INITIAL COMMENTS
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This report is a result of an on-site Plan of Correction follow-up inspection conducted on November 22, 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 each counselor completed at least 25 clock hours of training annually during the facility's July 1, 2023 through June 30, 2024 training year in one of two applicable personnel records reviewed.
Employee # 4 was hired as a counselor on May 8, 2023. The personnel record documented 20 hours of training completed during the reviewed training year.
This is a repeat citation from the March 11, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The agency has hired a Clinical Supervisor that will be dedicated to ensuring that training is completed as mandated by licensing body.
The Clinical Supervisor will develop a spreadsheet for all staff that will not required trainings and timeframe for completion. The Clinical Supervisor will review the spreadsheet with staff monthly.
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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 ensuring 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, October 10, 2023, and March 11, 2024 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 November 22, 2024 licensing inspection.
A plan of correction for failing to ensure 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, October 10, 2023, and March 11, 2024 licensing inspections. Not ensuring treatment and rehabilitation plans were reviewed and updated at least every sixty days was again found to be a deficiency in the November 22, 2024 licensing inspection.
A plan of correction for failing to ensure 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, October 10, 2023, and March 11, 2024 licensing inspections. Not ensuring counseling services were being provided according to the individual treatment and rehabilitation plan was again found to be a deficiency in the November 22, 2024 licensing inspection.
This is a repeat citation from the April 20, 2022, November 2, 2022, March 29, 2023, October 10, 2023, and March 11. 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Clinical Supervisor (CS) has been hired that is dedicated to chart reviews and staff training. The
The Clinical Supervisor and Program Director are meet monthly with the Single County Authority's Technical Assistant Team. We are working with them to develop tools for ensuring compliance.
There is an agency Compliance Team that will be consulted for assistance with this issue.
The CS will also review 20% of all charts for compliance monthly. |
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 six of nine applicable client records reviewed.
Client # 5 was admitted on June 6, 2024 and was still active at the time of the inspection. A treatment plan update was completed on September 2, 2024 and another update was due no later than November 2, 2024; however, the update was not completed at the time of the inspection.
Client # 7 was admitted on November 9, 2022 and was still active at the time of the inspection. A treatment plan update was completed on May 31, 2024 and another update was due no later than July 31, 2024; however, the update was not completed at the time of the inspection.
Client # 9 was admitted on May 4, 2023 and was still active at the time of the inspection. A treatment plan update was completed on September 8, 2023 and another update was due no later than November 8, 2023; however, the update was not completed at the time of the inspection.
Client # 10 was admitted on February 5, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 27, 2024 and an update was due no later than April 27, 2024; however, the update was not completed at the time of the inspection.
Client # 11 was admitted on October 25, 2023 and was discharged on May 16, 2024. A treatment plan update was completed on January 9, 2024 and another update was due no later than March 9, 2024; however, the update was not completed prior to discharge.
Client # 14 was admitted on July 1, 2023 and was discharged on July 11, 2024. A treatment plan update was completed on February 5, 2024 and another update was due no later than April 5, 2024; however, the update was not completed prior to discharge.
This is a repeat citation from the March 29, 2023, October 10, 2023, and March 11, 2024 licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A Clinical Supervisor has been hired that is dedicated to chart reviews and staff training.
The Clinical Supervisor will develop a file with all participants admission dates and the dates of completion for treatment plans. the file will be reviewed with staff at least once a month during supervision.
There will be a training with all clinical staff that will outline the timeframes for completion of training plans. This training will be facilitated by Clinical Supervisor/Program Director.
Charts that were noted as deficient in the last inspection will be reviewed. The treatment plans that were not in compliance will be corrected by 1/31/25. The Clinical Supervisor will oversee this process. |
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 assure counseling services were being provided according to the individual treatment and rehabilitation plan in three of eight applicable client record reviewed.
Client # 7 was admitted on November 9, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on May 31, 2024, indicated the client was to receive monthly individual counseling sessions; however, there was no documentation in the record indicating the client was provided any individual counseling sessions during the months of June 2024 and September 2024.
Client # 9 was admitted on May 4, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan and treatment plan update, completed on August 29, 2023 and September 8, 2023, indicated the client was to receive weekly individual counseling sessions. The client record documented there were no individual sessions provided during the months of June 2024, July 2024, and September 2024; there was one individual session provided during the months of August 2024 and October 2024; and there were two individual sessions provided during the month of May 2024.
Client # 10 was admitted on February 5, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on February 27, 2024, indicated the client was to receive two individual counseling sessions per month. The client record documented that there were no individual sessions provided during the months of May 2024, June 2024, September 2024, and October 2024; and there was one individual session provided during the month of July 2024.
This is a repeat citation from the March 29, 2023, October 10, 2023, and March 11, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A Clinical Supervisor has been hired that is dedicated to chart reviews and staff training.
All clinical staff will engage in an additional training that includes ensuring that the counseling services provided for the participant are in alignment with the treatment plan. The training will also focus on documenting engagement that differs from the treatment plan. Clinical staff will be directed to reach out to participants when there is lack of engagement and to document this interaction.
Clinical staff will also be trained to provide a minimum number of sessions, as opposed to a direct number of sessions. This training will be facilitated by the Clinical Supervisor/Program Director.
The Clinical Supervisor will meet with the staff and present a form for notifying primary therapist of lack of engagement of participants. It is incumbent upon the Primary Therapist of designee to contact the participant to ascertain issues with compliance with treatment schedule. During Supervision, the Clinical Supervisor will review documentation noting issues with adherence to treatment schedule.
Clinical Staff will engage in additional training by 1/31 and directed to provide a minimum number of sessions required on the treatment plan in lieu of a hard-set number of sessions. The Clinical Director will monitor the treatment plans closely prior to endorsing. |
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 five of five applicable client records reviewed.
Client # 11 was admitted on October 23, 2024 and was discharged on May 16, 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client # 12 was admitted on March 26, 2024 and was discharged on July 8, 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client # 13 was admitted on September 16, 2024 and was discharged on October 7, 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client # 14 was admitted on July 1, 2023 and was discharged on July 11, 2024. There was no follow-up information documented in the record as of the date of the inspection.
This is a repeat citation from the March 11, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Clinical Supervisor has been hired that is dedicated to chart reviews and staff training.
The Clinical Supervisor and Program Director will train the Peer Support Team to engage discharged participants in completion of follow-up. The form for follow-up will be scanned in the EMR or paper chart upon completions.
The Clinical Supervisor will review follow-up engagement during chart reviews. |
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 four of fifteen client records reviewed.
Client # 2 was admitted on May 24, 2022 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on May 24, 2022 and expired on May 24, 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 May 24, 2023.
Client # 3 was admitted on June 26, 2023 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on June 26, 2023 and expired on June 26, 2024. 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 June 26, 2024.
Client # 7 was admitted on November 9, 2022 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on November 9, 2022 and expired on November 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 November 9, 2023.
Client # 9 was admitted on May 4, 2023 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on May 4, 2023 and expired on May 4, 2024. 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 May 4, 2024.
This is a repeat citation from the March 11, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Clinical Supervisor has been hired that is dedicated to chart reviews and staff training.
The Clinical Supervisor will meet with the clinical staff to stress the importance of completing consent forms. The staff will be reminded to ensure that consents expire and that a new consent form must be completed in a timely manner.
All current clients' files are being reviewed and expired consents will be updated. The Clinical Supervisor will monitor the consent forms during chart reviews. |
711.93(c)(2)(iv) LICENSURE Signature Client/Guardian
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:
(iv) The dated signature of the client or guardian.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a release of information form in one of fifteen client records reviewed.
Client # 8 was admitted on June 11, 2024 and was still active at the time of the inspection. The release of information form to a pregnancy care provider was signed by a witness on June 13, 2024; however, the consent form did not include the signature of the client.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A Clinical Supervisor has been hired that is dedicated to chart reviews and staff training.
The Clinical Supervisor will meet with the clinical staff to ensure that all are aware of the importance of completion of consent forms. This will include the need for participants to sign and date the form. The Clinical Supervisor will monitor the successful completion of the forms during chart reviews.
The client records that were noted as being deficient will be updated with new consent forms for those that remain active by 1/31/2025. The forms will be completed forms will include the client's signature and dates. |
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 fifteen client records reviewed.
Client # 8 was admitted on June 11, 2024 and was still active at the time of the inspection. In the record, there was a release of information form to a pregnancy care provider was signed by a witness on June 13, 2024, a release of information form to an attorney was signed by the client on June 27, 2024, a release of information form to a family member was signed by the client on September 11, 2024, and a release of information form to another treatment provider was signed by the client on November 20, 2024. There was no documentation in the client record indicating a copy of any of the mentioned consent to release information forms were offered to the client.
This is a repeat citation from the April 8, 2021, April 20, 2022, November 2, 2022, March 29, 2023, October 10, 2023, and March 11, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A Clinical Supervisor has been hired that is dedicated to chart reviews and staff training.
The Clinical Supervisor/Program Director will meet with the clinical staff to review the completion of consent forms. The consent forms provide the opportunity for staff to note that a copy of the form was offered to the participants. The importance of completing the entire form will be stressed with the staff.
The Clinical Supervisor or designee will review all charts to ensure that participants are offered a copy of the completed form.
As of the first week in January 2025, all active clients will complete new consents. Going forward, January of every new year clients will complete new consents, regardless of the date of expiration. The forms will note the offering of the completed copy to the client. |