INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 12, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Treatment Trends, 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:
|
Plan of Correction
|
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on a review of personnel records, the facility failed to ensure that two out of three counselor assistants were counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #5 was hired on September 8, 2022 as a counselor assistant and is still current in that position. Employee # 5 has a high school diploma and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Employee #5 did not receive close supervision the weeks of January 16, 23, 30, February 6, 20, 27, April 3, 7, and 10th, 2023. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . During documented supervision there was only direct observation documented on March 1, 17, May 9, 23 and June 22, 2023.
Employee #7 was hired on August 29, 2023 as a counselor assistant and is current in that position. Employee #7 has a bachelor ' s degree with nine months of previous experience. Employee #7 may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first six months of employment. Employee #7 did not receive close supervision the week of September 25, 2023. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . During documented supervision there was only direct observation documented on October 25 and November 1, 2023.
This is a repeat citation from the January 6, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
To ensure compliance with supervision of a counselor assistant, Quality Assurance Coordinator on 1/12/24 sent out an email of the DDAP Licensing Alert 4-02 to the Clinical Supervisors and Program Directors. This licensing alert will be addressed with Program Directors and Clinical Supervisors in their supervisions by 2/29/24. In order to fulfill the documentation of close supervision of a counselor assistant, a spot on TTI's supervision notes has been added, labeled "Direct Observation". New Supervision notes were sent out on 1/12/24, with the same implementation date. Based on counselor assistant's level of education and experience, clinical supervisor will create a direct observation plan within the first two weeks of hire date. An expected end date for direct observation will be documented on each supervision note. Clinical Supervisor will share direct observation plan in supervision with Program Director. |
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.
|
Observations
Based on a review of the personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level in two out seven employee records reviewed.
Employee #5 was hired on September 8, 2022 as a counselor and was still in the position as of the date of the inspection. The individual training plan in the record was dated November 23, 2022.
Employee #7 was hired on August 29, 2023 as a counselor assistant and was still in the position as of the date of the inspection. There was no documented individual training plan in the record.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
To ensure compliance with developing Training Plans for all future employees, each employee will develop a training plan on their second day of hire with Director of Training & Development effective 01/08/24. Employee #5 training plan will be developed by 2/29/24. Employee #7 training plan will be developed by 2/29/24. The plans will be developed by the Clinical Supervisor. The Program Director is responsible to ensure that all employees have a training plan in their personnel record. |
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).
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which included the dated signature of the client in four out of seven records reviewed.
Client # 4 was admitted on March 16, 2023 and discharged on April 17, 2023. The client record contained a release of information form to a drug and alcohol facility dated April 5, 2023, that did not include the dated signature of the client. The release had " verbal consent " written on the form and the facility acknowledged disclosure was made.
Client #5 was admitted on January 10, 2023 and was discharged on March 22, 2023. The client record contained a release of information form to a funding source that was dated February 17, 2023 and a release of information form to a drug and alcohol facility dated March 15, 2023 that did not include the dated signature of the client. The release had " verbal consent " written on the form and the facility acknowledged disclosure was made.
Client #6 was admitted on April 17, 2023 and discharged on May 30, 2023. The client record contained a release of information form for a drug and alcohol facility and a mental health facility that were dated May 23, 2023, that did not include the dated signature of the client. The releases had " verbal consent " written on the forms and the facility acknowledged disclosure was made.
Client #7 was admitted on June 5, 2023 and discharged on July 11, 2023. The client record contained a release of information to a medical provider that was dated July 5, 2023 that did not include the dated signature of the client. The release had " verbal consent " written on the form and the facility acknowledged disclosure was made.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
To ensure compliance of voluntary consent with client's signature, all staff will utilize the signatures pads purchased for our EMR. In the event that a signature pad is not available or is not working, the staff member will print out the consent/release of information and have the client physically sign it. The signed consent will then be uploaded in the client's EMR. All staff were informed on 01/17/24 with the same effective date. All documents divert to a supervisor for review in the EMR; that supervisor is responsible to ensure that the client signature is present on each relevant document in the record. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in seven out of seven client records reviewed.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
To address this deficiency, the Quality Assurance Coordinator will alter the electronic releases of information to include an area that illustrates that clients are offered a copy of this documentation at time of signature and upon request. The Quality Assurance Coordinator will submit these amendments to the contracted electronic medical record (EMR) company utilized by the facility. This submission will occur within 30 days. Until this submission request is completed by the EMR platform development team, staff will write a note in the client's chart indicating that copies of the signed releases of information were offered to the client at the time of signature. All work is diverted to a supervisor who is responsible to ensure that copies were offered to the client. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility failed to complete treatment plans within the regulatory timeframe in four out of six applicable records reviewed.
Client #1 was admitted on December 5, 2023 and was still active at the time of the inspection. A treatment plan was completed on December 6, 2023. The next treatment plan update was due no later than January 6, 2024; however, it was not completed until January 8, 2024.
Client #3 was admitted on November 30, 2023 and was still active at the time of the inspection. A treatment plan was completed on December 1, 2023. The next treatment plan update was due no later than January 1, 2024; however, it was not completed until January 3, 2024.
Client #5 was admitted on January 10, 2023 and discharged on March 22, 2023. A treatment plan was completed on January 13, 2023. The next update was due no later than February 13, 2023; however, it was not completed until February 16, 2023.
Client #6 was admitted on April 17, 2023 and discharged on May 30, 2023. A treatment plan was completed on April 20, 2023. The next update was due no later than May 20, 2023; however, it was not completed until May 23, 2023.
This is a repeat citation from the January 27, 2022 and January 6, 2023 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
To ensure that treatment plan updates are completed within the regulatory timeframe, the counselor will utilize their Outlook and EMR calendars to set reminders of due dates; this will be created in their supervisions by 2/29/24. The weekly staff meeting agenda will be altered, by 2/29/24, to reflect the due dates of treatment plans. Counselors will bring their caseload treatment plan initial and update data to the weekly staff meeting to present during that time. The Clinical Supervisor will also review this data during supervision and is to ensure that the plan of correction is being followed. |
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.
|
Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting treatment plan updates was submitted and approved by the Department for the January 27, 2022 and January 6, 2023 annual licensing inspections. Completing and documenting treatment plan updates was again found to be a deficiency on the January 12, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
It is the responsibility of the Program Director to ensure that the facility is following the plans of corrections. A section of the weekly staff meeting agenda will be revised to include an area addressing compliance with plans of correction; revision due by 2/29/24. During the monthly supervision of the Program Director, with the Associate and Executive Directors, the Program Director will provide updates on compliance with all plans of correction. |