INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
Part 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
Part 2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on July 31, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Lebanon Treatment Center 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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704.9(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 one counselor assistant's personnel record. The facility failed to provide close supervision by a lead counselor or clinical supervision for a counselor assistant with a high school diploma or GED equivalent.
Employee # 7 only received thirty minutes of the required one hour per week of close supervision for the weeks of February 9-15, 2020, February 16-22, 2020, March 1-7, 2020, March 15-21, 2020, March 29-April 4, 2020, April 12-18, 2020, May 3-9, 2020, May 10-16, 2020, May 31-June 6, 2020, June 28-July 4, 2020, and July 5-11, 2020.
Employee # 7 also only received fifty minutes of the required one hour per week of close supervision for the week of July 19-25.
These findings were reviewed with facility staff during the licensing process.
This was a repeat citation from a licensing inspection that took place on October 11, 2019.
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Plan of Correction
Counselor assistant is scheduled for no less than one hour of close direct supervision weekly with new clinical supervisor. These session have been implemented as of 8/1/2020, and are documented accordingly.
Clinical supervisor is responsible for maintaining weekly supervision with staff and reporting to clinical director monthly for review.
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of seven counselor caseloads on July 31, 2020, the project failed to comply with the full-time equivalent (FTE) maximum caseload for counseling in outpatient programs that may not exceed 35 active clients.
The overall FTE outpatient caseload ratio was documented as 51/1 active clients at the time of the inspection.
Staff # 4 was hired on November 6, 2019 as a Lead Counselor. Staff #4 ' s individual counselor to client ratio was 50/1.
Staff # 5 was hired on February 24, 2020 as a Counselor. Staff # 5 ' s individual counselor to client ratio was 58/1.
Staff # 6 was hired on January 20, 2020 as a Counselor. Staff # 6 ' s individual counselor to client ratio was 66/1.
Staff # 7 was hired on March 11, 2020 as a Counselor. Staff # 7 ' s individual counselor to client ratio was 46/1.
Staff # 8 was hired on November 24, 2016 as a Counselor. Staff # 8 ' s individual counselor to client ratio was 64/1.
Staff # 9 was hired on July 15,2019 as a Counselor. Staff # 9 ' s individual counselor to client ratio was 58/1.
Staff #10 was hired on September 16, 2019 as a Counselor. Staff #10 ' s individual counselor to client ratio was 60/1.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Counselor caseloads are within allowable ratios as each counselor does not have more than the 35 standard hour patients. Any patients on caseload above this amount are at reduced hours. Lebanon CTC will review ratios against Licensing Alert 01-14 by August 21. Clinical supervisor will review ratios quarterly to ensure compliance is maintained. Corrective actions, up to and including adding clinical personnel, will be completed by September 18, 2020.
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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 7 staff files on July 31, 2020, the faciltiy failed to instruct two staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
Staff #5 was hired on February 24, 2020 as a counselor but fire extinguisher training was not documented until July 30, 2020.
Staff # 6 was hired on January 20, 2020 as a counselor but fire extinguisher training was not documented until July 30, 2020.
These findings were reviewed with faciltiy staff during the licensing process.
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Plan of Correction
All staff have been trained on how to utilize the fire extinguishers as of 8/3/2020, and all new hires will complete as part of their onboarding/new hire training within first 3 days of employment.
Clinical and Nurse supervisors will be responsible for ensuring completion of training upon hire. Clinical director will monitor and track. |
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 five fire drill records submitted by the facility for February 2020 - June 2020, the facility failed to maintain a written fire drill log including 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.
These findings were reviewed with facility staff during the licensing process.
This was a repeat citation from a licensing inspection that took place on October 11, 2019.
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Plan of Correction
Written documentation of drill will include the date, time, amount of time for evacuation, exit route, persons in facility at time of drill, and any problems encountered and whether the alarm was operative.
Facility will utilize an updated drill form that has included each of these measures for all drills going forward to ensure that corrective actions have been implemented. A staff member is elected to be our health & safety officer. This officer is responsible for conducting monthly drills. Clinical director will review completed drill forms each month for completion. |
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 five fire drill records submitted by the facility for February 2020 - June 2020, the facility failed to prepare alternate exit routes to be used during fire drills. The fire drill records did not identify which exit was used during any documented fire drills.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All fire drills will include exit route used and identify alternative routes.
A health and safety officer will be selected to oversee monthly drills and review procedures and routes with staff periodically. |
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 five fire drill records submitted by the facility for February 2020 - June 2020, the facility failed to set off a fire alarm or smoke detector during each fire drill. The records indicated that when a fire drill was completed, they used a verbal means for alerting those in the facility.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
An exception for the utilization of alternative notification of alarm has been submitted due to alarm system being interconnected with another program, which makes coordination difficult. A request has been submitted to allow the use of a handheld siren for the purpose of drills. Facility is awaiting response. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of seven staff on July 31, 2020, the facility failed to conduct annual written individual staff performance evaluations for two staff, copies of which shall be reviewed and signed by the employee.
Staff #1 was hired on April 16, 2017 as the Project Director. Staff # 1's last annual performance evaluation was signed and dated on April 18, 2019. There was no documentation of an April 2020 evaluation provided by the facility.
Staff #7 was hired on March 11, 2019 as Counselor Assistant. Staff #7 had a semiannual performance evaluation on July 24, 2019. Staff # 7 had no further documented performance evaluations as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Annual written staff evaluations have all been brought up to date as of 8/7/2020. As indicated, company policy has changed for the completion of performance evaluations from date of hire to the end of the calendar year. Lebanon CTC is poised to comply with DDAP yearly regulation and also have such completed per our internal policy. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of doctor ' s hours and program census that took place on July 31, 2020, the narcotic treatment program was unable to provide documentation that the narcotic treatment physician provided services at least 1 hour per week onsite for every ten patients.
The week of June 1-6, 2020 the program census was 374. The documented narcotic treatment physician hours were 34.5 rather than the required 37.4.
The week of June 7-13, 2020 the program census was 372. The documented narcotic treatment physician hours were 36 rather than the required 37.2.
The week of June 21-27, 2020 the program census was 367. The documented narcotic treatment physician hours were 34 rather than the required 36.7.
The findings were reviewed with program staff during the licensing process.
This was a repeat citation from a licensing inspection that took place on October 11, 2019.
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Plan of Correction
Lebanon Treatment Center has brought on a new medical director in addition to two physicians and a physician's assistant to provide sufficient coverage for the facility weekly. This was corrected on 8/6/2020.
Clinic director as well as Regional director will periodically review hours to ensure that adequate coverage is maintained to meet state requirements. |