officer. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of four personnel files, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one of one applicable record reviewed.Employee #4 was hired as a counselor on May 2, 2022 and was due to be trained in the use of fire extinguishers upon hire; however, fire safety training was not documented as completed in the personnel record until June 1, 2022.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning on March 6, 2023 all new employees will be required to meet with a member of the HR/Training department on their first day to complete the fire safety and fire extinguisher training. the Director of Training will monitor the completion of this training on a weekly basis for all new hires to ensure the training is completed upon hire. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of seven client records, the facility failed to ensure that informed and voluntary consent from the client for the disclosure of information forms included the name, agency or organization to whom disclosure is made in three records reviewed.Client #1 was admitted on June 1, 2022 and discharged on August 9, 2022. The record contained a consent to release information form signed by the client on June 1, 2022 that was missing the name, agency, or organization to whom disclosure was to be made. Client #2 was admitted on May 10, 2022 and discharged on December 13, 2022. The record contained a consent to release information form signed by the client on May 10, 2022 that was missing the name, agency, or organization to whom disclosure was to be made. Client #6 was admitted on September 29, 2022 and was active at the time of the inspection. The record contained a consent to release information form signed by the client on September 29, 2022 that was missing the name, agency, or organization to whom disclosure was to be made. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on requirements for completion of patient "releases of information" forms (disclosures). This training will occur by 3/3/23 and will be documented. The Medical Records department will review patient records on a quarterly basis to ensure all required elements of the form are being completed. The Director of the Outpatient site will be notified of the results of the review. |
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 a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in three of seven records reviewed.Client #3 was admitted on January 12, 2022 and discharged on September 29, 2022. The treatment plan update completed on April 6, 2022 indicated that the client was to receive twice weekly individual sessions; however, the record only contained documentation of weekly individual sessions between April 5, 2022 and June 6, 2022, when the next treatment plan update was completed, except for the week of May 16, 2022 when no individual sessions were documented. The treatment plan update completed on June 6, 2022, indicated that the client was to receive once weekly individual sessions; however, the record did not contain documentation of an individual session during the week of June 13, 2022. Client #5 was admitted on April 24, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on April 29, 2022, as well as the updates completed on July 8, 2022 and August 24, 2022, indicated that the client was to receive biweekly family counseling sessions; however, the record only contained documentation of one family session on May 6, 2022.Client #7 was admitted on July 7, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on July 6, 2022, as well as the treatment plan updates completed on August 26, 2022 and October 19, 2022, indicated that the client was to receive one individual counseling session per week; however, the record did not contain documentation that individual sessions occurred the weeks of August 1, 2022, August 15, 2022, October 3, 2022, and October 31, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the completion of treatment plans and treatment plan updates to ensure the services and treatment being delivered is reflected accurately in the treatment plan. The Executive Director will provide the re-education by 3/3/23.
The Quality Department will update the monthly chart review form to include monitoring of treatment plans and treatment plan updates to ensure they are reflective of the services delivered.
The Executive Director will complete the monthly chart reviews to ensure the treatment plans accurately reflect services being delivered. |