INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 30, 2023 through August 31, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Self Help Movement, 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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704.11(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 the review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe for the position of counselor in one of three applicable personnel records reviewed.
Employee #13 was hired as a counselor on November 30, 2021 and was due to receive the minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than November 30, 2022; however, there was no documentation of the completion of the TB/STD training at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resources Director and/or designee, and Clinical Supervisor will ensure that all clinical staff, support staff and volunteers receive 6 hours of HIV/AIDS and 4 hours of TB,STD training within the timeframe required by DDAP. They will do this by checking quarterly to ensure that all trainings required are on the employee's training plans and are completed within the proper timeframe as well as being documented in our RELIAS (training) system.
Clinical personnel will receive the trainings (if they have not already had it) within the first year of hire. Any other staff will complete the training within 2 (two) years of their hire date.
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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 annual training during the facility's January 2022 through December 2022 training year in two of seven applicable personnel records reviewed.
Employee #4 was promoted to clinical supervisor on March 21, 2023; however, the employee was in the position of a counselor for the entire 2022 training year reviewed. The personnel record documented 11.75 hours of annual training during the review period.
Employee #13 was hired as a counselor on November 30, 2021. The personnel record documented 17.5 hours of annual training during the review period.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Human Resources Director and/or designee, and Clinical Supervisor will ensure that all clinical staff receive 25 clock hours of training annually. They will do this by checking quarterly to ensure that all trainings that are required are on the employee's training plan and that they are completed and documented in our RELIAS (training) system before the end of the annual training plan year. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that inpatient nonhospital treatment and rehabilitation projects serving adult clients maintained one Full Time Equivalent (FTE) counselor for every eight clients.
The FTE is determined by dividing the total number of hours counselors devoted to their clients (445) by the project workweek (40) =11.125. Then, to obtain the overall ratio, the total number of clients on the residential caseload (113) is divided by the FTE (11.125) = 10.15 or 10:1
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will look to recruit enough counselors from different outside sources such as colleges and from within to ensure that Self Help Movement has enough clinical staff to comply with the FTE ratio of one counselor for every eight clients. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in one of three applicable personnel records reviewed.
Employee #7 was hired as a counselor on July 25, 2023. There was no fire extinguisher training completion documentation in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resources Director and/or designee will ensure that all staff receive, during orientation (the first week of hire), fire extinguisher training. They will do this during orientation by checking to ensure that the employee has completed the training in the RELIAS (training) system before the start of their employment. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in one of three applicable personnel records reviewed.
Employee #7 was hired as a counselor on July 25, 2023. There was no emergency preparedness training completion documentation in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resources Director and/or designee will ensure that all staff, receive during orientation (the first week of hire) emergency drill training. They will do this during orientation by checking to ensure that the employee has completed the training in the RELIAS (training) system before the start of their employment. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's September 2022 through July 2023 fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The facility's sleeping hours are from 11:00PM to 6:00AM. There was documentation a fire drill was conducted during sleeping hours during the month of January 2023; however, there was no additional overnight fire drills conducted through July 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Building and Maintenance Manager will ensure that Self Help Movement is in compliance with conducting the fire drills by ensuring that the drills that are conducted on the 11pm -7am shift are completed while the facility is sleeping (after 11:00 pm and before 6:00 am) every 6 months and documented in the fire drill log. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, which is to include the reason for termination, in two of two applicable client records reviewed.
Client #9 was admitted to on December 7, 2022 and was administratively discharged on December 14, 2022. There was no documentation, in the record, indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
Client #10 was admitted to on February 8, 2023 and was administratively discharged on March 28, 2023. There was no documentation, in the record, indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will meet with the clinical team to ensure that they are aware that any client that is terminated involuntarily needs to receive written notification that they are being terminated and the reason for termination.
If the counselor/counselor assistant is unable to meet with the client and hand them the written notification, they will attempt to mail the termination notification to the last known or forwarding address.
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on review of the client records, the facility failed to notify the Department within 3 business days of a physical or sexual assault by staff or a client.
On March 27, 2023, there was a physical altercation between two clients at the facility; however, there was no documentation this incident was reported to the Department within 3 business days.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will meet with the clinical team to ensure that they are aware that when there is an unusual incident involving physical or sexual assault with any client that they are to send a report to DDAP within 3 days of the assault and t give a copy to the Clinical Supervisor. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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 the type and frequency of treatment on the individual treatment and rehabilitation plan in nine of nine applicable client records reviewed.
Client #1 was admitted on March 22, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on March 28, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #2 was admitted on April 11, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on April 14, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #4 was admitted on May 9, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on May 16, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #5 was admitted on November 14, 2022 and was discharged on December 28, 2022. The individual treatment and rehabilitation plan was completed on November 21, 2022; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #6 was admitted on January 25, 2023 and was discharged on April 24, 2023. The individual treatment and rehabilitation plan was completed on January 26, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #7 was admitted on February 21, 2023 and was discharged on May 13, 2023. The individual treatment and rehabilitation plan was completed on March 1, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #8 was admitted on December 27, 2022 and was discharged on March 21, 2023. The individual treatment and rehabilitation plan was completed on January 3, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #9 was admitted on December 7, 2022 and was discharged on December 14, 2022. The individual treatment and rehabilitation plan was completed on December 13, 2022; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #10 was admitted on February 8, 2023 and was discharged on March 28, 2023. The individual treatment and rehabilitation plan was completed on February 15, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will amend the form in the KIPU (EMR) so that it will show and include the type and frequency of treatment on the individual treatment plan. The Clinical Supervisor will then meet with the clinical team to ensure that they know to fill out the amended form. |