INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 25, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Colonial House Outpatient 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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704.7(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
704.7(b) - Qualifying degree
Based on a review of personnel files, the facility failed to document that each counselor met the educational qualifications for the position.
Employee #5, who was hired as a counselor on April 28, 2021, did not meet the educational qualifications for the position of counselor. Employee #5 has a Bachelor of Arts in History, which is not a qualifying degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor has changed the employee title to Counselor Assistant and will have employee #5 sign a new job description. The clinical supervisor will adhere to the counselor assistant guidelines for required staff supervision and outlined in 704.8 |
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
Based upon review of personnel files, the facility failed to collect feedback following staff trainings in four out of four personnel files.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor, along with the Operations Manager, will ensure that employees, following trainings, submit required training feedback. This process will be reviewed monthly during staff supervisions. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document a training plan for employees #2, #3, #4 and #6 in their employee record.
Employee #2 was hired as a counselor on June 4, 2018 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2019 through June 20, 2020. Employee #2's record did not document a training plan for the training year reviewed.
Employee #3 was hired as a counselor on January 22, 2019 and was still in the position as of the date of the onsite inspection. The facility ' s training year that was reviewed was from July 1, 2019 through June 20, 2020. Employee #3's record did not document a training plan for the training year reviewed.
Employee #4 was hired as a counselor on March 4, 2019 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2019 through June 20, 2020. Employee 4's record did not document a training plan for the training year reviewed.
Employee #6 was hired as a counselor assistant on October 1, 2019 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2019 through June 20, 2020. Employee #6's record did not document a training plan for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical supervisor, along with the Operations Manager, will conduct and collect training plans from each individual staff member during the yearly annual review. This annual review adheres to the fiscal dates of July 1st-June 30th each year. The training plans will be reflective of the required core trainings/hours needed yearly. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that CPR certification was provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operations.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor, along with the Operations Manager, will ensure that sufficient number of staff members are CPR trained and one person trained is on-site during business hours. All staff have been CPR certified at this site effective May 14, 2021. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #3 and #4's employee record.
Employee #3 was hired as a counselor on January 22, 2019 and was still in the position as of the date of the onsite inspection. The facility ' s training year that was reviewed was from July 1, 2019 through June 20, 2020. Employee #3's record only documented 17 hours of annual training for the training year reviewed.
Employee #4 was hired as a counselor on March 4, 2019 and was still in the position as of the date of the onsite inspection. The facility ' s training year that was reviewed was from July 1, 2019 through June 20, 2020. Employee #4 ' s record only documented 15.5 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure that all counseling staff are in compliance with the 25 hours of training needed per DDAP requirements. Training adherence will be discussed and documented monthly during staff supervision. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
A review of the May 2020 through April 2021 fire drill logs was conducted during the onsite inspection. The facility failed to conduct an unannounced drill during the month of October, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor, along with over-sight by the Operations Manager, will ensure that monthly unannounced fire drills are conducted and documented in the fire drill log. Adherence to this policy and procedure will be reviewed and documented by the Executive Director during Management supervision monthly |
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 personnel records, the facility failed to document an annual work performance for employee #2 in their employee record. Additionally, the facility failed to have the employee #3 and #4 sign the annual written individual staff performance evaluation.
Employee #2 was hired as a counselor on June 4, 2018 and was still in the position as of the date of the onsite inspection. Employee #2's record did not document an annual work performance for year June1, 2019 through May 31, 2020.
Employee #3 was hired as a counselor on January 22, 2019 and was still in the position as of the date of the onsite inspection. Employee #3's record did document an annual work performance for period June 1, 2019 through May 31, 2020 however, it was not signed.
Employee #4 was hired as a counselor on March 4, 2019 and was still in the position as of the date of the onsite inspection. Employee #4's record did document an annual work performance for period June 1, 2019 through May 31, 2020 however, it was not signed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor, along with over-sight by the Operations Manager, will conduct annual employee performance evaluations for the fiscal year July 1st through June 30th. The appropriate staff with sign off to ensure that the evaluation was reviewed and accepted. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the facility failed to document a completed informed and voluntary consent to release information form in three out of seven client records reviewed, as the form did not include a dated client signature.
Client #1 was admitted on a March 9, 2021 and was still active at the time of the inspection. A consent to release information form dated February 10, 2021 was to a billing agency.
Client #3 was admitted on September 18, 2020 and was still active at the time of the inspection. The seven consent to release information forms dated September 18, 2020 were to a funding source, five government agencies and a family member.
Client #4 was admitted on November 20, 2020 and was still active at the time of the inspection. A consent to release information form dated October 20, 2020 was to a billing agency.
Client #7 was admitted February 10, 2021 and was still active at the time of the inspection. A consent to release information form dated January 26, 2021 was to a billing agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure that release of information consents are properly completed with beginning and end dates in accordance with facility policy and procedures. Monthly chart audits will be completed by the Clinical Supervisor to ensure thorough and accurate documentation is adhered to.
The Clinical Supervisor will work with her team of clinicians to have current clients complete the consents appropriately by June 30, 2021. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to inform the client's of all of their rights. The client rights form given to the client did not identify that clients may not be discriminated against on the basis of national origin in seven out of seven records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager will modify the Clients Rights Form to ensure that the language communicates that a client may not be discriminated against on the basis of national origin.
This was updated and added to policy May 25, 2021. All current clients, who signed the client rights form prior to May 25, 2021, will be made aware of the updated form and be given an opportunity to sign by June 30, 2021. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to inform the client's of all of their rights. The client rights form given to the client did not identify that the facility must document the reasons for removing sections of the record in seven out of seven records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager will ensure that the clients Rights Form is edited and states that the facility must document why sections of a clients record were removed when a copy of said record was requested.
This change has been completed and implemented into policy effective May 25, 2021. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document frequency of counseling services on the client's treatment plan in six out of six records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure that documentation on client treatment plans showcase the frequency of counseling services specific to the individual plan. The Clinical Supervisor will ensure that monthly chart audits are conducted to ensure compliance and individual staff supervision and monthly staff supervision include discussions around adherence.
The current treatment plans, missing frequency of counseling sessions, will be restructured to include the frequency times. The Clinical Supervisor will work with the treatment team to have this accomplished by June 30, 2021. |