INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 14, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Renewal Treatment, Inc. 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to document that clinical supervisors without two years of supervisory experience completed a core curriculum in clinical supervision in one of one staff records.Staff #3 was hired on May 7, 2019 and promoted to clinical supervisor on September 12, 2021. At the time of promotion, staff #3 did not have at least two years of supervisory experience. There was no documentation that Staff #3 completed a core curriculum in clinical supervision training.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. will ensure that clinical supervisors without two years of supervisory experience complete the the core curriculum in clinical supervision. The VP HR and Compliance will work directly with the Clinical Director and Staff #3 to ensure that they are scheduled as soon as possible for the core curriculum in clinical supervision courses. The clinical supervisor #3 will have this curriculum made part of their training plan and will have to report back when this training is scheduled. The clinical supervisor #3 will be scheduled for the next available courses in clinical supervision. The VP HR and Compliance and Clinical Director will ensure that the certificate of completion for this course work is received upon completion and that the certification is placed in staff #3's training file. This plan of correction is in place. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document each counselor met both the educational and experiential requirements for the position in two of eight records.Staff #4 was hired as a counselor on September 13, 2021. Staff #4 holds a bachelor ' s degree in a qualifying area; however, staff #4 does not have documentation of one year of clinical experience. At the time of hire, staff #4 did not have documentation of any clinical experience.Staff #11 was hired as a counselor on July 18, 2022. Staff #11 holds a bachelor ' s degree in a qualifying area; however, staff #11 does not have documentation of one year of clinical experience. At the time of hire, staff #11 did not have documentation of any clinical experience.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall document that we meet the educational and experiential requirements for all Counselors. Staff #4 and Staff #11 will be moved to the position of Counselor Assistant and will follow all regulatory requirements for that position until they meet both the educational and experiential requirements for the position of Counselor. Once Staff #4 and Staff #11 meet the regularity requirements for the position of Counselor, they will be promoted to that position. Sufficient documentation of Staff #4 and Staff #11's qualifications for the position of Counselor shall be received by the HR Department and placed in each employee's personnel file. The VP HR and Compliance shall work with the Clinical Director and Clinical Supervisors to ensure that these staff are placed in their new role. The VP HR and Compliance shall have oversight responsibility for this plan of correction. This plan of correction is in place. |
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
Based on a review of the facility ' s Staffing Requirements Facility Summary Report and discussion with staff, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in three of nine applicable personnel reviewed. Employee # 18 was hired as a counselor on December 9, 2019 and was due to have the TB/STD training no later than December 9, 2020. The TB/STD training was not completed at the time of the inspection. Employee # 19 was hired as a counselor on June 4, 2021 and was due to have HIV/AIDS training and TB/STD training no later than June 4, 2022. The HIV/AIDS and the TB/STD training was not completed at the time of the inspection. Employee # 20 was hired as a counselor assistant on August 16, 2021 and was due to have HIV/AIDS training and TB/STD training no later than August 16, 2022. The HIV/AIDS and the TB/STD training was not completed at the time of the inspection. This finding was reviewed with facility staff during the licensing process. This is a repeat citation from the September 7, 2021, July 14, 2020, October 15-17, 2019 annual licensing inspection.
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Plan of Correction
Renewal Treatment, Inc. will ensure that all staff receive; at a minimum, of six (6) hours of HIV/AIDS training and at least four (4) hours of TB/STD and other health related topics training within the regulatory timeframe. Renewal Treatment, Inc. will either use internal staff that are certified in the HIV/AIDs and STD/TB trainings or will contract with a certified trainer to provide this course work in-house using the regulatory/DDAP approved curriculum. Staff will also have the opportunity to take these courses online (DDAP approved trainers and curriculum). The VP HR and Compliance will work directly with the Clinical Director and Clinical Supervisors to ensure all staff that need these courses are scheduled for them. Staff will take these classes in-house and online over the next two (2) months to ensure that all required staff receive this training. Staff completing these classes will receive certificates that will be placed in each staff person's training file to document completion. Renewal's Director of HR and Compliance will ensure that our Compliance Specialist audits each staff persons training file on a monthly basis to ensure continual compliance. The VP HR and Compliance and Director HR and Compliance shall have oversight responsibility for this plan of action. This plan of action is in place. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up contact within 30 days of discharge, as per agency policy, in two of four client records.Client #4 was admitted on April 27, 2022 and discharged on July 1, 2022. There was no follow up documented in client record #4.Client #7 was admitted on March 16, 2022 and discharged on May 23, 2022. There was no follow up documented in client record #7.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall document follow up contact within 30 days of discharge as per our policy. The Clinical Director and Clinical Supervisors shall provide training for the Counselors and Counselor Assistants on this deficiency and our follow-up policy. The Clinical Supervisors shall ensure compliance by auditing the Counselors and Counselor Assistant's files on a monthly basis. These audits will include discharged/closed out files. The Clinical Director and Clinical Supervisors shall have overall oversight responsibility. This plan of correction is in place. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license 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 the facility ' s Staffing Requirements Facility Summary Report and discussion with staff, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for TB/STD and HIV/AIDS training within the regulatory requirements was submitted and approved by the Department for the September 7, 2021, July 14, 2020, and October 15-17, 2019 annual licensing inspections. TB/STD and HIV/AIDS training within the regulatory requirements was again found to be a deficiency in the September 14, 2022, annual licensing inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall comply with plans of correction that are approved by the Department. The Project Director and Clinical Director shall meet with the Executive Management team (CEO, VP HR and Compliance, VP Administration) on a bi-weekly basis to review the status of Department approved plans of correction. Reporting on plans of correction status will be a standing agenda item. At that time any barriers to compliance will be resolved ensuring that all plans of correction are completed within the corrective action date. Meeting minutes will be taken to document discussions, elimination of barriers and expectations for compliance. Oversight staff that fail to follow through with plans of correction will receive disciplinary personnel actions. The executive management team has met with the Project Director and Clinical Director to establish these expectations and set the meeting time frames for corrective action plan review. The VP HR and Compliance shall have oversight responsibility for this plan of correction. This plan of correction is in place and shall ensure compliance with all plans of correction including the HIV/AIDS and TB/STD staff regulatory requirements. |