INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 1, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Monroe County Counseling Services, 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)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to follow their staff development policy and procedures ensuring that there was documented feedback on all completed trainings in one of one personnel records reviewed. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
A Training Feedback Form was developed on December 24th, 2020. The form will be completed by each employee after each training program effective immediately. The form includes information on the content of the training program, date and hours on which the staff took the training, location where the training was held along with the purpose of the training, and the name of the trainer. The Project Director will ensure there is a completed Feedback Form in the staff's personnel record for each training program completed by staff effective immediately. |
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
The facility failed to ensure that all staff completed the mandatory 6 hours of HIV/AIDS and/or TB/STD trainings within the regulatory time frame in one of one personnel records reviewed.Employee # 1 was hired as a Project Director/Facility Director/Counselor on February 1, 2017. HIV/AIDS and TB/STD trainings were due no later than February 1, 2019. Trainings for both HIV/AIDS and TB/STD were not completed at the time of inspection. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director revised the Individual Training plan for himself on December 23, 2020, by prioritizing the HIVAIDS and TB/STD pieces of training to be completed by January 30, 2021, or shortly thereafter. The Project Director arranged and scheduled the required training sessions with NOVUS ACS Medical Services in Stroudsburg, PA, and the DDAP's Training Management System. The Project Director will monitor this training schedule effective immediately to ensure that training requirements are met and avoid the reoccurrence of this deficiency in the next year. |
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
The facility failed to document the completion of 25 clock hours of annual training required for counselors during the facility's January 1, 2019 through December 31, 2019 training year training year in one of one employee files reviewed.Employee #1 ' s employee file documented 6 hours of annual training.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On December 26, 2020, The Project Director/Counselor completed a revised Individual Training Plan Form for Employee#1 that includes a minimum of 25 clock hours of training to be completed by the first quarter -- or sooner if possible -- of the new DDAP licensing period.
This Employee #1 individual Plan will be monitored immediately by the Project Director to ensure that DDAP training requirements are met as soon as possible. The Project Director has scheduled most of the required training sessions with the DDAP's Training Management System. Documentation of all training will be maintained in the employee's personnel record and made available to DDAP at their request.
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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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.Client #3 was admitted on November 4, 2020 and was active at the time of inspection. There was evidence of communication with a judge and a probation officer; however, there was no consent to release information forms signed by the client to either entity prior to the disclosure of information. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On December 26, 2020, the appropriate annotations were made to the Informed and Voluntary Consent to Release Information Form and executed with Client #3. The Project Director was aware of this deficiency in the Client Record but was not able to arrange for the appropriate revisions to the Release Form due to the Client's sporadic attendance. The Project Director will ensure that no communication occurs with third parties in the future for any clients without duly executed Release Forms. |
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
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in six of seven client records reviewed.Client #1 was admitted on December 17, 2020 and was active at the time of inspection. There was a release of information form to a judge, signed and dated by the client, that included the drug and alcohol assessment, which exceeded the limits established by 4 Pa. Code 255.5.Client # 2 was admitted on December 29, 2020 and was active at the time of inspection. There was a release of information form to a judge, signed and dated by the client, that included the drug and alcohol assessment, which exceeded the limits established by 4 Pa. Code 255.5.Client #4 was admitted on January 2, 2020 and was discharged March 2, 2020. There was a release of information form to a judge, signed and dated by the client, that included the drug and alcohol assessment, which exceeded the limits established by 4 Pa. Code 255.5.Client #5 was admitted on January 3, 2020 and was discharged March 8, 2020. There was a release of information form to a judge, signed and dated by the client, that included the drug and alcohol assessment, which exceeded the limits established by 4 Pa. Code 255.5.Client #6 was admitted on March 26, 2020 and was discharged May 26, 2020. There was a release of information form to a judge, signed and dated by the client, that included the drug and alcohol assessment, which exceeded the limits established by 4 Pa. Code 255.5.Client #7 was admitted on September 4 ,2020 and was discharged October 4, 2020. There was a release of information form to a judge, signed and dated by the client, that included the drug and alcohol assessment, which exceeded the limits established by 4 Pa. Code 255.5.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director can attest to the fact that the agency has never released a full D/A assessment. That was not the intent of this Consent Release. In any case, the Project Director immediately removed "the drug and alcohol assessment" language on the said Consent to Release Information Form.
An annotation was made to the Consent to Release for Client #1.
See above response regarding " D/A assessment." An annotation was made to the Consent to Release for Client #2.
See above response regarding " D/A assessment." An annotation was made to the Consent to Release for Client #4.
See above response regarding "D/A assessment." An annotation was made to the Consent to Release for Client #5.
See above response regarding "D/A assessment." An annotation was made to the Consent to Release for Client #6.
See above response regarding "D/A assessment." An annotation was made to the Consent to Release for Client #7.
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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
The facility failed to ensure there was documentation that a copy of all of the client's informed and voluntary consent to release information forms were offered to the client in three of seven client record reviewed.Client #1 was admitted on December 17, 2020 and was active at the time of inspection.Client #5 was admitted on January 3, 2020 and was discharged March 8, 2020. Client #7 was admitted on September 4 ,2020 and was discharged October 4, 2020. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
A copy of all client consents is always verbally offered to clients and a copy maintained in the client record. These were clerical and staff oversight errors that should not have occurred.
The Project Director immediately developed a checklist to be used at the time of assessment to avoid this paperwork processing error in the future.
Since Client #1 was still active in Program this deficiency was immediately corrected.
Client #5's record was annotated to reflect this omission.
Client #7 record was annotated to reflect this omission. |
709.34 (a) (2) 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:
(2) Selling or use of illicit drugs on the premises.
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Observations
The facility failed to include, within their unusual incident reporting policy and procedures, a specific policy/procedure that addresses selling or use of illicit drugs on the premises. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on December 28, 2020. The updated Manual clearly outlines how the facility would respond to the selling or use of illicit drugs on the premises of the facility. To avoid future Agency Manual deficiencies, the Project Director is committed to an annual review of the Manual when the facility director reviews and signs off on the policy and procedure manual. |
709.34 (a) (5) 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:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
The facility failed to include, within their unusual incident reporting poicy and procedures, a specific policy/procedure that addresses a theft, burglary, break-in or similar incident at the facility. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on December 28, 2020. The updated Manual clearly outlines how the facility would respond to the following unusual incidents: (5) Theft, burglary, break-in, or similar incident at the facility.
To avoid future Agency Manual deficiencies, the Project Director is committed to an annual review of the Manual when the facility director reviews and signs off on the policy and procedure manual. |
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
The facility failed to include, within their unusual incident reporting poicy and procedures, a specific policy/procedure that addresses a fire or structural damage to the facility.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency Policies and Procedures Manual was carefully reviewed and revised by the Project Director on December 28, 2020. The updated Manual clearly outlines how the facility would respond to a fire or structural damage to the facility. To avoid future Agency Manual deficiencies, the Project Director is committed to an annual review of the Manual when the facility director reviews and signs off on the policy and procedure manual. |