INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26 - 28, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Christian Counseling Associates of Western Pennsylvania 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to develop a comprehensive staff development program for the agency. The procedure failed to include time frames for each component, and the training year should be clarified.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director added policy and procedure to staff manual that outlines comprehensive staff development program for agency with required time frames.
Facility director or their designee will monitor survey forms and training plan forms completed by staff Counselors in the specified training year as outlined in policy 1-28 in CCA Staff Manual.
Facility Director will ensure completion of training program with all staff.
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the administrative information, the facility failed to develop an overall plan for addressing training needs for the 2021 training year.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The overall training plan will be documented by the Facility Director on the Facility Training Calendar.
Facility Director will develop an overall Training Plan annually based on staff feedback provided staff by December 31st of previous year.
Facility Director will develop overall annual training plans by January 15th for Calendar year for CCA.
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705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
Based on the review of the facility policy and procedure, the facility failed to develop an emergency evacuation plan to transfer clients and staff to a safe location.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Emergency evacuation plan was developed and added to Policy 5-15 in Policy and Procedure Manual by Project Director.
Facility Director will notify staff of plan.
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705.27 (4) (ii) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(ii) Assignments of staff during emergencies.
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Observations
Based on the review of the policy and procedure, the facility failed to develop a procedure that includes the assignment of staff during emergencies.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director developed plan and is responsible for adding plan to Policy 5-15 #2 in policy and procedure manual.
Facility Director will notify staff of this plan.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill records between September 2020 and May 2021, the facility failed to conduct unannounced fire drills at least once monthly.
Fire drills were not documented for September 2020 - March 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: Facility Director will ensure monthly fire drills by recording on Drill Log. Monthly Drills have been ongoing since April of 2021. |
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 ' s fire drill records between September 2020 and May 2021, the facility failed to maintain a written drill documenting all exits use and if fire alarm/smoke detector were operative.
Fire drills records for April and May 2021 did not include the exit used or if the fire alarm/smoke detector were operative.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrections were made to Fire Drill Log by Project Director to document that fire/smoke alarm was operative and specify if the front or rear entrance was used.
Facility Director will review fire drill logs monthly to ensure completion of all required areas.
All required areas will be included in the drill log.
Each drill will be done independently and documented by Facility Director based on what occurred. Exits used will vary and be randomized.
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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 ' s fire drill records between September 2020 and May 2021, the facility failed to document which alternate exit routes were used during the drills.
Fire drills records for April and May 2021 did not include the alternate exit used.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director specified that Front Entrance was used in drills in April and May. Facility Director or designee in future monthly drills will randomly specify use of front and rear exits and indicate which was used in the drill log.
Facility Director will review fire drill logs monthly to ensure completion of all required areas. |
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 ' s fire drill records between September 2020 and May 2021, the facility failed to provide documentation the fire alarm or smoke detector were set off during the drill.
Fire drills records for April and May 2021 did not include if the fire alarm/smoke detector were operative.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Request for Exception Letter was sent to DDAP on 6/28/21 by email. Facility is shared with other medical professional offices and actual fire alarm activation would cause interruption and possible harm to others on the premises. Property owner maintains and tests fire alarms once a year to ensure alarm is in working order. This provision is according to current building code.
If acception is not granted, Facility Director or designee will have building landlord test system monthly outside of regular business hours to verify system works correctly. Facility director will oversee and verify landlords report is accurate 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 facility policy and procedure manual, the facility failed to provide a procedure that included record of service, and case consultation. The procedure also needs to include a consistent time frame for the completion of the treatment plan, treatment plan update, and discharge summary.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Added to Policy 3-1 by Project Director.
The policy and procedure was revised to include all required areas and was placed in the manual by Project Director.
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709.28 (a) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to provide a procedure that is within the limits established by 4 Pa. Code 255.5.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Revision of Specified in Policy 4-3 # 6 - revised by Program Director. The revision includes all required information, and will be placed in policy and procedure manual.
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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 a release of information for a funding source in two of two records.
Client # 1 was admitted on April 10, 2021.
Client # 2 was admitted on April 15, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CCA program will require a Release of Information (ROI) for their specific Insurance Payor.
CCA Counselor will obtain specific ROI at the beginning of treatment for all clients.
Facility Director or their designee will review client records monthly to ensure completion of all required ROI.
Clients noted in this observation were already discharged. Clinical Supervisor or designee will ensure that Release of Information for funding sources are obtained for all future clients. |
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 indicate the specific information to be disclosed in one of two records.
Client # 1 was admitted on April 10, 2021. A release of information signed by the client on April 10, 2021 did not include the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director revised Release of Information form to remove "All" information category, and require check box to identify specific information to be released.
Counselor will be responsible for indicating by checking box that will specify exact information to be released.
Facility Director or their designee will review client records monthly to ensure completion of all required ROI.
Client #1 was discharged before change. All future clients will be given updated Release of Information form. |
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 client records, the facility written acknowledgement failed to include they would not discriminate based on sex, and 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 in two of two client records.
Client # 1 admitted on April 10, 2021.
Client # 2 admitted on April 15,2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director added required information to written acknowldgment which clients will receive when completing initial client information at beginning of program.
Client will sign acknowledgment indicating that they received and reviewed information.
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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
Based on a review of policy and procedure and client records, the facility failed to document a policy and infom clients the facility will not discriminate in the provision of services on the basis of sex in two of two client records
Client # 1 admitted on April 10, 2021.
Client # 2 admitted on April 15, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy 5-5 was revised by Project Director to add "sex" on item #14 p. 150 of Staff manual.
Required information was added Project Director to client acknowledgement form.
Client 1 and 2 where discharged so could not sign form. All future clients will receive ammended client acknowledgment form. |
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 policy and procedure and client records, the facility failed to document a policy and procedure and written acknowlegement that includes the right to inspect their own records in two of two client records.
Client # 1 admitted on on April 10, 2021.
Client # 2 admitted on on April 15, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director ammended all Client Information Forms that will include the required information.
Facility director or their designee will review completion of forms monthly to ensure clients receive required information at Intake.
Client rights will be included on initial patient information forms to be completed by client at time of intake. Clients will be able to review, and sign acknowledging that they have received, and reviewed client rights information that includes the right to inspect records.
This will be given to every client at time of initial intake.
Client 1 and 2 were discharged and unable to receive this updated process. All future clients will receive required information at Intake.
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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 client records reviewed, the facility failed to include verbiage in the client rights written acknowledgement form that the client has the right to appeal a decision limiting access to their records to the director in two of two records.
Client # 1 admitted on April 10, 2021.
Client # 2 admitted on April 15, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director ammended all Client Information Forms. Facility director or their designee will monitor that client will receive acknolwedgement form that outlines right to appeal by having client review and sign information at initial intake:
Client rights to appeal a decision limiting their access to records will be included on initial patient information forms to be completed by client at time of intake.
Clients will be able to review, and sign acknowledging that they have received, and reviewed client rights information that includes the right to inspect records.
This will be given to every client at time of initial intake.
Client 1 and 2 were discharged before above was implemented. All future clients will receive updated procedure as listed above. |
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 client records reviewed, the facility failed to include verbiage in the client rights written acknowledgement form that the client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in two of two records.
Client # 1 admitted on April 10, 2021.
Client # 2 admitted on April 15, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director amended all Client Information Forms to include required information. Facility director or their designee will monitor that client will receive acknowledgement form that outlines right to request the correction of inaccurate, irrelevant, outdated or incomplete information by having client review and sign acknowledgment form at initial intake:
Client will be informed of the right to request the correction of inaccurate, irrelevant, outdated or incomplete information which will be included on initial patient information forms to be completed by client at time of intake.
Clients will be able to review, and sign acknowledging that they have received, and reviewed client rights information that includes the right to inspect records.
This will be given to every client at time of initial intake.
Client 1 and 2 were discharged before the above was implemented. All future clients will receive updated procedures as listed above. |
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 client records reviewed, the facility failed to include verbiage in the client rights written acknowledgement form that the client has the right to submit rebuttal data or memoranda to their own records in two of two records.
Client # 1 admitted on April 10, 2021.
Client # 2 admitted on April 15, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director amended all Client Information Forms to include required information. Facility director or their designee will monitor that client will receive acknowledgement form that outlines right to submit rebuttal data or memoranda to their own records by having client review and sign acknowledgment form at initial intake:
Client will be informed of the right to submit rebuttal data or memoranda to their own records. This information which will be included on initial patient information forms to be completed by client at time of intake.
Clients will be able to review, and sign acknowledging that they have received, and reviewed client rights information that includes the right to inspect records.
This will be given to every client at time of initial intake.
Client 1 and 2 were discharged before the above was implemented. All future clients will receive updated procedures as listed above. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to develop an unusual incident procedure for responding to a fire or structural damage to the facility.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy 5-16 was created by Project Director and added to Policy and Procedure Manual to address deficiency.
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709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to provide an unusual incident procedure that includes the prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy 5-9 was created by Project Director and was placed in CCA policy and procedure manual to address deficiency. |
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 provide documentation for criteria for admission, treatment method and requirements for completion of treatment in two of two records.
Client # 1 admitted on April 10, 2021.
Client # 2 admitted on April 15, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Criteria for admission, treatment method, and requirement for completion of treatment was added to initial client information packet by the Project Director.
Facility Director or their designee will monitor that client has received this information at intake by verifying that client has signed information packet signifying their acknowledgment of criteria.
Clients 1 and 2 were discharged from program before policy was amended. All future clients will receive procedure as listed above.
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to provide a record of service in two of two records.
Client # 1 admitted on April 10, 2021.
Client # 2 admitted on April 15, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director or their designee will monitor Record of Service form through monthly reviews of client charts.
Record of Service form has been developed by Project Director and will be entered in every client chart as of 7/6/21.
Client #1 and #2 have been discharged and unable to complete form. All future clients will complete at time of each visit.
Includes Client Name, Location attended, Date Attended, Time In, Time Out, and client electronic signature verifying accuracy. |