INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 3-4, 2022 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 Associates of Western Pennsylvania 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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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to prohibit heaters that are not permanently mounted or installed.A physical plant inspection was conducted on May 4, 2022. At the time of the physical plant inspection, portable heaters were observed in one counseling office and the director's office.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director will ensure that all non-permanently mounted/prohibited heaters are either removed or properly mounted by 6/20/22. Facility will be in full compliance by 7/11/22. Director will regularly inspect offices for adherence to this policy. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs, the facility failed to document alternate exit routes to be used during fire drills.The fire drills that were conducted between May 2021 to April 2022 were reviewed. Every fire drill conducted during that timeframe had "front/back" recorded as the exit route.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Alternative exit routes will be prepared and documented. Beginning by July 2022 Fire Drill these alternative exits will be used and documented. Director will enforce policy adherence. Facility will be in full compliance with this standard by 8/1/22. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs, the facility failed to document the annual testing of the fire system in lieu of setting off the fire alarm or smoke detector, as required by the approved DDAP exception.The facility has documentation for an exception for alternate methods of announcing fire drills. As required by this exception, the facility is required to maintain documentation the fire system is tested annually. There was no documentation of annual fire system testing.These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the May 28, 2021 annual licensing inspection.
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Plan of Correction
Director will acquire documentation regarding fire system testing. Fire system testing report/record will be obtained annually. Facility will be in full compliance with this standard by 9/1/22. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document consistent timeframes for the documentation of treatment plans.The policy and procedure manual contained three different timeframes for the completion of treatment plans - 15 days from first visit - 30 days from intake - by the third appointment.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the May 28, 2021 annual licensing inspection.
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Plan of Correction
The policy and procedure manual will contain one time frame for treatment plans for drug and alcohol service clients. Treatment plan reviews must occur at least every 60 days per PA Code 709.92.b. Editing of the policy and procedure manual will occur by 8/1/22 and Director is responsible person providing oversight. Director will follow up/review this policy with counselors by 8/31/22. Facility will be in full compliance with this standard by 8/31/22. |
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 the client record in one of four client records.Client record #4 had documentation of a letter sent to the courts dated February 9, 2022, with no corresponding signed release of information.These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the May 28, 2021 annual licensing inspection.
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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 properly signed". Director via QA will ensure counselor charts are audited for releases of information and that counselors will be trained on this policy. Director will follow up/review this policy with counselors by 6/20/22. Facility will be in full compliance with this standard by 8/31/22. |
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 the client records, the facility failed to document that each client was informed of the following client rights in three of four client records:Client records #1, 2 and 3 did not include documentation of client acknowledgment of the following client right: The project may not discriminate in the provision of services of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.Client #1 was admitted on November 23, 2021 and was still an active client at the time of the inspection.Client #2 was admitted on March 28, 2022 and was still an active client at the time of the inspection.Client #3 was admitted on November 10, 2021 and was discharged on March 18, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client rights document has been updated to include all DDAP's required client rights. Clients will be provided with these rights and will sign an acknowledgment that they received these rights and this will be placed in the client record. Chart audits will be completed to monitor compliance. The clinical supervisor or lead counselor will be responsible (once hired). The director will complete chart audits until that time. |
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 the client records, the facility failed to document that each client was informed of the following client rights in three of four client records:Client records #1, 2 and 3 did not include documentation of client acknowledgment of the following client right: 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.Client #1 was admitted on November 23, 2021 and was still an active client at the time of the inspection.Client #2 was admitted on March 28, 2022 and was still an active client at the time of the inspection.Client #3 was admitted on November 10, 2021 and was discharged on March 18, 2022.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the May 28, 2021 annual licensing inspection.
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Plan of Correction
The client rights document has been updated to include all DDAP's required client rights. Clients will be provided with these rights and will sign an acknowledgment that they received these rights and this will be placed in the client record. Chart audits will be completed to monitor compliance. The clinical supervisor or lead counselor will be responsible (once hired). The director will complete chart audits until that time. |
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 the client records, the facility failed to document that each client was informed of the following client rights in three of four client records:Client records #1, 2 and 3 did not include documentation of client acknowledgment of the following client right: Clients have the right to appeal a decision limited access to their records to the director.Client #1 was admitted on November 23, 2021 and was still an active client at the time of the inspection.Client #2 was admitted on March 28, 2022 and was still an active client at the time of the inspection.Client #3 was admitted on November 10, 2021 and was discharged on March 18, 2022.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the May 28, 2021 annual licensing inspection.
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Plan of Correction
The client rights document has been updated to include all DDAP's required client rights. Clients will be provided with these rights and will sign an acknowledgment that they received these rights and this will be placed in the client record. Chart audits will be completed to monitor compliance. The clinical supervisor or lead counselor will be responsible (once hired). The director will complete chart audits until that time. |
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 the client records, the facility failed to document that each client was informed of the following client rights in three of four client records:Client records #1, 2 and 3 did not include documentation of client acknowledgment of the following client right: Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.Client #1 was admitted on November 23, 2021 and was still an active client at the time of the inspection.Client #2 was admitted on March 28, 2022 and was still an active client at the time of the inspection.Client #3 was admitted on November 10, 2021 and was discharged on March 18, 2022.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the May 28, 2021 annual licensing inspection.
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Plan of Correction
The client rights document has been updated to include all DDAP's required client rights. Clients will be provided with these rights and will sign an acknowledgment that they received these rights and this will be placed in the client record. Chart audits will be completed to monitor compliance. The clinical supervisor or lead counselor will be responsible (once hired). The director will complete chart audits until that time. |
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 the client records, the facility failed to document that each client was informed of the following client rights in three of four client records:Client records #1, 2 and 3 did not include documentation of client acknowledgment of the following client right: Client have the right to submit rebuttal data or memoranda to their own records.Client #1 was admitted on November 23, 2021 and was still an active client at the time of the inspection.Client #2 was admitted on March 28, 2022 and was still an active client at the time of the inspection.Client #3 was admitted on November 10, 2021 and was discharged on March 18, 2022.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the May 28, 2021 annual licensing inspection.
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Plan of Correction
The client rights document has been updated to include all DDAP's required client rights. Clients will be provided with these rights and will sign an acknowledgment that they received these rights and this will be placed in the client record. Chart audits will be completed to monitor compliance. The clinical supervisor or lead counselor will be responsible (once hired). The director will complete chart audits until that time. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a procedure that addressed an event at the facility requiring the presence of police, fire or ambulance personnel.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy Number 5-16 contains policy and procedure regarding presence of police, fire, or ambulance personnel. Policy will be enforced by Director. Director will review policy with counselors by 8/1/22. |
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 disclose the criteria for admission, treatment methodology and requirements for the completion of treatment in four of four client records.Client records #1, 2, 3 and 4 did not include documentation of the disclosure of the 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 28, 2021 annual licensing inspection.
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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. Director will ensure this policy is disclosed to client. Facility will be in full compliance by 8/1/22. Chart audits will be completed to monitor compliance. The clinical supervisor or lead counselor will be responsible (once hired). The director will complete chart audit until that time. |
709.91(b)(2)(iv) 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:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to provide clients with orientation to the project which included services provided in four of four client records.Client records #1, 2, 3 and 4 did not include documentation of client orientation which included services provided.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each client will be provided details will be provided with orientation to the project which contains services provided Clients will sign an acknowledgement form that will be placed in the record. Director will ensure this policy is disclosed to client. Facility will be in full compliance by 8/1/22. Chart audits will be completed to monitor compliance. The clinical supervisor or lead counselor will be responsible (once hired). The director will complete chart audit until that time. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan with the client in one of three applicable client records.Client #4 was admitted on June 30, 2021 and discharged on October 1, 2021. The treatment plan was signed by the client on October 6, 2021 and the therapist on October 7, 2021. The treatment plan was signed after the client's discharge. There was no treatment plan developed during the entire treatment episode.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plans will be developed with clients by the 3rd session. Chart audits will be completed to monitor compliance. The clinical supervisor or lead counselor will be responsible (once hired). The director will complete chart audits until that time. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the treatment plan in one of three applicable client records.Client #4 was admitted on June 30, 2021 and discharged on October 1, 2021. The sole treatment plan was signed by the client on October 6, 2021 and the therapist on October 7, 2021. This treatment plan did not include documentation of proposed type of support services.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plans will be developed with clients by the 3rd session. Treatment plans will contained the proposed type of support service. Chart audits will be completed to monitor compliance. The clinical supervisor or lead counselor will be responsible (once hired). The director will complete chart audits until that time. |
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 document that treatment plans were reviewed and updated at least every 60 days in one of two client records. Client #3 was admitted on November 10, 2021 and discharged on March 18, 2022. A treatment plan was completed on December 29, 2021. A treatment plan review/update was due to be completed by February 28, 2022. The treatment plan review/update was signed by the counselor on April 20, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plans will be developed with clients by the 3rd session. Treatment plans will be reviewed and updated at least every 60 days. Chart audits will be completed to monitor compliance. The clinical supervisor or lead counselor will be responsible (once hired). The director will complete chart audits until that time. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete record of service in two of four client records.Client #3 was admitted on November 10, 2021 and discharged on March 18, 2022. Client #3 had notes documented for January 18 and February 1, 2022; however, they were not documented on the record of service.Client #4 was admitted on June 30, 2021 and discharged on October 1, 2021. The record of service documented in client record #4 was blank.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the May 28, 2021 annual licensing inspection.
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Plan of Correction
A record of service will be documented in the client chart. Chart audits will be completed to monitor compliance. The clinical supervisor or lead counselor will be responsible (once hired). The director will complete chart audits until that time. |
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 document an aftercare plan in one of two applicable client records.Client #4 was admitted on June 30, 2021 and successfully discharged on October 1, 2021. There was no documentation of an aftercare plan in client record #4.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An aftercare plan will be documented in the client chart for those clients who are successfully discharged. Chart audits will be completed to monitor compliance. The clinical supervisor or lead counselor will be responsible (once hired). The director will complete chart audits until that time. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary, per agency policy of 4 weeks from inactivity or the final session, in one of two applicable client records.Client #4 was admitted on June 30, 2021 and successfully discharged on October 1, 2021. Client #4's last session was also on October 1, 2021. The discharge summary that was documented was dated April 23, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A discharge summary will be documented in all discharged client charts. Chart audits will be completed to monitor compliance. The clinical supervisor or lead counselor will be responsible (once hired). The director will complete chart audits until that time. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up contact in two of two client records.Client #3 was admitted on November 10, 2021 and discharged on March 18, 2022. There was no follow up documented in client record #3.Client #4 was admitted on June 30, 2021 and discharged on October 1, 2021. There was no follow up documented in client record #4.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up will be documented in all discharged client charts within 7-10 days post-discharge. Chart audits will be completed to monitor compliance. The clinical supervisor or lead counselor will be responsible (once hired). The director will complete chart audits until that time. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a clear, written client follow up policy.There were three conflicting timeframes for client follow up contained in policy. The following timeframes were documented: 4 weeks, 15 business days and 30 days.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The follow up policy has been updated to indicate a follow-up timeframe of 7-10 days post-discharge. Director will review and approve policies on an annual basis. |