INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 8, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, KARE Services, LLC dba Kolmac Outpatient Recovery 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(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors and lead counselors, who have not functioned for 2 years as a supervisor in the provision of clinical services, completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed.
Employee #3 was promoted to a lead counselor on March 31, 2020 and did not have clinical supervision experience prior to being promoted. There was no documentation of the clinical supervision core curriculum training on file at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical director will oversee and ensure that all required training is completed within one (1) calendar year in order to be compliant with the Department's requirements. The HR specialist will act as second personnel to confirm the process has been completed within the one-year's timeframe. The clinical director will work with the staff to ensure that all required training has been signed up for and completed within the one-year time frame.
The employees will complete the required training within one (1) calendar year.
The employees will complete the required training within one (1) calendar year. |
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 provide documentation of an individual training plan, developed with input from both the employee and the supervisor, in two of five applicable employees reviewed.
Employee # 1 was hired as the Project Director on August 3, 2020. The annual individual training plan was not completed as of the date of the inspection.
Employee #2 was hired as the Facility Director on March 27, 2021. The annual individual training plan was not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The person responsible for ensuring this process will take place is the Regional Director.
To prevent this from recurring, at hire, the Regional Director will complete all training plans for new employees at the director level within 14 business days.
At hire, the Clinical Director will complete all training plans for new employees within 14 business days. The Regional Director will review and verify all plans have been completed within 14 business days.
Any outstanding training plans will be completed within the next 60 days. For employees that are no longer with the agency, any outstanding plans will remain in their current form. |
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 personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training during the facility's January 1, 2020 through December 31, 2020 training year in one of one applicable personnel records reviewed.
Employee #4 was hired as a counselor on September 23, 2019. The personnel record documented 12 hours of training.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A new compliance portal is being introduced starting in 2022 and employees will be trained to utilize this system. The LMS system within the portal will be tracking ongoing training hours completed throughout the year. Supervisors will utilize this platform to verify that training is on track to be completed by the end of the year. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguishers upon employment in two of five personnel records reviewed.
Employee #1 was hired as the Project Director on August 3, 2020. The fire extinguisher training was not documented as of the date of the inspection.
Employee #2 was hired as the Facility Director on March 27, 2021. The fire extinguisher training was not documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The office manager is responsible for completing the training with new employees and documenting that the training has been successfully completed. The human resource specialist will verify all training has been completed within 60 days of hire.
In deficient employee files, the office manager will schedule and complete the training with the employees within the next 60 days.
We will be utilizing the Workforce ADP system starting next year and that system will be used to ensure that new employees are trained properly at hire in the use of fire extinguishers. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on review of the facility's November 2020 through August 2021 fire drill logs, the facility failed to conduct unannounced fire drills for the months of November 2020, December 2020, as well as January 2021 through August 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A new compliance portal is being introduced starting in 2022 and employees will be trained to utilize this system. The audit system within the portal will be tracking ongoing drills completed throughout the year. Supervisors will utilize this platform to verify that audits are on track to be completed each month.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel are trained to perform assigned tasks during emergencies in two of five employees reviewed.
Employee #1 was hired as the Project Director on August 3, 2020. The emergency preparedness training was not documented as of the date of the inspection.
Employee #2 was hired as the Facility Director on March 27, 2021. The emergency preparedness training was not documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The office manager is responsible for completing the training with new employees and documenting that the training has been successfully completed. The human resource specialist will verify all training has been completed within 60 days of hire.
In deficient employee files, the office manager will schedule and complete the training with the employees within the next 60 days.
A new compliance portal is being introduced starting in 2022 and employees will be trained to utilize this system. The audit system within the portal will be tracking ongoing drills completed throughout the year. Supervisors will utilize this platform to verify that audits are on track to be completed each month.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to provide documentation that an annual written individual staff performance evaluation was reviewed and signed by the employee in one of four applicable personnel records reviewed.
Employee #1 was hired as the Project Director on August 3, 2020. The annual performance evaluation for 2020 was present in the record, but the evaluation was not signed by the employee at the time of the inspection.
Employee #4 was hired as a counselor on September 23, 2019. The annual performance evaluation for 2020 was present in the record, but the evaluation was not signed by the employee at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
We will be utilizing the Workforce ADP system starting next year and that system will be used to ensure that employees are provided yearly written annual staff performance evaluations. The system software will track and monitor evaluation deadlines and report needed evaluations to supervisors. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in one of seven client records reviewed.
Client #1 was admitted on May 28, 2021 and was active at the time of inspection. A release of information form to an emergency contact was signed and dated by the client on May 28, 2021 and the form did not indicate the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To correct the deficiency, the office manager will contact the client and complete a revised ROI within the next 30 days.
In Mid-October of 2021, we will be switching to a new electronic health record that will manage this process more closely. The implementation date of the new EHR will be 10/15/21. In addition, the clinical director will address this issue in a staff meeting to reinforce the importance of completing the consent. |
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 the purpose of disclosure on consent to release information forms in three of seven client records reviewed.
Client #5 was admitted on April 23, 2021 and was discharged on May 24, 2021. Release of information forms to the funding source and a pharmacy were signed and dated by the client on April 29, 2021 and neither form indicated the purpose of disclosure.
Client #6 was admitted on April 30, 2021 and was discharged on May 26, 2021. A release of information form to the primary care physician was signed and dated by the client on April 30, 2021 and the form did not indicate the purpose of disclosure.
Client #7 was admitted on May 28, 2021 and was discharged on July 13, 2021. A release of information form to another treatment provider was signed and dated by the client on May 27, 2021 and the form did not indicate the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In Mid-October of 2021, we will be switching to a new electronic health record that will manage this process more closely. The implementation date of the new EHR will be 10/15/21. In addition, the clinical director will address this issue in a staff meeting to reinforce the importance of completing the consent.
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document a dated the signature of witness on release of information forms in five of seven client records reviewed.
Client #2 was admitted on July 12, 2021 and was active at the time of inspection. There was a release of information form to a pharmacy, signed by the client on July 12, 2021. However, the signature of the witness was dated July 9, 2021, which was prior to the client's dated signature.
Client #3 was admitted on July 28, 2021 and was active at the time of inspection. There were release of information forms to a pharmacy, a funding source, and an emergency contact, all signed by the client on July 28, 2021. However, the signature of the witnesses on all the forms was dated July 27, 2021, which was prior to the client's dated signature.
Client #5 was admitted on April 23, 2021 and was discharged on May 24, 2021. There were release of information forms to a pharmacy and a funding source, both signed by the client on April 29, 2021. However, the signature of the witnesses on both forms was dated April 22, 2021, which was prior to the client's dated signature.
Client #6 was admitted on April 30, 2021 and was discharged on May 26, 2021. There were release of information forms to an emergency contact and a funding source, both signed by the client on April 30, 2021. However, neither form documented the dated signature of a witness.
Client #7 was admitted on May 28, 2021 and was discharged on July 13, 2021. There were release of information forms to an emergency contact, another treatment provider, a pharmacy, and a funding source, all signed by the client on May 27, 2021. However, the signature of the witnesses on all of the forms were all dated May 26, 2021, which was prior to the client's signatures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The office manager will correct the deficiency by contacting active clients and resubmitting the corrected form by the end of the next 30 days.
The facility has corrected the form in DocuSign and will use the new form going forward. The office manager will train all staff within the next 30 days and at hire on the process of filling out a complete ROI.
We corrected this by amending the signature order utilized in DocuSign to ensure that the client signs the ROI prior to the witness. |
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.
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Observations
Based on a review of client records, the facility failed to document that a copy of client consent to release forms were offered to the client in five of seven client records reviewed.
Client #1 was admitted on May 28, 2021 and was active at the time of inspection. A release of information form to an emergency contact, signed and dated by the client on May 28, 2021, did not include documentation that a copy was offered to the client.
Client #2 was admitted on July 12, 2021 and was active at the time of inspection. A release of information form to an emergency contact, signed and dated by the client on July 12, 2021, did not include documentation that a copy was offered to the client.
Client #3 was admitted on July 28, 2021 and was active at the time of inspection. A release of information form to an emergency contact, signed and dated by the client on August 2, 2021, did not include documentation that a copy was offered to the client.
Client #6 was admitted on April 30, 2021 and was discharged on May 26, 2021. A release of information form to an emergency contact, signed and dated by the client on April 30, 2021, did not include documentation that a copy was offered to the client.
Client #7 was admitted on May 28, 2021 and was discharged on July 13, 2021. There were release of information forms to an emergency contact and another treatment provider, both signed on May 27, 2021, that did not include documentation that copies were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The office manager will correct the deficiency by contacting active clients and resubmitting the corrected form by the end of the next 30 days.
The facility has corrected the form in DocuSign and will use the new form going forward. The office manager will train all staff within the next 30 days and at hire on the process of filling out a complete consent.
We have corrected this by amending the document version in DocuSign to ensure that the client is given the corrected form with the language indicated in the observation.
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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 a maintain a complete client record on an individual, which is to include follow-up information, in four of four applicable client records reviewed.
Client #4 was admitted on June 9, 2021 and was discharged on August 4, 2021.
Client #5 was admitted on April 23, 2021 and was discharged on May 24, 2021.
Client #6 was admitted on April 30, 2021 and was discharged on May 26, 2021
Client #7 was admitted on May 28, 2021 and was discharged on July 13, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new compliance portal is being introduced starting in 2022 and employees will be trained to utilize this system. The audit system within the portal will be tracking follow-ups completed throughout the required 30/60/90 days intervals. Supervisors will utilize this platform to verify that contacts are on track to be completed each month.
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