INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and a complaint investigation conducted on July 28 -30, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Step-By-Step Support, 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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704.7(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 a review of personnel records, the facility failed to ensure each counselor met the requirements for the position in one of two counselor personnel records.
Employee #4 was hired as a counselor on February 5, 2021. The employee did not have a qualifying degree and did not meet the education qualification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/9/2021, employee #4 is now titled a counselor assistant. She will be supervised by facility director in all counseling sessions from that date forward. In the future, the facility director will ensure that any new hire will be placed in the appropriate position based on their qualifications. |
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 on a review of administrative information, the facility failed to document the supervision period for a high school level Counselor assistant #2.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/3/2021, Counselor assistant #2 is no longer employed by this facility. In the future, any new hires of a counselor assistant with a high school equivalent will only counsel clients under direct supervision of the facility director for the first 3 months after hire. For the next 9 months, the counselor assistant will only counsel clients under very close supervision of the facility director. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on observation, the facility failed to ensure the exterior of the building grounds or yard are free of hazards. The rear exit door exits into a small area that had numerous large tree limbs throughout the area creating a hazard.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/11/2021, tree limbs were removed making the rear exit free of any hazards by a landscaper. Office manager will do weekly checks to make sure exit routes remain unobstructed. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation, the facility failed to ensure exits from the facility were unobstructed. The second exit was blocked by a plant and a cooler.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/30/2021, the office manager removed the plant and cooler making the exit unobstructed. Nothing will be placed in front of any exit from that date forward and the office manager will ensure nothing is ever placed in front of any exits on a daily basis. |
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 employee records, the facility failed to document staff were instructed in the use of the fire extinguishers upon staff employment in five of five personnel records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/11/2021, all employees watched a video on how to use a fire extinguisher.
This was documented by the office manager and placed in the employee files. In the future, any new hires will watch this video and the office manager will document it and place it in their employee file. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of employee records, the facility failed to ensure all staff were trained to perform assigned tasks in the event of an emergency in five of five personnel records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/11/2021, all staff were trained to perform assigned tasks in the event of an emergency. This was documented by the office manager and placed in all employee files. In the future, any new hires will be trained on emergency protocol upon hire. This will be documented and placed in employee files by the office manager. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility fire drill records between October 2020 and July 2021, the facility failed to maintain a written drill documenting the amount of time it took for evacuation, exit route used, problems encountered, and whether the fire alarm or smoke detector was operative. Each fire drill documented between October 2020 and July 2021 did not include the items noted.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/5/2021, the office manager revised the fire drill logs to include the amount of time it took for evacuation, the exit route used, problems encountered, and if the smoke detector was operative. These new revised forms will be used in all fire drills from that date forward and the office manager will ensure those forms are used to document the fire drills on a monthly basis. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility fire drill records between October 2020 and July 2021, the facility failed to document which alternate routes were used during fire drills. This information was missing on all drills documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/5/2021, fire drill logs were revised to include alternate routes that were used during fire drills by the office manager. All future fire drills will be documented using this form. Office manager will ensure that these forms are used for all fire drills on a monthly basis. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility fire drill records between October 2020 and July 2021, the facility failed to set off a fire alarm or smoke detector during each fire drill. This information was missing on all drills documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/5/2021, fire drill logs were revised by the office manager to include the information that the smoke detector was set off to alert a fire drill. In the future, the alarm on the smoke detector will be set off to alert all employees of a fire drill. This will be documented by the office manager on the revised forms on a monthly basis. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedures, the facility failed to include a written procedure that includes medical history, drug and alcohol history, personal history, psychosocial evaluation, treatment plan, record of service, progress notes, case consultation, and discharge summary. Procedures need to clarify the time frames, how each one will be documented, and who is responsible for completion.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/28/2021, the policies and procedures manual will be revised by the office manager to include a written procedure for the medical history, drug and alcohol history, personal history, psychosocial evaluation, treatment plan, record of service, progress notes, case consultation, and discharge summary. The revision of the policies and procedures manual will reflect the time frames on when these are to be completed, how they will be documented and who will be responsible for their completion. This revision to the policies and procedures manual will be in the manual going forward. |
709.24 (a) (4) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
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Observations
Based on a review of the policy and procedures, the facility failed to provide the written procedure for outgoing referrals.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/28/2021, the office manager will update the policies and procedures manual to include a written procedure for outgoing referrals. This revised manual will be used in the future. |
709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
Based on a review of personnel records, the facility failed to include written verification of qualifying professional credentials in three of five personnel records reviewed.
Personnel records #2, 3, and 4 did not include written verification of credentials.
Staff #2 was hired as a counselor assistant on October 6, 2020.
Staff #3 was hired as a counselor assistant on October 6, 2020.
Staff #4 was hired as a counselor on February 5, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/28/2021, staff #3 & #4 will have appropriate verification of credentials such as official transcripts that the office manager will ensure is included in the employee files. Staff #2 is no longer working for this facility. In the future, the office manager will review all new hires to ensure all appropriate credentials are included in employee files. |
709.26 (c) LICENSURE Personnel management.
§ 709.26. Personnel management.
(c) There shall be written job descriptions for project positions.
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Observations
Based on a review of the administrative information, the facility failed to have written job descriptions for project positions. The facility did not have job descriptions for the positions of counselor assistant, and volunteer.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On or by 9/28/2021, the office manager will create a job description form that describes all positions in the facility. This will include job descriptions for the position of counselor, counselor assistant, and volunteer. In the future, the office manager will ensure all new hires are given job descriptions and they will be placed in their employee files. |
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
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client in six of seven client records reviewed.
Client records #1, 2, 3, 4, 5, and 7 did not include a release of information permitting disclosure to their funding source.
Client #1 was admitted on November 23, 2020 and discharged on March 13, 2021.
Client #2 was admitted on December 14, 2020 and discharged on February 22, 2021.
Client #3 was admitted on January 26, 2021 and discharged on April 27, 2021
Client #4 was admitted on March 29, 2021 and discharged on May 3, 2021.
Client #5 was admitted on December 8, 2020 and was still a client at the time of the inspection.
Client #7 was admitted on February 9, 2021 and was still a client at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/11/2021, a new intake packet was implemented which includes an informed and voluntary consent strictly for funding. This form was created by the office manager. Client #5 & #7 will sign new consent form at their next scheduled appointment. In the future, this form will be included in the intake packet and signed by clients upon admission. Intake counselor will make sure all clients sign appropriate releases. |
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 the review of client records, the facility failed to obtain an informed and voluntary consent that included the name of the person, agency, or organization to whom disclosure was to be made, in two of seven client records.
Client #4 was admitted on March 29, 2021 and discharged on May 3, 2021. A release was signed by the client on March 29, 2021 but did not document the name of the person, agency, or organization to whom the information was to be released.
Client #6 was admitted on April 5, 2021 and was still a client at the time of the inspection. A release was signed by the client on April 5, 2021, but did not document the name of the person, agency, or organization to whom the information was to be released.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 9/28/2021, counselor will ensure that client #6 signs proper consent which documents the name of the person, agency or organization to whom the information is to be released. In the future, counselors will ensure that all consents are completely filled out and that clients only sign consents with proper documentation of the person, agency or organization to whom disclosure is to be made. Counselors will review their client files on a monthly basis to ensure all proper documentation is filled out completely. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent that included the specific information to be disclosed in six of seven client records.
Client #1 was admitted on November 23, 2020 and discharged on March 13, 2021. A release of information signed on November 23, 2020 failed to indicate the specific information to be disclosed.
Client #2 was admitted on December 14, 2020 and discharged on February 22, 2021. A release of information signed on December 14, 2020 failed to indicate the specific information to be disclosed.
Client #4 was admitted on March 29, 2021 and discharged on May 3, 2021. A release of information signed on March 29, 2021 failed to indicate the specific information to be disclosed.
Client #5 was admitted on December 8, 2020 and was still a client at the time of the inspection. A release of information signed on December 8, 2020 failed to indicate the specific information to be disclosed.
Client #6 was admitted on April 5, 2021 and was still a client at the time of the inspection. A release of information signed on April 5, 2021 failed to indicate the specific information to be disclosed.
Client #7 was admitted on February 9, 2021 and was still a client at the time of the inspection. A release of information signed on February 9, 2021 failed to indicate the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/28/2021, Clients #5, #6 & #7 will sign new consent forms which will include the specific information to be disclosed. In the future, intake counselor will ensure that all future clients will sign consents that include the specific information to be disclosed. Counselors will review their client files on a monthly basis to ensure all proper consents are signed and filled out properly. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent that included the dated signature of the witness in two of seven client records.
Client #6 was admitted on April 5, 2021 and was still a client at the time of the inspection. A release of information signed on April 5, 2021 failed to include the dated signature of the witness.
Client #7 was admitted on February 9, 2021 and was still a client at the time of the inspection. A release of information signed on February 9, 2021 failed to include the dated signature of the witness.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/28/2021, clients #6 & #7 will sign new informed and voluntary consents that include their dated signatures. In the future, intake counselors will ensure that all consents have dated signatures and counselors will review their client files on a monthly basis to ensure all consents are filled out properly. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent that included the date, event, or condition upon which the consent will expire in two of seven client records.
Client #4 was admitted on March 29, 2021 and discharged on May 3, 2021. A release of information signed on March 29, 2021 failed to indicate an expiration.
Client #7 was admitted on February 9, 2021 and was still a client at the time of the inspection. A release of information signed on February 9, 2021 failed to indicate an expiration.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/28/2021, counselor will have client #7 sign a new consent that indicates the expiration date. In the future, intake counselors will ensure that all clients sign consents which include expiration dates. Counselors will review their client files on a monthly basis to ensure all consents include expiration dates and that all proper documentation is in these files. |
709.30 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.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop a procedure that includes 709.30(3), 709.30 (4), 709.30 (5), and 709.30 (6), and based on a review of the client records, the facility failed to notify the client of all their rights in seven of seven client records.
The policy and procedure failed to include the procedures for (3) the right to inspect their own records, (4) the right to appeal a decision limiting access to their records to the director, (5) the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records, (6) the right to submit rebuttal data or memoranda to their own records.
Seven of seven client records reviewed failed to document written acknowledgement by clients that they have been notified of their rights.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/28/2021, the policies and procedures manual will be revised to include the procedure for the client's right to inspect their own records, the right to appeal a decision limiting access to their records to the director, the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, and the right to submit rebuttal data or memoranda to their own records. In the future, the intake counselor will ensure clients sign a form indicating they have been notified of these rights. Counselors will review their client files on a monthly basis to ensure all proper documentation is in these files. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of the policy and procedure, the facility failed to document a procedure for the clients right to inspect their own records. The procedure and the written acknowledgement also need to inform clients the project, facility or clinical director may temporarily remove portions of the record.
Seven of seven client records reviewed failed to document written acknowledgement by clients that they have been notified of their rights.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/3/2021, the office manager revised the clients rights form to document the procedure for the clients rights to inspect their own records. This form also notifies them that the director may temporarily remove portions of their records. Counselors will ensure all active clients sign this revised form. In the future, intake counselors will ensure all new clients sign this form upon admission. Counselors will review their client files on a monthly basis to ensure all proper documentation is in these files. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of the policy and procedure, the facility failed to document a procedure for the clients right to appeal a decision limiting access to their records to the director.
Seven of seven client records reviewed failed to document written acknowledgement by clients that they have been notified of their rights.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/3/2021, the client's rights form was updated by the office manager to include the procedure for the clients right to appeal a decision limiting access to their records to the director. Counselors will ensure all active clients sign this new form. In the future, the intake counselor will ensure that all new clients sign this form upon admission. Counselors will review their client files on a monthly basis to ensure all proper documentation is in these files. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of the policy and procedure, the facility failed to document a procedure for the clients right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.
Seven of seven client records reviewed failed to document written acknowledgement by clients that they have been notified of their rights.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/3/2021, the office manager updated the clients rights form to document the procedure for the client's right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. Counselors will ensure all active clients sign this new form. In the future, intake counselors will ensure all new clients sign this new form upon admission. Counselors will review their client files on a monthly basis to ensure all proper documentation is in these files. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of the policy and procedure, the facility failed to document a procedure for the clients right to submit rebuttal data or memoranda to their own records.
Seven of seven client records reviewed failed to document written acknowledgement by clients that they have been notified of their rights.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/3/2021, the office manager updated the clients rights form to include the procedure for the client's right to submit rebuttal data or memoranda to their own records. Counselors will ensure all active clients sign this new form. In the future, intake counselors will ensure all new clients sign this form upon admission. Counselors will review their client files on a monthly basis to ensure all proper documentation is in these files. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document the disclosure of criteria for admission, completion, and discharge to clients during intake in seven of seven client records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/3/2021, the office manager updated the therapist-client agreement to include the criteria for admission, completion and discharge. Counselors will ensure all active clients sign this revised form. In the future, intake counselors will ensure all new clients sign this form upon admission. Counselors will review their client files on a monthly basis to ensure that all proper documentation is in these files. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document the client orientation included the project policies in seven of seven client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/28/2021, the office manager will create a form that will be included in the intake packet which states they were given a client orientation packet. The office manager will create a client orientation packet for the facility and it will include familiarization with the project policies. Once this is finished, counselors will ensure all active clients are given a copy of the client orientation packet and they will sign off that they received it. In the future, the intake counselor will ensure all new clients will be given this packet and will sign the form stating that they received it. Counselors will review their client files on a monthly basis to ensure all proper documentation is in these files. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document the client orientation included the hours of operation in seven of seven client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/28/2021 the office manager will create a client orientation packet that will include the hours of operation. Once this is created, counselors will ensure all active clients are given a copy of this. They will sign a form stating they have received it. In the future, intake counselors will give all new clients a copy of this orientation packet and ensure they sign the form stating they received it. Counselors will review client files on a monthly basis to ensure all proper documentation is in these files. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in six of seven client records reviewed. Client records #1, 2, 4, 5, 6, and 7 did not include a psychosocial evaluation.
Client #1 was admitted on November 23, 2020 and discharged on March 13, 2021.
Client #2 was admitted on December 14, 2020 and discharged on February 22, 2021.
Client #4 was admitted on March 29, 2021 and discharged on May 3, 2021.
Client #5 was admitted on December 8, 2020 and was still a client at the time of the inspection.
Client #6 was admitted on April 5, 2021 and was still a client at the time of the inspection.
Client #7 was admitted on February 9, 2021 and was still a client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/3/2021, psychosicial evaluations were added to the intake packets by the office manager. Counselors will add psychosocial evaluations to clients #5, #6, & #7's files. In the future, intake counselors will be responsible for completing the psychosocial evaluations for all new clients on the day of their intake and admission. Counselors are responsible for reviewing their client files on a monthly basis to ensure all appropriate documentation is in place.
Also, the facility director will conduct random client record reviews to ensure all appropriate documentation is in place. |
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 the review and update of treatment and rehabilitation plans at least every 60 days in five of five client records.
Client #1 was admitted on November 23, 2020 and discharged on March 13, 2021. The individual treatment plan was completed on November 23, 2020. A treatment plan update was due to be completed on January 23, 2021 and was not documented.
Client #2 was admitted on December 14, 2020 and discharged on February 22, 2021. The individual treatment plan was completed on December 14, 2020. A treatment plan update was due to be completed on February 14, 2021 and was not documented.
Client #3 was admitted on January 26, 2021 and discharged on April 27, 2021. The individual treatment plan was completed on January 26, 2021. A treatment plan update was due to be completed on March 26, 2021 and was not documented.
Client #5 was admitted on December 8, 2020 and was still a client at the time of the inspection. The individual treatment plan was completed on December 8, 2020. A treatment plan updates were due to be completed on February 8, 2021, April 8, 2021, and June 8, 2021. No treatment plan updates were documented.
Client #6 was admitted on April 5, 2021 and was still a client at the time of the inspection. The individual treatment plan was completed on April 5, 2021. A treatment plan update was due to be completed on June 5, 2021 and was documented late on July 6, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/28/2021, counselors will be responsible for updating new treatment plans for clients #5 & #6. In the future, counselors will be responsible for making sure treatment plans on all active and future clients are updated every 60 days. Counselors are responsible to review their client files on a monthly basis to ensure all proper documentation is in place. The facility director will conduct random record reviews to ensure treatment plans are up to date in client files. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a complete client record which includes case consultation notes in four of four discharged client records. Client records # 1, 2, 3, and 4 did not include a case consultation.
Client #1 was admitted on November 23, 2020 and discharged on March 13, 2021.
Client #2 was admitted on December 14, 2020 and discharged on February 22, 2021.
Client #3 was admitted on January 26, 2021 and discharged on April 27, 2021.
Client #4 was admitted on March 29, 2021 and discharged on May 3, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/19/2021, the office manager created a case consultation form which is to be documented by counselors and placed in the client files for all active and future clients. Counselors will be responsible for reviewing client files on a monthly basis to ensure all proper documentation is in place. |
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 document follow up per the facility policy in four of four discharged client records.
The facility follow-up policy states each discharged client will be contacted by phone, email, or text every 30 days for 3-month period.
Client #1 was admitted on November 23, 2020 and discharged on March 13, 2021. Follow up was due to be completed on April 13, 2021, May 13, 2021, and June 13, 2021. Follow up was not documented.
Client #2 was admitted on December 14, 2020 and discharged on February 22, 2021. Follow up was due to be completed on March 22, 2021, April 22, 2021, and May 22, 2021. Follow up was not documented.
Client #3 was admitted on January 26, 2021 and discharged on April 27, 2021. Follow up was due to be completed on May 27, 2021, June 27, 2021, and July 27, 2021. Follow up was not documented for June 27, 2021, and July 27, 2021.
Client #4 was admitted on March 29, 2021 and discharged on May 3, 2021. Follow up was due to be completed on June 3, 2021, and July 3, 2021. Follow up was not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/28/2021, the facility's policy will be changed by the office manager to state that each discharged client will be contacted by phone, email or text once, 30 days from the date of discharge. In the future, counselors will be responsible for conducting these follow-ups and documenting them. The facility director will conduct random reviews of client records to ensure follow-ups are done on discharged clients. |