INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 5, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Christian Counseling of Western Pennsylvania 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of staff records, the facility failed to provide documentation that clinical supervisors participated in monthly meetings with their supervisors to discuss their duties and performance for the first six months of employment in that position in one of one record.
Staff #2 was promoted to Clinical Supervisor February 7, 2023. No monthly meeting between the clinical Supervisor and their supervisor were documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning July 1, 2023, the Clinical Supervisor's Supervisor will document monthly meetings with Clinical Supervisor. Also, Supervisor of Clinical Supervisor will provide an overall summary of Clinical Supervisor's performance and competence, strengths and weaknesses, at the end of the six month period. |
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 staff records, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in two of five records.
Staff #1 was hired as the project director on August 12, 2020 and is still in the position. The HIV/AIDS and TB/STD training was due to be completed within the first two years of employment, by August 12, 2022. Staff #1 had completed HIV/AIDS training on March 30, 2023, and TB/STD training on March 31, 2023.
Staff #4 was hired as a counselor on May 12, 2021 and is still in the position. The HIV/AIDS and TB/STD training was due to be completed within the first year of employment, by May 12, 2022. Staff #4 record did not contain documentation of a completed TB/STD training at time of review.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #4 will complete TB/STD training by 7/1/2023. Clinical Supervisor will follow up with Staff #4 to ensure this training is completed. |
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 staff records, the facility failed to ensure that each counselor complete at least 25 clock hours of training annually in one of three records.
Staff #4 was hired to the position of counselor on May 12, 2021. At the time of review, staff #4 had documentation for only 5.75 hours of training during the facilities training year spanning January 1, 2022 through December 31, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will provide training recommendations and will review the standards from Chapter 704 f (2) of the PA Code by 7/1/23. Clinical Supervisor will ask monthly in Group Supervision about the Counselors progress on training hours. Clinical Supervisor will also have Counselors track their training hours in a shareable document. Clinical Supervisor will complete an After Action Review with Counselor focusing on the failure to obtain required training hours to prevent repeating the failure. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on an inspection of the facility, the facility failed to ensure all fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
Upon inspection of the facility ' s fire extinguishers, the fire extinguisher located outside of the director ' s office was found to have been last inspected in August of 2021. This fire extinguisher was due to be re-inspected by August of 2022, but failed to be inspected by this date.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will assess why the fire extinguishers were not inspected and approved by due date. Clinical Supervisor will ensure fire extinguishers are re-inspected by 8/1/23. Facility will create a repeating reminder in June to schedule fire extinguisher inspection. Clinical Director follow up with Clinical Supervisor during Quarterly Meeting regarding inspection status of fire extinguishers. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative information, the facility failed to provide an annual report for 2022 which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
Facility staff confirmed that an annual report had not been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will ensure that an annual report is submitted at the next DDAP Inspection. This report will be for the 2023 year. Clinical Supervisor will add the Annual Report to the agenda for our annual DDAP Inspection Preparation Meeting. |
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 a review of administrative information, the project failed to 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 for the year of 2022, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
Facility staff confirmed that a financial audit had not been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will complete a financial audit for 2023. Clinical Supervisor will add Financial Audit to to the agenda for annual DDAP Inspection Preparation Meeting. Clinical Supervisor will meet with Clinical Director to discover any barriers or problems with obtaining financial audit. |
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 an informed and voluntary consent from the client for the disclosure of information contained in two of six client records.
Client # 4 was admitted January 23, 2023 and was active at time of review. The client record did not contain an informed and voluntary consent from the client for the disclosure of information for the client ' s funder. The facility staff confirmed billing had been occurring since admission.
Client # 6 was admitted September 13, 2022 and was discharged April 4, 2023. The client record did not contain an informed and voluntary consent from the client for the disclosure of information for the client ' s funder. The facility staff confirmed billing had occurred throughout the client ' s treatment.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 4, 2022 and May 28, 2021 annual licensing renewal inspections.
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Plan of Correction
Counselor will provide evidence of auditing his/her own charts by using some form of a Client Chart Checklist. This checklist will include a section/item/line called: "Necessary releases properly completed and signed". Clinical Supervisor will ensure counselor charts are audited for releases of information and that counselors will be trained on this policy. Clinical Supervisor will follow up/review this policy with counselors by 6/12/23. Facility will be in full compliance with this standard by 6/12/23. |
709.91(b)(1) LICENSURE Intake and admission
709.91. 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 provide documentation of disclosure to the client of criteria for admission, treatment, completion and discharge in five of seven client records.
Client #1 was admitted February 13, 2023 and was active at the time of review. Client record did not contain documentation of disclosure to the client of criteria for admission, treatment, completion and discharge.
Client #3 was admitted January 12, 2023 and was active at the time of review. Client record did not contain documentation of disclosure to the client of criteria for admission, treatment, completion and discharge.
Client #4 was admitted January 23, 2023 and was active at the time of review. Client record did not contain documentation of disclosure to the client of criteria for admission, treatment, completion and discharge.
Client #5 was admitted December 7, 2022 and was active at the time of review. Client record did not contain documentation of disclosure to the client of criteria for admission, treatment, completion and discharge.
Client #6 was admitted September 13, 2023 and was discharged April 4, 2023. Client record did not contain documentation of disclosure to the client of criteria for admission, treatment, completion and discharge.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 4, 2022 and May 28, 2021 annual licensing renewal inspections.
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Plan of Correction
Each client will be provided details about admission, treatment, completion, and discharge. Clients will sign an acknowledgement form that will be placed in the record. Clinical Supervisor will ensure compliance. Facility will be in full compliance by 6/1/23. Chart audits will be completed monthly by Clinical Supervisor to monitor compliance. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to provide documentation of client orientation to the project in five of seven records.
Client #1 was admitted February 13, 2023 and was active at the time of review. Client record did not contain documentation of client orientation.
Client #3 was admitted January 12, 2023 and was active at the time of review. Client record did not contain documentation of client orientation.
Client #4 was admitted January 23, 2023 and was active at the time of review. Client record did not contain documentation of client orientation.
Client #5 was admitted December 7, 2022 and was active at the time of review. Client record did not contain documentation of client orientation.
Client #6 was admitted September 13, 2023 and was discharged April 4, 2023. Client record did not contain documentation of client orientation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will conduct monthly chart audits. Chart audits will be done on current clients to ensure these current clients have been oriented to the program. Facility will be in full compliance by 7/1/2023. The orientation of client to the project will be documented in the client chart/record and confirmed by client signature. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide an aftercare plan in one of one record.
Client #7 was admitted August 3, 2022 and was successfully discharged December 8, 2022. The client record did not contain an aftercare plan.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 4, 2022 annual licensing renewal inspection.
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Plan of Correction
Clinical Supervisor will conduct monthly chart audits. Clinical Supervisor will conduct an after action review with all Counselors to discover the Counselor's current level of knowledge, skills, and abilities relative to Aftercare Planning. This review will occur during Group Supervision and will happen by 7/1/2023. Aftercare Plan will be completed and documented in client chart/record prior to Discharge. The Counselor Chart Checklist includes Aftercare Plan and this Checklist will be submitted to Clinical Supervisor. Employee Performance Improvement Plan will be implemented if Aftercare Plans are missing. |
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.
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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 an informed and voluntary consent was submitted and approved by the Department for the May 28, 2021 and May 4, 2022 annual licensing inspections. Informed and voluntary consent forms were again found to be a deficiency in the April 5, 2023 licensing inspection.
A plan of correction for documentation of disclosure to the client of criteria for admission, treatment, completion and discharge was submitted and approved by the Department for the May 28, 2021 and May 4, 2022 annual licensing inspections. Documentation of disclosure to the client of criteria for admission, treatment, completion and discharge was again found to be a deficiency in the April 5, 2023, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will conduct monthly chart/record audits. Counselor will submit Chart Audit Checklist on a monthly basis. Employee Performance Plan will be implemented if Informed and Voluntary Consent Forms or Admission, Treatment, Completion, and Discharge criteria Forms are discovered during monthly Chart Audits. |