INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 9, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Addiction and Behavioral Counseling Associates 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 personnel records, the facility failed to ensure staff persons received the required HIV/AIDS and/or STD/TB training within the required timeframes in four of five records reviewed.
Employee # 10 was hired as a counselor on October 18, 2019. STD/TB training was to be completed by October 18, 2020. There was no documentation the training had been completed.
Employee # 12 was hired as support staff on June 10, 2019. HIV/AIDS training was to be completed by June 10, 2021. There was no documentation the training had been completed.
Employee # 13 was hired as support staff on June 1, 2019. HIV/AIDS and STD/TB training was to be completed by June 1, 2021. There was no documentation the training had been completed.
Employee # 14 was hired as support staff on January 14, 2019. HIV/AIDS and STD/TB training was to be completed by January 14, 2021. There was no documentation the training had been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately and moving forward all clinical staff will complete a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training using DDAP approved curriculum within the first year of employment, and all other staff will complete the trainings within the first 2 years of employment. All employees will be made aware of the required trainings and time frames by Office Manager during new hire orientation. Clinical Supervisor will ensure that required trainings are completed within the required timeframes by reviewing individualized training plans for all staff at least quarterly. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on the review of administrative documentation, the facility failed to document an annual financial audit for the fiscal year ending in 2020.
There was no documentation that an audit had been completed for the year ending in 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will be responsible to ensure that the annual financial audit is completed every year. The Project Director will obtain an independent CPA by the completion of every fiscal year to conduct the annual financial audit. The Project Director will be responsible to ensure the audit is completed each year, and the Project Director will also ensure this deficiency does not recur. |
709.28 (c) 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.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client in seven of seven records review.
Client records # 1, 2, 3, 4, 5, 6 and 7 documented releases of information for third party payer that were not signed by the client. Information was released to the third-party payer without a valid release.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately and moving forward counselors will complete all releases of information in person with the client to ensure a dated signature is obtained, and not by telehealth and verbal consent prior to any information being released. All counselors have been informed, and Clinical Supervisor will review charts at least monthly to monitor compliance. |
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 obtain an informed and voluntary consent from the client that included the dated signature of the client, in seven of seven records review.
Client records # 1, 2, 3, 4, 5, 6 and 7 documented releases of information that were not signed by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately and moving forward counselors will complete all releases of information and consent to treatment in person with the client and not by telehealth and verbal consent. The consent will be in writing and include, but not limited to: dated signature of client or guardian. All counselors have been informed, and Clinical Supervisor will review charts at least monthly to monitor compliance. |
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 the review of client records, the facility failed to document the type and /or frequency of treatment and rehabilitation services in three of seven client records reviewed.
Client # 4 was admitted on January 19, 2021 and discharged on July 26, 2021. The treatment plan, dated March 1, 2021, did not document the type of treatment services.
Client # 5 was admitted on December 14, 2020 and discharged on June 14, 2021. The treatment plan, dated February 28, 2021, did not document the type or frequency of treatment services.
Client # 7 was admitted on February 19, 2021 and discharged on July 23, 2021. The treatment plan, dated March 25, 2021, did not document the frequency of treatment services
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately and moving forward all counselors will ensure they are identifying type and frequency of treatment and rehabilitation services clearly in all treatment plans. Clinical Supervisor will review charts at least monthly to monitor compliance. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
The facility failed to document case consultation notes in two of three client records reviewed.
Per facility policy, case consultation notes are to be completed six months from the date of the client's first counseling session.
Client # 2 was admitted on January 2, 2021 and was still an active client at the time of the inspection. The client's first counseling session was completed on January 28, 2021. A case consultation note was to be completed by July 28, 2021. There was no documentation of a case consultation note.
Client # 6 was admitted on November 12, 2020 and discharged on June 2, 2020. The client's first counseling session was completed on November 18, 2020. A case consultation note was to be completed by May 18, 2021. There was no documentation of a case consultation note.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately and moving forward all counselors will ensure they are completing case consultations within the required time frame by setting reminders in our EHR System. Counselors will complete case consultations within six months of the client's first counseling session, and every six months thereafter. Clinical Supervisor will review charts at least monthly to monitor compliance. |