INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 23, 2022 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel / training records and the facility ' s Staffing Requirements Facility Summary Report, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of two applicable records reviewed.
Employee # 3 was hired as a counselor assistant on February 21, 2021 and was due to have HIV/AIDS training and TB/STD training no later than February 21, 2022. The HIV/AIDS training was not completed until March 23, 2022 and the TB/STD training was not completed at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The plan of correction for Employee #3 with regard to this deficiency is as follows. We acknowledge the fact that the HIV/AIDS training was to have been completed no later than February 21, 2022, when in fact it was not completed until March 23, 2022. In terms of TB/STD training, Employee #3 is scheduled to have her training in this subject on July 13, 2022. We will keep verification of her training on file for inspector(s) to reviewn at our next inspection. In the future, all staff members and/or employees will have their mandatory training in HIV/AIDS and TB/STD in a timely fashion before they are actually hired or promoted to another position. The Project Director will be the staff member responsible for ensuring that the required trainings are done in a timely fashion. In this way, our staff members will be well-trained and prepared before they actually assume their job responsibilities. The same policy and procedure shall take place with other mandatory trainings such as CPR and Basic First Aid. |
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 client records, the facility failed to document the name of the person, agency or organization to whom the disclosure is made on the consent to release information forms in two of five applicable client records.
Client # 6 was admitted on March 7, 2022 and was discharged on June 9, 2022. Two release of information forms, one for funding and one for coordination of care, were both signed by the client on March 7, 2022. Both releases of information failed to indicate the name of the person, agency or organization to whom the disclosure would be made.
Client # 7 was admitted on April 12, 2022 and was still active at the time of the inspection. Two release of information forms, one for funding and one for coordination of care, were both signed by the client, but the client signature was not dated. Both releases of information failed to indicate the name of the person, agency or organization to whom the disclosure would be made.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the July 30, 2021 and the February 9, 2022 on-site inspections.
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Plan of Correction
We admit that the releases of information were deficient at the time of inspection for Clients #6 and #7. We also acknowledge that this citation is a repeat one from both the July 30, 2021 inspection and the February 9, 2022 inspection. In the future all current clients and future clients will be compliant and have the proper signatures in the proper places on all forms. By 7/20/2022 we will have had two separate training sessions (One or before July 8, 2022 and one on or before July 15, 2022) with all counseling staff to review how to fill out the release of information forms and other matters related to the proper paperwork required to continue to operate in a professional manner. Our project director, will lead the training sessions. The counseling staff of two individuals will take the trainings. The director of development will take minutes from the training sessions to document who was present and the subjects covered. Another part of this plan of correction involves oversight. All files of active, discharged and about to be discharged clients will be reviewed by our project director on a bi-weekly basis (Once every two weeks) to ensure that all releases of information are properly filled out, particularly with regard to indicating the names of the persons, agencies or organizations to whom disclosure should be made, that client signatures are dated and other relevant areas of our paperwork. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document a dated signature of the client on the consents to release information in one of five applicable client records.
Client # 7 was admitted on April 12, 2022 and was still active at the time of the inspection. Two release of information forms, one for funding and one for coordination of care, were both signed by the client, but the client signature was not dated.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
We acknowledge the fact that, for Client #7, both releases of information contained signatures of the client, but that the client signature was not dated.
In the future all current clients will be compliant and the correct releases of information will be dated by the client in the active client records addressed in the deficiency. By 7/20/2022 we will have had two separate training sessions (One or before July 8, 2022 and one on or before July 15, 2022) with all counseling staff to review how to fill out the release of information forms and other matters related to the proper paperwork required to continue to operate in a professional manner. Our Project Director, will lead the training sessions. Our counseling staff of 2 individuals will take the trainings. Our director of development will take minutes from the training sessions to document who was present and the subjects covered. Another part of this plan of correction involves oversight. All files of active, discharged and about to be discharged clients will be reviewed by our Project Director on a bi-weekly basis (Once every two weeks) to ensure that all releases of information are properly filled out, particularly with regard to ensuring that the client signatures are dated. |
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 document a dated signature of the witness on consents to release information in one of five applicable client records.
Client # 6 was admitted on March 7, 2022 and was discharged on June 9, 2022. Two release of information forms, one for funding and one for coordination of care, were both signed by the client on March 7, 2022. Both releases of information failed to include a dated signature of a witness.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
We acknowledge the fact that, for Client #6, both releases of information failed to include a dated signature of a witness. In the future, all clients and future clients will e compliantBy 7/20/2022 we will have had two separate training sessions (One or before July 8, 2022 and one on or before July 15, 2022) with all counseling staff to review how to fill out the release of information forms and other matters related to the proper paperwork required to continue to operate in a professional manner. Our Project Director will lead the training sessions. The counseling staff of two individuals will take the trainings.
Our Director of Development will take minutes from the training sessions to document who was present and the subjects covered. Another part of this plan of correction involves oversight. All files of active, discharged and about to be discharged clients will be reviewed by our Project Director on a bi-weekly basis (Once every two weeks) to ensure that all releases of information are properly filled out, particularly with regard to ensuring that releases information include a dated signature of a witness. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document a copy of a client consent was offered to the client in two of five applicable client records.
Client # 6 was admitted on March 7, 2022 and was discharged on June 9, 2022. Two release of information forms, one for funding and one for coordination of care, were both signed by the client on March 7, 2022, but there was no documentation a copy of either of the consents were offered to the client.
Client # 7 was admitted on April 12, 2022 and was still active at the time of the inspection. Two release of information forms, one for funding and one for coordination of care, were both signed by the client, but the client signature was not dated. There was no documentation a copy of either of the consents were offered to the client.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
We acknowledge the fact that, for Clients #6 and #7, both releases in both cases failed to document a copy of either of the consents were offered to the clients. In the future all current clients and future clients will be compliant and that copies of the releases of information will be offered in the active client records addressed in the deficiency.)
By 7/20/2022 we will have had two separate training sessions (One or before July 8, 2022 and one on or before July 15, 2022) with all counseling staff to review how to fill out the release of information forms and other matters related to the proper paperwork required to continue to operate in a professional manner. Our Poject Director, will lead the training sessions. The counseling staff of two individuals will take the trainings. Our Director of Development will take minutes from the training sessions to document who was present and the subjects covered. Another part of this plan of correction involves oversight. All files of active, discharged and about to be discharged clients will be reviewed by our Project Director on a bi-weekly basis (Once every two weeks) to ensure that all releases of information are properly filled out and that documentation is included providing that the clients are offered copies of the consents that they sign with our organization., |
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 review and update treatment and rehabilitation plans at least every sixty days in three of six applicable client records.
Client # 1 was admitted on March 21, 2022 and was discharged on June 20, 2022. The individual treatment plan was completed on March 21, 2022 and the update was due no later than May 21, 2022; however, the update was not completed prior to discharge.
Client # 4 was admitted on April 19, 2022 and was still active at the time of the inspection. A treatment plan update was completed on April 19, 2022 and the update was due no later than June 19, 2022; however, the update was not completed.
Client # 6 was admitted on March 7, 2022 and was discharged on June 9, 2022. The individual treatment plan was completed on March 7, 2022 and the update was due no later than May 7, 2022; however, the update was not completed prior to discharge.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the July 30, 2021 and the February 9, 2022 on-site inspections.
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Plan of Correction
We acknowledge the deficiencies concerning the failure to review and update the treatment plans for Client #1, Client #4 and Client #6 and, moreover, that these are repeat citations from the July 30, 2021 and February 9, 2022 on site inspections.
In the future, all current clients and future clients will be compliant andthat treatment plan updates will be completed in the active client records addressed in the deficiency. By 7/20/2022 we will have had two separate training sessions (One or before July 8, 2022 and one on or before July 15, 2022) with all counseling staff to review how to fill out the treatment and rehabilitation plans and other matters related to the proper paperwork required to continue to operate in a professional manne. Our Project Director, will lead the training sessions. The counseling staff of two individuals will take the trainings.
Our Director of Development will take minutes from the training sessions to document who was present and the subjects covered. Another part of this plan of correction involves oversight. All files of active, discharged and about to be discharged clients will be reviewed by our Project Director on a bi-weekly basis (Once every two weeks) to ensure that all treatment plans are properly filled out in a timely manner, i.e. that the treatment and rehabilitation plans have been reviewed and updated at least every sixty days. |
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 one of one applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy. The facility policy indicates a follow-up to the client occur within 30 days after discharge.
Client # 2 was admitted on October 28, 2021 and discharged on April 22, 2022. The follow up was due to be completed by May 22, 2022. There was no follow-up information documented in the client record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
We acknowledge the fact that, for Client #2, SBSS did not follow up with the Client within the proscribed 30 day timeframe after discharge. Moreover, there was no follow-up information in the client record. By 7/20/2022 we will have had two separate training sessions (One or before July 8, 2022 and one on or before July 15, 2022) with all counseling staff to properly conduct follow ups with clients within the 30 day timeframe and other matters related to the proper paperwork required to continue to operate in a professional manner. Our Project Director, will lead the training sessions. The counseling staff of two individuals will take the training. Our Director of Development will take minutes from the training sessions to document who was present and the subjects covered. Another part of this plan of correction involves oversight. All files of discharged and about to be discharged clients will be reviewed by our Project Director on a bi-weekly basis (Once every two weeks) to ensure that all follow ups are conducted within the 30 day timeframe and documented properly in the client records. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for treatment plan updates was submitted and approved by the Department for the July 28 - 30, 2021 and the February 9, 2022 on-site licensing inspections. Treatment plan updates were again found to be a deficiency in the June 23, 2022 on-site licensing inspection.
A plan of correction for a consent to release information indicating the name of the person, agency or organization to whom the disclosure would be made was submitted and approved by the Department for the July 28 - 30, 2021 and the February 9, 2022 on-site licensing inspections. Consents to release information indicating the name of the person, agency or organization was again found to be a deficiency in the June 23, 2022 licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
We acknowledge that we have failed to fully implement previous plans of correction fully. The plan of correction for treatment updates that was submitted and approved by the Department of the July 28-30, 2021 and the February 9, 2022 on site licensing inspections was not fully implemented during the June 23, 2022 inspection. Furthermore, a plan of correction for the same time period mentioned above for a consent to release information indicating the name of the person, agency or organization to whom the disclosure would be made was also not fully implemented during the June 23, 2022 inspection. Therefore, our plan of correction for this citation will follow some of the strategies as mentioned above in the previous citations for the inpsection that took place on June 23, 2022. Our Project Director is the person responsible for ensuring that our plan of correction outlined herein is followed thoroughly. She will also be responsible for monitoring the plan of correction to make sure that it is being followed. The way that she will ensure that the plan of correction is being followed is to periodically review the counselors' work product and the client charts (Please see below). If our Project Director spots out a deficiency in the paperwork, she will immediately contact the counselor in question and point out where potential changes need to be made.
By 7/20/2022 we will have had two separate training sessions (One or before July 8, 2022 and one on or before July 15, 2022) with all counseling staff to review and how to prepare timely treatment plans and how to fill out the consents to release of information forms and other matters related to the proper paperwork required to continue to operate in a professional manner. Our Project Directlor will lead the training sessions. The counseling staff of two individuals that will take the training. Our Director of Development will take minutes from the training sessions to document who was present and the subjects covered. Another part of this plan of correction involves oversight. All files of active, discharged and about to be discharged clients will be reviewed by our Project Director on a bi-weekly basis (Once every two weeks) to ensure that all releases of information are properly filled out, particularly with regard to treatment plan updates and consent to release information and other relevant areas of our paperwork. We are taking the additional step of having an extra training session on or before July 19, 2022 specifically related correcting the deficiencies outlined in this citation, proper protocols to follow in completing paperwork, quizzing the staff on those protocols, oversight and coaching by management to ensure that mistakes are not completed and documenting that this additional training has been absorbed by the staff. |