INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25, 2019 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, Laure Rohrs Gargano 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
During a licensing inspection conducted on September 25, 2019, the facility failed to provide the required 25 clock hours of annual training for employee # 1.
Employee # 1 was hired on November 27, 2012 and was still in this postilion as of the date of the inspection. A review of personnel record shows only 19 documented training hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will identify a new EMR/upgrade that provides monitoring of staff training hour compliance /reminders of progress toward required training hours. Each January when the annual training plans are completed the project director will enter quarterly task reminders (March/June/September/December) for all staff for the calendar year. As training attendance is completed by staff; the training evaluations/certificates are filed in personnel files; the project director will update the quarterly reminder detailing remaining required annual training hours.
The facility will utilize the following sources for training:
DDAP training website
CE4Life - online training opportunities
PESI - online and in-person training opportunities
HVPI- a training institute for experiential training
the list of training options will be expanded by the project director as new sources are identified |
709.22 (b) (2) LICENSURE Governing Body
§ 709.22. Governing body.
(b) The duties of the governing body include, but are not limited to, the following:
(2) Identifying the project ' s purpose and philosophy directly related to drug and alcohol services.
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Observations
During a licensing inspection conducted on September 25, 2019, the project failed to provide a Policy and Procedure providing the project's Purpose and Philosophy directly related to drug and alcohol services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
the facility has written a purpose and philosophy statement that will be added to the policy and procedure manual.
Subject: Governing Body
Policy:
(a) A project shall have a governing body and legal responsibility for the project rests in the governing body.
(b) The duties of the governing body include, but are not limited to, the following:
(1) Designating the position to serve as project director as the person officially responsible to the governing body either directly or indirectly.
(2) Identifying the project's purpose and philosophy directly related to drug and alcohol services.
The project purpose is to provide effective evidence-based services to individuals and families suffering with substance use disorders. The project approaches substance use disorders as a biomedical and behavioral illness benefiting from both mental health and behavioral interventions in conjunction with medical treatment when needed. Embracing update to research in the treatment of subs use disorders to improve treatment outcomes.
(3) Documenting the project's organizational structure.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
The project director will post an annual report of the project website by January 31st detailing the prior years progress toward goals; outlining the plans and goals for the current year.
The projector director will add the 709.22 to the policy & procedural manual by 11/30/19.
The purpose and philosophy statement will be posted in the office waiting area for staff & clients to review.
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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
During a licensing inspection conducted on September 25, 2019, the project failed to update an informed and voluntary consent that had expired in client record # 2. The project ' s informed and voluntary consent form states it is valid 1 year from the date on consent.
Client # 2 was admitted on September 24, 2018 and was still an active client at the time of the inspection. Informed and voluntary consent forms with an expiration date of September 24, 2019 had not been updated in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will replace:
" is valid 1 year from the date on consent"
with
"consent will expire in 6 months post-discharge unless otherwise specified below."
This change will prevent an ROI expiration while a client is actively in treatment.
The project director will update and implement this new language to ROI forms by 10/30/2019.
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709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
During a licensing inspection conducted on September 25, 2019, the project failed to ensure that there was appropriate documentation of written acknowledgment by the client in client record # 1 that the client had been made aware of their right to receive care or treatment under section 7 of the act (71 P. S. 1690.107) to retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
Client # 1 was admitted on March 7, 2019 and was still an active client at the time of inspection. The client rights form in the client record did not contain a signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will identify a new EMR/upgrade that provides reminders for all required chart entries and time frame due dates to assist facility staff to maintain timely completion of required documents. The time frame of January 6th allows for a thorough review of available EMR options to ensure HIPPA compliance and the monitoring required to ensure compliance with chart policy/procedure.
The facility currently has a policy and procedure in place for all clients to sign ROI; consent to treatment; client rights and preliminary treatment upon the completion of the client's bio-psychosocial assessment.
The EMR will provide a checklist of required chart entries and due dates based on the initial session date. The checklist creates alerts when an entry is past due date - alerting the staff member to complete the entry. This will provide monitoring and prevent this from reoccurring. |
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
During a licensing inspection conducted on September 25, 2019, the project failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware that 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 client record # 1.
Client # 1 was admitted on March 7, 2019 and was still an active client at the time of inspection. The client rights form in the client record did not contain a signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will identify a new EMR/upgrade that provides reminders for all required chart entries and time frame due dates to assist facility staff to maintain timely completion of required documents. The time frame of January 6th allows for a thorough review of available EMR options to ensure HIPPA compliance and the monitoring required to ensure compliance with chart policy/procedure.
The facility currently has a policy and procedure in place for all clients to sign ROI; consent to treatment; client rights and preliminary treatment upon the completion of the client's bio-psychosocial assessment.
The EMR will provide a checklist of required chart entries and due dates based on the initial session date. The checklist creates alerts when an entry is past due date - alerting the staff member to complete the entry. This will provide monitoring and prevent this from reoccurring. |
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
During a licensing inspection conducted on September 25, 2019, the project failed to ensure that there was appropriate documentation of written acknowledgment by the client in client record #1 that the client had been made aware of their 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.
Client # 1 was admitted on March 7, 2019 and was still an active client at the time of inspection. The client rights form in the client record did not contain a signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will identify a new EMR/upgrade that provides reminders for all required chart entries and time frame due dates to assist facility staff to maintain timely completion of required documents. The time frame of January 6th allows for a thorough review of available EMR options to ensure HIPPA compliance and the monitoring required to ensure compliance with chart policy/procedure.
The facility currently has a policy and procedure in place for all clients to sign ROI; consent to treatment; client rights and preliminary treatment upon the completion of the client's bio-psychosocial assessment.
The EMR will provide a checklist of required chart entries and due dates based on the initial session date. The checklist creates alerts when an entry is past due date - alerting the staff member to complete the entry. This will provide monitoring and prevent this from reoccurring. |
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
During a licensing inspection conducted on September 25, 2019, the project failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their right to appeal a decision limiting access to their records to the director in client record # 1.
Client # 1 was admitted on March 7, 2019 and was still an active client at the time of inspection. The client rights form in the client record did not contain a signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will identify a new EMR/upgrade that provides reminders for all required chart entries and time frame due dates to assist facility staff to maintain timely completion of required documents. The time frame of January 6th allows for a thorough review of available EMR options to ensure HIPPA compliance and the monitoring required to ensure compliance with chart policy/procedure.
The facility currently has a policy and procedure in place for all clients to sign ROI; consent to treatment; client rights and preliminary treatment upon the completion of the client's bio-psychosocial assessment.
The EMR will provide a checklist of required chart entries and due dates based on the initial session date. The checklist creates alerts when an entry is past due date - alerting the staff member to complete the entry. This will provide monitoring and prevent this from reoccurring. |
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
During a licensing inspection conducted on September 25, 2019, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in client record # 1.
Client # 1 was admitted on March 7, 2019 and was still an active client at the time of inspection. The client rights form in the client record did not contain a signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will identify a new EMR/upgrade that provides reminders for all required chart entries and time frame due dates to assist facility staff to maintain timely completion of required documents. The time frame of January 6th allows for a thorough review of available EMR options to ensure HIPPA compliance and the monitoring required to ensure compliance with chart policy/procedure.
The facility currently has a policy and procedure in place for all clients to sign ROI; consent to treatment; client rights and preliminary treatment upon the completion of the client's bio-psychosocial assessment.
The EMR will provide a checklist of required chart entries and due dates based on the initial session date. The checklist creates alerts when an entry is past due date - alerting the staff member to complete the entry. This will provide monitoring and prevent this from reoccurring. |
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
During a licensing inspection conducted on September 25, 2019, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their right to submit rebuttal data or memoranda to their own records in client record # 1.
Client # 1 was admitted on March 7, 2019 and was still an active client at the time of inspection. The client rights form in the client record did not contain a signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will identify a new EMR/upgrade that provides reminders for all required chart entries and time frame due dates to assist facility staff to maintain timely completion of required documents. The time frame of January 6th allows for a thorough review of available EMR options to ensure HIPPA compliance and the monitoring required to ensure compliance with chart policy/procedure.
The facility currently has a policy and procedure in place for all clients to sign ROI; consent to treatment; client rights and preliminary treatment upon the completion of the client's bio-psychosocial assessment.
The EMR will provide a checklist of required chart entries and due dates based on the initial session date. The checklist creates alerts when an entry is past due date - alerting the staff member to complete the entry. This will provide monitoring and prevent this from reoccurring. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
During a licensing inspection conducted on September 25, 2019, the facility failed to provide documentation of a completed comprehensive treatment and rehabilitation plan in four of seven client records reviewed.
Client # 3 was admitted on July 22, 2019 and was still an active at the time of the inspection. There was no documentation of an individual treatment and rehabilitation plan in the client record.
Client # 4 was admitted on June 28, 2019 and was still an active at the time of the inspection. There was no documentation of an individual treatment and rehabilitation plan in the client record.
Client # 5 was admitted on July 22, 2019 and discharged on May 30, 2019. There was no documentation of a signature by the client documentation in the individual treatment and rehabilitation plan.
Client # 7 was admitted on March 9, 2018 and discharged on June 7, 2018. There was no documentation of a signature by the client in the individual treatment and rehabilitation plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will identify a new EMR/upgrade that provides reminders for all required chart entries and time frame due dates to assist facility staff to maintain timely completion of required documents. The time frame of January 6th allows for a thorough review of available EMR options to ensure HIPPA compliance and the monitoring required to ensure compliance with chart policy/procedure.
Until the new/upgraded EMR is implemented the project director will review charting of existing and new admissions for compliance with required chart entries ensuring treatment plans are completed within three weeks of admission as outlined in the policy and procedural manual, reviewed with clients and signed & dated by the client. |