INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, MCP/Caring Together 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
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's July 1, 2022 through June 30, 2023 training year in one of two applicable personnel records reviewed.
Employee # 3 was hired as a counselor on December 20, 2019. The personnel record documented 18.5 hours of training received during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will continue to monitor the training log to ensure that 25 hours of training is completed by clinical staff regardless of time away from the office.
Program Director will review completed trainings with clinical staff monthly.
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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 an administrative review of the facility's April 2023 through February 2024 fire drill logs, the facility failed to ensure that their written fire drill logs included the time of the drill.
Every monthly fire drill log reviewed did not include the time of the fire drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review with the designated staff, the completion of the Fire Drill Log. Program Director will monitor the fire Drill Log after each epidsode.
The Program Director will create an updated version of the Fire Drill Log by 4/22/2024 and will begin use at that time. The updated log will include the time of the Fire Drill, entrance of exit, number of individuals involved and any issues that resulted at the time of the drill. |
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 an administrative review of the facility's April 2023 through February 2024 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
Every monthly fire drill log reviewed indicated that only the front exit was utilized during fire drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will direct staff to utilize both exists during fire drills. Program Director will monitor the Fire Drill Logs to ensure compliance. |
711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance 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 developing and documenting an individual's treatment and rehabilitation plan was submitted and approved by the Department for the April 8, 2021, April 20, 2022, November 2, 2022, March 29, 2023, and October 10, 2023 licensing inspections. Not developing and documenting an individual's treatment and rehabilitation plan was again found to be a deficiency in the March 11, 2024 licensing inspection.
A plan of correction for ensuring that a copy of a client consent was offered to the client was submitted and approved by the Department for the April 8, 2021, April 20, 2022, November 2, 2022, March 29, 2023, and October 10, 2023 licensing inspections. Not ensuring that a copy of a client consent was offered to the client was again found to be a deficiency in the March 11, 2024 licensing inspection.
A plan of correction for failing to ensure that treatment and rehabilitation plans were reviewed and updated at least every sixty days was submitted and approved by the Department for the March 29, 2023 and October 10, 2023 licensing inspections. Not ensuring that treatment and rehabilitation plans were reviewed and updated at least every sixty days was again found to be a deficiency in the March 11, 2024 licensing inspection.
A plan of correction for failing to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan was submitted and approved by the Department for the March 29, 2023 and October 10, 2023 licensing inspections. Not ensuring that counseling services were being provided according to the individual treatment and rehabilitation plan was again found to be a deficiency in the March 11, 2024 licensing inspection.
This is a repeat citation from the April 20, 2022, November 2, 2022, March 29, 2023, and October 10, 2023 licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will facilitate additional training for the completion of treatment plans and consent forms.
Program Director or designee will increase the review of charts.
Program Director will review/monitor current POCs monthly to ensure that trainings and chart reviews addresses the planned changes. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) 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
Based on a review of client records, the facility failed to develop and document an individual treatment and rehabilitation plan with the client in two of three applicable client records reviewed.
Client # 1 was admitted on December 4, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was not completed at the time of inspection.
Client # 2 was admitted on December 4, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was not completed at the time of inspection.
This is a repeat citation from the April 8, 2021, April 20, 2022, November 2, 2022, March 29, 2023, and October 10, 2024 licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will continue to offer training to enhance the skills of the counselors. Program Director will work with individual counselors to ensure that staff understand the need for compliance.
Program Director will complete a sample chart and provide access to a completed chart that will serve as a reference.
Program Director will review charts and documentation more frequently.
The corrections will be made in the client's charts by 4/30/2024. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) 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 ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in two of three applicable client records reviewed.
Client # 5 was admitted on September 20, 2023 and was discharged on January 18, 2024. The individual treatment and rehabilitation plan was completed on October 4, 2023, and the first update was due no later than December 4, 2023; however, the update was not completed prior to discharge.
Client # 6 was admitted on October 23, 2023 and was discharged on February 6, 2024. The individual treatment and rehabilitation plan was completed on November 22, 2023, and the next update was due no later than January 22, 2024; however, the update was not completed prior to discharge.
This is a repeat citation from the March 29, 2023 and October 10, 2023 licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director must review the POCs on an ongoing basis to ensure that the trainings and chart reviews are aligned with the changes.
The Program Director will create a spreadsheet that will note upcoming treatment plans that should be completed and reviewed. The spreadsheet will be a tracking tool that will aid in compliance.
The charts will continue to be reviewed at a minimum of 60 days.
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711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in one of one applicable client record reviewed.
Client # 3 was admitted on January 11, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 8, 2024 and indicated that the client was to receive weekly individual counseling sessions. As of the date of the inspection, the only individual session documented in the record was on February 9, 2024.
This is a repeat citation from the March 29, 2023 and October 10, 2023 licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will facilitate training to address the need to document compliance with engagement as outlined in the treatment plan. Training will encompass the documentation in the treatment plan and progress notes. Training will also include the need to make adjustments to the treatment plan and participants' schedules.
Program Director will monitor all charts for updated treatment plans at a minimum of every 60 days.
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711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include follow-up information, in three of four applicable client records reviewed.
Client # 4 was admitted on Mach 9, 2022 and was discharged on January 8, 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client # 5 was admitted on September 20, 2023 and was discharged on January 18, 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client # 6 was admitted on October 23, 2023 and was discharged on February 6, 2024. There was no follow-up information documented in the record 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
Program Director will facilitate a training for the treatment that will focus on Follow-ups. The training will review the policy for follow-ups and discuss the timeframe for completing the appropriate documentation.
Program Director will develop a spreadsheet to be shared with the staff to ensure monitoring of this task. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client # 4 was admitted on Mach 9, 2022 and was discharged on January 8, 2024. The release of information form to the funding source was signed by the client on March 9, 2022 and expired on March 9, 2023. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after March 9, 2023. Additionally, the release of information form to a laboratory was signed by the client on March 9, 2022 and expired on March 9, 2023. There was evidence of disclosures to the laboratory after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after March 9, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review the need for timely consent forms. The individual spreadsheets that each counselor will devise to aid in completion of documents in a timely manner will include the dates of the consent forms.
Program Director will review the spreadsheets twice a month. |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in one of seven client records reviewed.
Client # 1 was admitted on December 4, 2024 and was active at the time of inspection. There was a release of information form to a pharmacy that was signed by the client on December 4, 2024; however, there was no documentation in the record that a copy of the release form was offered to the client.
This is a repeat citation from the April 8, 2021, April 20, 2022, November 2, 2022, March 29, 2023, and October 10, 2023 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will facilitate an additional training to ensure that the consents note that a copy was offered to the participant.
Program Director will meet with the Information Technology Team to enquire about adding a hard stop on the electronic version of the consent forms.
Program Director will begin to monitor all admission packets within 72 hours of completion, to ensure compliance.
Changes to the active client chart will be completed by 4/30/2024. |