INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 18, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Bold Steps of PA 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(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 a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #2 was hired as a Clinical Supervisor on June 1, 2022 and was due to have the communicable disease trainings no later than June 1, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS training until July 7, 2023 and the TB/STD training until September 29, 2023.
Employee #4 was hired as a counselor on November 7, 2022 and was due to have the communicable disease trainings no later than November 7, 2023. There was no documentation in the personnel file of the completion of the TB/STD training until February 27, 2024.
Employee #7 was hired as a Counselor Assistant on February 22, 2023 and was due to have the communicable disease trainings no later than February 22, 2024. There was no documentation in the personnel file of the completion of the TB/STD training at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director, in cooperation with nurse practitioner, will create a training based on licensing alert 6-97 containing the content requirements for the Pennsylvania Department of Health Approved Tuberculosis and STD Curriculum. Executive Director will have medical staff provide the four hour training to all staff so it is completed within the regulated timeframe. Staff will be provided with a dated certificate when completed. Facility will be in compliance with this regulation by 8/27/2024. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment in fourteen out of fourteen client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Program Supervisor have corrected client rights in medical records system to include A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment. Executive Director will have client rights reviewed and signed by current clients. Facility will be in full compliance with regulation by 7/15/24. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including the project may not discriminate in the provision of services on the basis of ethnicity marital status, sexual orientation, handicap and religion in fourteen out of fourteen applicable client records.
These findings were reviewed with facility staff during the licensing
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Plan of Correction
Executive Director and Program Supervisor have corrected client rights in medical records system to include the project may not discriminate in the provision of services on the basis of ethnicity marital status, sexual orientation, handicap and religion. Executive Director will have client rights reviewed and signed by current clients. Facility will be in full compliance with regulation by 7/15/24. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including that Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record in fourteen out of fourteen applicable client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Program Supervisor have corrected client rights in medical records system to include Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. Executive Director will have client rights reviewed and signed by current clients. Facility will be in full compliance with regulation by 7/15/24. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including that Clients have the right to appeal a decision limiting access to their records to the director in fourteen out of fourteen applicable client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Program Supervisor have corrected client rights in medical records system to include Clients have the right to appeal a decision limiting access to their records to the director. Executive Director will have client rights reviewed and signed by current clients. Facility will be in full compliance with regulation by 7/15/24. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including that Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in fourteen out of fourteen applicable client records reviewed
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Program Supervisor have corrected client rights in medical records system to include Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. Executive Director will have client rights reviewed and signed by current clients. Facility will be in full compliance with regulation by 7/15/24. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including that Clients have the right to submit rebuttal data or memoranda to their own records in fourteen out of fourteen applicable client records reveiwed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Program Supervisor have corrected client rights in medical records system to include Clients have the right to submit rebuttal data or memoranda to their own records. Executive Director will have client rights reviewed and signed by current clients. Facility will be in full compliance with regulation by 7/15/24. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in seven out of seven client records reviewed.
Client #1 was admitted on May 20, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on May 20, 2024 with no type identified.
Client #2 was admitted on May 30, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 4, 2024 with no type identified.
Client #3 was admitted on June 4, 2024. A comprehensive treatment plan was developed on June 4, 2024 with no type identified.
Client #4 was admitted on April 19, 2024. A comprehensive treatment plan was developed on April 19, 2024 with no type identified.
Client #5 was admitted on November 10, 2023 and discharged February 28, 2024. A comprehensive treatment plan was developed on November 10, 2023 with no type identified.
Client #6 was admitted on April 9, 2024 and was discharged on May 13, 2024. A comprehensive treatment plan was developed on April 9, 2024 with no type identified.
Client #7 was admitted on February 19, 2024 and was discharged on May 1, 2024. A comprehensive treatment plan was developed February 19,2024 with no type identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Supervisor will train clinical staff to develop treatment plans with clients that include the type and frequency of treatment and rehabilitation services for PHP services. Program supervisor will document in clinician training plans that the training has been completed. Facility will be in full compliance with the regulation by 8/1/2024. |
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 a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in seven out of seven client records reviewed.
Client #10 was admitted on March 4, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on March 6, 2024 with no type identified.
Client #11 was admitted on April 19, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on April 23, 2024 with no type identified.
Client #12 was admitted on March 15, 2024. A comprehensive treatment plan was developed on March 18, 2024 with no type identified.
Client #13 was admitted on April 10, 2024. A comprehensive treatment plan was developed on April 11, 2024 with no type identified.
Client #14 was admitted on October 10, 2023 and discharged January 26, 2024. A comprehensive treatment plan was developed on October 13, 2023 with no type identified.
Client #15 was admitted on October 24, 2023 and was discharged on April 25, 2024. A comprehensive treatment plan was developed on October 24, 2023 with no type identified.
Client #16 was admitted on January 3, 2024 and was discharged on April 30, 2024. A comprehensive treatment plan was developed January 3, 2024 with no type identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Supervisor will train clinical staff to develop treatment plans with clients that include the type and frequency of treatment and rehabilitation services for OP services. Program supervisor will document in clinician training plans that the training has been completed. Facility will be in full compliance with the regulation by 8/1/2024. |