INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 28, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Monroe County Counseling Services, LLC 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 one personnel record, the facility failed to document the completion of 25 clock hours of annual training required for counselors.Employee # 1 functions as the Project Director, Facility Director and counselor since being hired on February 1, 2017. The facility's training year that was reviewed was from February 1, 2021 through January 31, 2022. Employee #1's employee record only documented 16 hours of training for the period reviewed.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the November 9, 2021 and December 1, 2020 annual licensing inspections.
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Plan of Correction
Since November 9, 2021, the Project Director took a number of proactive steps to "catch up" with this current and prior citation. To this end, the Project Director has completed a total of 35 training hours since 11/9/21, and is scheduled to complete another 15 hours before the end of this calendar year, thereby surpassing the required "25 hours" before the end of this current licensing period that ends on 1/31/23.
The Project Director has also added a number of new training providers to his Trainers Providers list with alternative/backup training dates to ensure that he does not fall short of the required 25 clock hours of training annually in the future. The Project Director is fully committed to monitoring his training schedule to ensure compliance.
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on October 28, 2022, the facility failed to have hot water in the men ' s bathroom in the main hallway or the bathroom in the group room. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director met with the landlord on Nov. 4 2022 and the Landlord had the problem with the men's room corrected by November 8, 2022.
Regarding the hot water in the Clients' Main Restroom in the group room, the issue was corrected immediately by the Project Director, who had mistakenly turned off the hot water circuit breaker earlier on October 28, 2022 as he tested an electrical smoke alarm.
The Project Director met with landlord on Nov.19, 2022 to have all "hot water" lines identified so that he can personally monitor them at all times to ensure this does not occur again and/or immediately notify the landlord to correct any physical plant issues beyond the Project Director/ Agency's control.
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705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection on October 28, 2022, the facility failed to light interior exits and stairs at all times as the emergency exit in the rear of the facility led to an unlit stairwell. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On November 4 and 19, the Project Director met with the landlord and another tenant who mistakenly turned the working lights off. It was agreed that the Landlord and his maintenance staff would immediately post signs to "KEEP LIGHTS ON AT ALL TIMES." The Project Director will personally monitor this agreement. |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record, to include an aftercare plan, in two of three applicable records reviewed.Client #2 was admitted on April 7, 2022 and discharged on May 28, 2022.Client #3 was admitted on December 16, 2021 and discharged on February 10, 2022.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the November 9, 2021 annual licensing inspection.
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Plan of Correction
A review of the entire Aftercare process revealed that this has happened with other clients throughout the entire year because, as with the cases of Client #2 and Client #3 records, some clients refuse to participate in the Aftercare process. Therefore, effective immediately the Project Director has revised the agency's policies and procedures to include where applicable documentation in the client record "that the client has refused to participate in the Aftercare process."
Also, effective immediately the Project Director will ensure that either a complete Aftercare Plan or "refusal' documentation is included in all client records.
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709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of client records, the facility failed to follow their written client follow-up policy, which includes documentation of follow-up attempts at one, two, and three months following discharge in five of five applicable records reviewed. Client #1 was admitted on July 20, 2022 and discharged on August 20, 2022.Client #2 was admitted on April 7, 2022 and discharged on May 28, 2022.Client #3 was admitted on December 16, 2021 and discharged on February 10, 2022.Client #4 was admitted on March 8, 2022 and discharged on March 31, 2022.Client #5 was admitted on May 12, 2022 and discharged on June 12, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A review of the five Discharged cases by the Project Director revealed that a follow-up letter was sent to all these clients only once.
No responses were received which is typical of the response rate from most of our clients.
This citation has led the Project Director to revise the current Policy and Procedures regarding follow-up contacts with discharged clients. The agency will no longer conduct follow-up contact "at one, two and three month intervals following discharge."
Instead, the new policy is to conduct follow-up contacts with "how are you doing' letters to all clients who have been discharged.
The contact will occur within 60 days after discharged date with documentation of follow-up attempts to be included in the Client record. The Project Director will monitor the implementation of this new Policy effective immediately.
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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 one personnel file, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for ensuring that staff functioning as counselors completed at least 25 hours of training per training year was submitted and approved by the Department for the November 9, 2021and December 1, 2020 annual licensing inspections. Ensuring that staff who function as counselors completed 25 hours of training was again found to be a deficiency in the October 28, 2022, licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately the Project Director will routinely (on a monthly basis) monitor all approved plans of correction to avoid any future repeat citation. |