INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10-11, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Adult and Teen Challenge 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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704.9(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.
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Observations
Based on a review personnel records, the facility failed to ensure counselor assistants received direct observation under the supervision of a trained counselor or clinical supervisor based on their education in one counsel assistant's personnel record.
Employee #9 was hired as a counselor assistant on November 8, 2021. Employee #9 was hired with a high school diploma and received a bachelor's degree on December 18, 2021. The facility failed to provide direct observation from November 8, 2021 until December 18, 2021.
This finding was reviewed with the facility staff during the inspection process.
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Plan of Correction
L0049 Director of Counseling Services reviewed requirements of supervision of a counselor assistant with clinical supervisor on April 6, 2022. Director and Supervisor will identify any Counselor Assistant in the future and review requirements for each new counselor assistant as they begin employment |
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 (SRFSR) form, the facility failed to ensure that Employee #8 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 #8 was hired on October 1, 2018 and promoted to a counselor on May 1, 2020 and was due to have the communicable disease training no later than May 1, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
This is a repeat citation from the annual inspection on June 25, 2021.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
L0067 All counselors including the counselor identified in the deficiency have now attended and completed HIV/AIDS and TB/STD trainings on March 16, 2022 (scheduled prior to DDAP audit). Director reviewed training requirements with Clinical Supervisor on March 30, 2022. On the week of April 11, 2022, Clinical Supervisor completed an audit of all training records, and scheduled any outstanding trainings for counselors for the current training year. Quality Assurance department has scheduled quarterly meetings to follow up and ensure that trainings are being completed ongoing. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of twelve clock hours of annual training required for clinical supervisors in employee #3's file.
Employee #3 was promoted to a clinical supervisor on February 1, 2020 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2020 to June 30, 2021. Employee #3's employee record did not document any annual trainings for the training year reviewed.
These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
L0079 Clinical Supervisor has completed trainings for current training year. On March 30, 2022, Director met with Clinical Supervisor and reviewed training requirements. Quality Assurance Department has scheduled quarterly meetings to review progress on trainings and ensure that trainings are completed ongoing throughout the year. |
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 the Staffing Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of twenty-five clock hours of annual training required for counselors in employee #8's employee file.
Employee #8 was promoted to a counselor on May 1, 2020 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2020 to June 30, 2021. Employee #8's employee record did not document any annual trainings for the training year reviewed.
This finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
L0083 This counselor has completed all trainings for the current training year. Director reviewed training requirements with Clinical Supervisor on March 30, 2022. On the week of April 11, 2022, Clinical Supervisor completed an audit of all training records, and scheduled any outstanding trainings for counselors for the current training year. Quality Assurance department has scheduled quarterly meetings to follow up and ensure that trainings are being completed ongoing. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of June 2021- January 2022 fire drill logs, the facility failed to include documentation of whether the fire alarm or smoke detector was operative on all logs.
These findings were reviewed with the facility staff during the licensing inspection.
This is a repeat citation from the annual inspection conducted on June 25, 2021.
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Plan of Correction
P279 On 03//15/2022 the Director of Quality Assurance updated the Fire Drill Log forms to require information related to whether smoke directors and/or fire alarms were working during the time of the drill. The Director of Quality Assurance will audit the fire drill logs quarterly to ensure compliance with regulatory standards and internal policies. |
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 a completed consent to release information in one out of seven records reviewed, as there were forms that were missing required information.
Client #4 was admitted on June 1, 2021 and was still active at the time of the inspection. There was a consent to release form, signed and dated on June 1, 2021 to emergency services; however the consent form did not include the purpose of disclosure.
This finding was reviewed with the facility during the licensing inspection.
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Plan of Correction
L0281 Clinical Supervisor will conduct monthly chart audits to ensure the Authorization to Release Information forms are completed according to regulatory standards and internal policies. Clinical Supervisor and Director will monitor trends in chart audit results and will address with counselors in individual supervision. Training with counselors completed on April 1 2022, reviewing requirements for Authorizations to Release Information . A chart review at the time of this Plan of Correction shows that the Authorization to Release Information has been updated to include the missing items. |
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 a completed consent to release information in one out of seven records reviewed, as there were forms that were missing required information.
Client #4 was admitted on June 1, 2021 and was still active at the time of the inspection. There was a consent to release form, signed and dated on June 1, 2021 to emergency services; however the consent form did not include documentation that a copy was offered to the client.
This is a repeat citation from the annual inspection conducted on October 1, 2020 and the annual inspection conducted on June 25, 2021.
This finding was reviewed with the facility during the licensing inspection.
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Plan of Correction
A0289 Clinical Supervisor will conduct monthly audits of all charts to ensure the Authorization to Release Information forms are completed according to regulatory standards and internal policies. Clinical Supervisor and Director will monitor trends in chart audit results and will address with counselors in individual supervision. Director of Counseling Services completed Training with counselors on April 1 2022, reviewing requirements for Authorizations to Release Information. A chart review at the time of this Plan of Correction shows that the Authorization to Release Information has been updated to include the missing items. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations according to the facility's written policy and procedure manual in the cases of Client #4, #5, and #7. The facility's policy manual indicated that case consults would be documented with the client's treatment plan updates every 60 days or less.
Client #4 was admitted on June 1, 2021 and was still active at the time of the inspection. Client #4 had a case consultation on June 24, 20221 and the next case consultation was due no later than August 24, 2021; however the case consultation was completed on December 1, 2021.
Client #5 was admitted on June 8, 2021 and was still active at the time of the inspection. Client #5 had a case consultation completed on August 12, 2021 and the next case consultation was due no later than October 12, 2021; however the case consultation was completed on December 27, 2021.
Client #7 was admitted on September 7, 2021 and was still active at the time of the inspection. Client #7 had a case consultation on October 18, 2021 and the next case consultation was due no later than December 18, 2021; however the case consultation was completed on January 21, 2022.
These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
I1905 Clinical Supervisor will conduct monthly chart audits to ensure case consultations are completed in 60 days or less as outlined by regulatory standards and internal policies. Director of Counseling Services completed Training with counselors on April 1 2022, reviewing requirements for Case Consultation. |
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 provide a discharge summary in two out of three applicable records reviewed.
Client #2 was admitted on August 13, 2021 and was discharged on January 15, 2022. The client record did not contain documentation of a discharge summary.
Client #3 was admitted on August 22, 2021 and was discharged on December 1, 2021. The client record did not contain documentation of a discharge summary.
These findings were reviewed with the facility during the licensing inspection.
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Plan of Correction
LI909 Clinical Supervisor will conduct monthly chart audits to ensure Discharge Summaries are completed in accordance with regulatory standards and internal policies. Director of Counseling Services completed Training with counselors on April 1, 2022, reviewing requirements for Discharge Summaries. A chart review at the time of this Plan of Correction shows that the Discharge Summaries that were missing have been completed. |
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 the plans of correction approved by the Department. A plan of correction was submitted to the Department for inspections occurring on October 1, 2020 and June 25, 2021, addressing the requirement to document offering a client a copy of their consent to release information form. A copy of a client consent to release information form shall be offered to the client and a copy maintained in the client record was found again to be deficient in the March 11, 2022 licensing inspection.
This finding was reviewed with staff during the licensing inspection process.
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Plan of Correction
A040 Clinical Supervisor will conduct monthly chart audits to ensure the Authorization to Release Information forms are completed according to regulatory standards and internal policies. Clinical Supervisor and Director will monitor trends in chart audit results and will address with counselors in individual supervision. Training with counselors completed on April 1 2022, reviewing requirements for Authorizations to Release Information. |