INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 13-14, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cornell Abraxas I 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(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 develop a written individual training plan for each employee in twelve of twelve records.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By April 15, 2024, supervisors will meet with all team members to complete their Professional Development Plans (PDPs). They will be submitted to the Training Department no later than April 30, 2024. A copy will be maintained in the employee supervision file and in the employee's training file. The Training Supervisors will track the submission to verify all employees have completed a PDP and submit a weekly report to the D/A Program Manager.
By October 1, 2024, the Training Supervisors will remind supervisors to complete PDPs with their employees for the 2025 calendar year. All PDPs will be submitted to the training department by November 15, 2024. A copy will be maintained in the employee supervision file and in the employee's training file. The Training Supervisors will track the submissions to verify all employees have completed a PDP and submit a report to the D/A Program Manager.
The Facility Director is responsible for oversight and will monitor the process to verify compliance. The facility will be in full compliance with the standard by April 30, 2024.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative information, the project director failed to prepare, annually update, and sign a written manual delineating project policies and procedures for the year 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
By April 15, 2024, the Facility Director/Project Director will sign a document to delineate and approve the project's policy and procedure manual for 2024.
By January 10, 2025, the Director of Quality & Compliance will submit the policy and procedure manual to the Facility Director/Project Director who will sign the document delineating the project's policies and procedures.
The Facility Director is responsible for oversight of this process. |
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 a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in two of seven records.
Client #2 admitted on August 7, 2023 and still a current client. Client #2 did not have any informed and voluntary consents in their record and disclosures were confirmed to the funding source, parent/guardian, and an agency from date of admission to current.
Client #4 admitted on September 29, 2023 and discharged October 23, 2023. There was no consent to release information form for the funding source. Facility staff confirmed billing had occurred.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
By April 8, 2024, the Program Manager will review the consent to release information forms in the client intake packet with Treatment Supervisors and provide training to verify their understanding of the full and accurate completion of the forms.
By April 30, 2024, Treatment Supervisors will inspect each client file and work with counselors to make the necessary corrections to the consent to release information forms. By April 30, 2024, Treatment Supervisors will notify the Program Manager to verify the corrections have been made.
Beginning April 15, 2024, Treatment Supervisors will complete a file review of all new clients' intake documentation within 72 hours of intake to verify consent to release information forms are fully and accurately completed.
The Program Manager is responsible for oversight of this process. She will verify the Treatment Supervisors' chart reviews have been completed during monthly supervision and findings and document in a supervisory conference. The facility will be in full compliance with the standard by May 1, 2024.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client which includes name of the person, agency, or organization to whom disclosure is made in one of seven records.
Client #4 admitted on September 29, 2023 and discharged October 23, 2023. Client record contained a release of information dated September 29, 2023 that did not contain the name of the person, agency, or organization to whom disclosure is made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By April 8, 2024, the Program Manager will review the consent to release information forms in the client intake packet with Treatment Supervisors and provide training to verify their understanding of the full and accurate completion of the forms.
By April 30, 2024, Treatment Supervisors will inspect each client file and work with counselors to make the necessary corrections to the consent to release information forms. By April 30, 2024, Treatment Supervisors will notify the Program Manager to verify the corrections have been made.
Beginning April 15, 2024, Treatment Supervisors will complete a file review of all new clients' intake documentation within 72 hours of intake to verify consent to release information forms are fully and accurately completed.
The Program Manager is responsible for oversight of this process. She will verify the Treatment Supervisors' chart reviews have been completed during monthly supervision and findings and document in a supervisory conference. The facility will be in full compliance with the standard by May 1, 2024.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document a purpose of disclosure on the release of information form in two of seven records.
Client #4 admitted on September 29, 2023 and discharged on October 23, 2023. A release of information was signed on September 29, 2023 did not indicate a purpose of disclosure.
Client #7 admitted on August 29, 2023 and discharged on December 15, 2023. A release of information was signed on August 30, 2023 to the funding source but did not indicate a purpose of disclosure.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By April 8, 2024, the Program Manager will review the consent to release information forms in the client intake packet with Treatment Supervisors and provide training to verify their understanding of the full and accurate completion of the forms, to include the purpose of the disclosure on each document.
By April 30, 2024, Treatment Supervisors will inspect each client file and work with counselors to make the necessary corrections to the consent to release information forms. By April 30, 2024, Treatment Supervisors will notify the Program Manager to verify the corrections have been made.
Beginning April 15, 2024, Treatment Supervisors will complete a file review of all new clients' intake documentation within 72 hours of intake to verify consent to release information forms are fully and accurately completed.
The Program Manager is responsible for oversight of this process. She will verify the Treatment Supervisors' chart reviews have been completed during monthly supervision and findings and document in a supervisory conference. The facility will be in full compliance with the standard by May 1, 2024.
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709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered that the facility had an unusual incident occur on September 16, 2023 which involved an event at the facility requiring the presence of police. Upon further inspection and confirmed by facility staff, it was determined that the facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By April 8, 2024, the Facility Director, the Program Manager and the Director of Quality & Compliance will review the standard and policy regarding the submission of unusual incident reports, to include the types of incidents requiring a report. The Director of Quality & Compliance will provide training to the Program Manager and the Facility Director on the process for submitting the unusual incident reports via the online portal, so that one of these three employees is always available to submit the report. The Facility Director will be responsible for oversight of the process. The facility will be in compliance with this standard by April 10, 2024. |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document the disclosure of the criteria for involuntary termination to clients, during the intake process, in seven of seven records.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By April 12, 2024, the Director of Quality & Compliance will add the criteria for involuntary termination to the Client Handbook and the Intake Checklist. Staff members who review the Client Handbook with clients during the admission process will verify on the Intake Checklist that the involuntary termination criteria have been reviewed. Treatment Supervisors will review the new Client Handbook with current clients by April 30, 2024 and highlight the revisions.
The Facility Director is responsible for oversight of the process. The facility will be in full compliance with this standard by May 1, 2024. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan within the facility ' s policy timeframe in four of seven records.
The facility ' s policy and procedure manual states the preliminary treatment plan must be completed within 72 hours of admission.
Client #1 admitted on October 16, 2023 and still a current client. The preliminary treatment plan was due on October 19, 2023; however, it was not completed until October 30, 2023.
Client #2 admitted on August 7, 2023 and still a current client. There was no documentation of a preliminary treatment plan at the time of the inspection.
Client #6 admitted on July 11, 2023 and discharged on November 22, 2023. There was no documentation of a preliminary treatment plan at the time of the inspection.
Client #7 admitted on August 29, 2023 and discharged on December 15, 2023. There was no documentation of a preliminary treatment plan at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
By April 8, 2024, the Program Manager will review with Treatment Supervisors the requirement for completing preliminary treatment plans within 72 hours. Treatment Supervisors will review this requirement, as well as the format for preliminary treatment plans, with the Counselors in their dorms.
By April 15, 2024, Treatment Supervisors will implement a tracking tool within their units to ensure that the Preliminary Treatment Plan is completed and in the file within 72 hours of admission.
Beginning April 15, 2024, Treatment Supervisors will complete a file review of all new clients' intake documentation within 72 hours of intake and verify Preliminary Treatment Plans have been completed, signed and filed.
The Program Manager is responsible for oversight of this process. She will verify the Treatment Supervisors' chart reviews have been completed during monthly supervision and findings and document in a supervisory conference. The facility will be in full compliance with the standard by May 1, 2024.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure the clients received counseling services according to their individual treatment plan in four of seven records. Each treatment plan indicated individual therapy should occur every seven days.
Client #1 admitted on October 16, 2023 and still a current client. There was no documentation the client received individual therapy the following weeks: October 16, October 23, October 30, November 13, and December 11.
Client #2 admitted on August 7, 2023 and still a current client. There was no documentation the client has received any individual therapy as of the date of inspection.
Client #3 admitted on October 2, 2023 and still a current client. There was no documentation the client received individual therapy from October 2nd to February 1st.
Client #6 admitted on July 11, 2023 and discharged on November 22, 2023. There was no documentation the client received individual therapy while inpatient at the facility.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Treatment Supervisors will complete a review of the Case Management Policy with all Counselors, to include the requirement that individual counseling sessions must be completed at least every seven days. This training will be documented in a supervisory conference note.
Treatment Supervisors will each complete a minimum of 3 file reviews per month (total of 6 per dorm) to verify that individual counseling sessions are completed on time.
The Program Manager is responsible for oversight of this process. She will verify the Treatment Supervisors' chart reviews have been completed during monthly supervision and document in a supervisory conference note. The facility will be in full compliance with the standard by May 1, 2024.
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709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to ensure the client record included progress notes in four of seven records.
Client #1 admitted on October 16, 2023 and still a current client. Record of service indicated individual sessions on December 27, 2023 and January 24, 2024 which did not have corresponding progress notes. Additionally, the following progress notes were found in the client record but not indicated on the clients record of service: November 9, November 22, December 4, December 6, December 21, December 28, January 11, January 25, February 1, and a family session on February 1.
Client #2 admitted on August 7, 2023 and still a current client. The clients record of service indicated one individual session on October 12, 2023 but no individual progress notes were found in client record.
Client #4 admitted on September 29, 2023 and discharged October 23, 2023. Record of service indicated individual sessions on October 19, 2023 which did not have a corresponding progress note. Additionally, a progress note was found in the client record which was not indicated on the clients record of service for September 29, 2023.
Client #6 admitted on July 11, 2023 and discharged on November 22, 2023. Record of service indicated individual session on July 20, August 3, August 11, August 16, August 25, August 31, September 7, September 22, September 29, October 3, October 12, October 18, October 27, November 3, and November 17, 2023 but no individual progress notes were found in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Supervisors will complete a review of the Record Keeping Policy with all Counselors, to include the requirement that progress notes must be completed for each individual counseling session, documented on the Record of Service, and filed on time in the client file. This training will be documented in a supervisory conference note.
Treatment Supervisors will each complete a minimum of 3 file reviews per month (total of 6 per dorm) to verify that progress notes are completed and filed for individual counseling sessions and documented on the Record of Service.
The Program Manager is responsible for oversight of this process. She will verify the Treatment Supervisors' chart reviews have been completed during monthly supervision and document in a supervisory conference note. The facility will be in full compliance with the standard by May 1, 2024.
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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
Based on a review of client records, the facility failed to document case consultations in three of five applicable records.
The facility's policy and procedure manual states a case consultation must be completed quarterly.
Client #2 admitted on August 7, 2023 and still a current client. There were no case consultations documented in client record.
Client #3 admitted on October 2, 2023 and still a current client. There were no case consultations documented in client record.
Client #6 admitted on July 11, 2023 and discharged on November 22, 2023. There were no case consultations documented in client record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
By April 8, 2024, the Program Manager will review with Treatment Supervisors the policy and procedures for completing clients' quarterly treatment reviews and documenting Case Consultations. Treatment Supervisors will review this requirement, as well as the Treatment Review process, with the Counselors in their dorms.
By April 15, 2024, Treatment Supervisors will implement a tracking tool within their units to ensure that Treatment Reviews are completed, and Case Consultations are documented at least quarterly.
Treatment Supervisors will each complete a minimum of 3 file reviews per month (total of 6 per dorm) to verify Case Consultations are completed and filed at least quarterly.
The Program Manager is responsible for oversight of this process. She will verify the Treatment Supervisors' chart reviews have been completed during monthly supervision and findings and document in a supervisory conference. The facility will be in full compliance with the standard by May 1, 2024.
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