INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25, 2023 through October 26, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, St. Luke's Penn Foundation 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project director completed at least 12 clock hours of training during the facility's July 1, 2022 through June 30, 2023 training year.
Employee #1 was hired as the Project Director on January 22, 2019. The personnel record documented 0 hours of training during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 12/1/2023, the compliance officer will assign a minimum of 12 hours of training to the project director for the current training year. The compliance officer will continue to assign 12 hours of training per training year in the My E-Learning system, to the project director. The facility director will monitor completion of training hours quarterly.
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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 that each counselor completed at least 25 clock hours of training during the facility's July 1, 2022 through June 30, 2023 training year in one of four applicable personnel records reviewed.
Employee #15 was hired as a counselor on February 20, 2018. The personnel record documented 22 hours and 5 minutes of training during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 1/1/2024, clinical supervisors will review annual training requirements with counseling staff in group supervision. Clinical supervisors will monitor compliance quarterly in individual supervision. If a counselor has a leave of absence during a training year that impacts their ability to meet training requirements, the clinical supervisor will submit an exception request to DDAP.
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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, including the reason for termination, in one of one applicable client records reviewed.
Client #19 was admitted to the inpatient non-hospital activity on July 29, 2023 and was administratively discharged on September 7, 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.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 12/1/2023, the program supervisor will notify the client in writing of the facility's decision to terminate treatment. A copy of the letter will be maintained in the client chart. The clinical supervisor will monitor compliance via monthly chart audits.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilititon plans were reviewed and updated within the regulatory timeframe in six of eight applicable client records reviewed.
Client #21 was admitted to the outpatient activity on June 19, 2023 and was discharged on October 5, 2023. The individual treatment and rehabilitation plan was completed on June 21, 2023 and an update was due no later than August 21, 2023; however, the update was not completed prior to discharge.
Client #22 was admitted to the outpatient activity on February 24, 2023 and was still active at the time of the inspection. A treatment plan update was completed on June 9, 2023 and another update was due no later than August 9, 2023; however, the update was not completed until September 8, 2023.
Client #26 was admitted to the outpatient activity on January 23, 2023 and was discharged on September 6, 2023. The individual treatment and rehabilitation plan was completed on March 27, 2023 and an update was due no later than May 27, 2023; however, the update was completed on June 5, 2023.
Client #28 was admitted to the outpatient activity on March 25, 2023 and was active at the time of inspection. A treatment plan update was completed on June 22, 2023 and another update was due no later than August 22, 2023; however, the update was completed on August 28, 2023.
Client #29 was admitted to the outpatient activity on March 23, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on March 30, 2023 and an update was due no later than May 30, 2023; however, the update was completed on July 20, 2023. Additionally, the next treatment plan update was due no later than September 20, 2023; however, the update was completed on September 28, 2023.
Client #30 was admitted to the outpatient activity on March 7, 2023 and was discharged on September 11, 2023. The individual treatment and rehabilitation plan was completed on March 30, 2023 and an update was due no later than May 30, 2023; however, the update was completed on August 2, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By November 30, 2023, the Clinical Supervisor will review compliance with documentation requirements in monthly individual supervisions with counselors. Clinical Supervisor will continue to audit open client charts to ensure treatment plan updates are completed within 60 days. If clients are not attending scheduled sessions when treatment plans are due, clinicians will update the treatment plan and comment that the client wasn't present, once the client attends the next scheduled session, it will be updated and signed with the client.
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