INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 21, 2018 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, Treatment Trends Inc. Keenan House 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
The facility failed to ensure that two of eight reviewed counselors met the required regulatory qualifications, based on a review of the facility ' s Staffing Requirements Facility Summary Report and personnel files.
Employee #6 was hired as a counselor with a master ' s degree on October 17, 2018. However, there was no documentation that a clinical practicum took place during the master ' s degree program.
Employee #7 was hired as a counselor assistant with a bachelor ' s degree on March 14, 2018. The employee was promoted to counselor status after being in the position for 9 months; however, the employee did not have any clinical experience prior to hiring and was required to have 1 full year of clinical experience prior to being promoted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the Program Director to ensure the standards of 704.7, "Qualifications for the position of counselor", are upheld. The Director will review the requirements for all positions by January 21, 2019. Before employment, transcripts and other supporting documentation will be requested from prospective employees to ensure practicums meet regulatory requirements. To ensure no counselor is promoted to counselor position who is not qualified, the Director will meet with Human Resources to review the personnel file and qualification before request for promotion is submitted to the Executive Secretary. This process will begin as of January 7, 2019. |
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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in five of eight client records reviewed.
Client #2 was admitted on September 25, 2018 and was still active at the time of the inspection. There were various communications with a government agency; however, there was no signed consent to release information form documented in the record prior to the disclosure of information. Additionally, there was a letter sent to a court on November 14, 2018; however, there was no signed consent to release information form documented in the record prior to the disclosure of information.
Client #4 was admitted on October 24, 2018 and was still active at the time of the inspection. There were multiple urinalysis samples sent to a urinalysis lab; however, there was no signed consent to release information form documented in the record prior to the disclosure of information.
Client #5 was admitted on May 22, 2017 and was discharged on July 24, 2017. There were multiple urinalysis samples sent to a urinalysis lab; however, there was no signed consent to release information form documented in the record prior to the disclosure of information.
Client #6 was admitted on September 13, 2017 and was discharged on October 24, 2017. There were multiple urinalysis samples sent to a urinalysis lab; however, there was no signed consent to release information form documented in the record prior to the disclosure of information.
Client #8 was admitted on August 8, 2018 and was discharged on November 1, 2018. There were multiple urinalysis samples sent to a urinalysis lab; however, there was no signed consent to release information form documented in the record prior to the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To rectify the confidentiality breech of standard 709.28 caused when sending urines for testing, an additional release specifically regarding urines, will be placed in the client file. All staff including the Admission Director will be trained by January 10, 2019 regarding standard 709.28. The process of including new paperwork into the admission process will begin on January 10, 2019. The Clinical Supervisor will review releases with counselors during supervision to ensure confidentiality releases are signed and the client is aware of what information is being sent and to whom. This will occur by January 10, 2019. |
709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
The facility failed to have all client records readily accessible, for at least 4 years, as there was one discharged client record that facility staff was unable to locate throughout the duration of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the policy of Keenan House to retain all client records for 7 years regardless of length of time in treatment. All staff will be trained by the Clinical Director by January 10, 2019 regarding standard 709.29 as well as Keenan House policy regarding retaining treatment records for clients in program regardless of the length of time in treatment. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to notify client #7 - admitted on March 14, 2018 and was involuntarily terminated on May 21, 2018 - in writing, of the facility ' s decision to involuntarily terminate the client from treatment. This was based on a review of eight client records, with only client #7 being involuntarily terminated.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review with clinical staff the requirements of standard 709.33 to ensure appropriate documentation, including the Notice of Termination is in the record. Training will take place by January 17, 2019 by the Clinical Supervisor and weekly chart reviews will be conducted to ensure any terminations are appropriately documented. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
The facility failed to document that they provided client #7 - admitted on March 14, 2018 and was involuntarily terminated on May 21, 2018 - the opportunity to appeal the facility ' s decision to involuntarily terminate the client ' s treatment. This was based on a review of eight client records, with only client #7 being involuntarily terminated.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The Clinical Supervisor will review with clinical staff standard 709.33 by January 17, 2019 to ensure Notice of Termination paperwork is included with all involuntary discharges. During Case Consults, when involuntary discharges are discussed, the Clinical Supervisor will review with staff the Notice of Termination and follow up during regular supervision to ensure the paperwork is in the chart. This paperwork includes option to appeal the decision within the body of the narrative. |
709.53(a) LICENSURE Complete Client Record
709.53. 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:
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Observations
The facility failed to provide a complete client record, which is to include records of service and/or follow-up information in six of eight client records reviewed.
Client #1 was admitted on September 11, 2018 and was still active at the time of the inspection. The client record failed to contain documentation of records of services for the months of October 2018 and November 2018.
Client #2 was admitted on September 25, 2018 and was still active at the time of the inspection. The client record failed to contain documentation of records of services for the months of October 2018 and November 2018.
Client #3 was admitted on November 1, 2018 and was still active at the time of the inspection. The client record failed to contain documentation of records of services for the client ' s entire treatment episode.
Client #4 was admitted on October 24, 2018 and was still active at the time of the inspection. The client record failed to contain documentation of records of services for the client ' s entire treatment episode.
Client #6 was admitted on September 13, 2017 and was discharged on October 24, 2017. The client record failed to contain documentation of any follow-up information.
Client #8 was admitted on August 8, 2018 and was discharged on November 1, 2018. The client record failed to contain documentation of a record of services for the month of October 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure standard 709.53 is met, the Clinical Supervisor will ensure Records of Service and follow-up information is placed in the client chart in a timely fashion during regular supervision and chart review. This standard will be reviewed with clinical staff by January 17, 2019 by the Clinical Director. To aid in this effort, two additional staff will be responsible for completing service entry into the record of service so we do not fall behind again. This correction and new staff assignment will begin January 17, 2019. |