INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 19, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Counseling and Adoption Services, Inc. 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:
|
Plan of Correction
|
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.
|
Observations
Based on a physical plant inspection, the facility failed to ensure there were no heaters that were not permanently mounted or installed in the facility outpatient building. Specifically, two space heaters were discovered in counselor offices and a surplus of space heaters found in the basement.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All auxiliary(space) heaters have been removed from the facility effective 3/27/24. In addition HVAC personnel were requested to come to the facility and make recommendations regarding adequacy of heating, for all areas of the building.
All CCCAS employees have been notified that space heaters are not to be utilized, and if there is a problem with adequate heat, they are to notify the CEO. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based on a review of administrative information, the project director failed to prepare, annually update, and sign a written manual delineating project policies and procedures for the year 2023. Additionally, the facility failed to provide all required policy, procedures, and plans. The following policy and procedures were not provided:-704.11(a) 1-4: Staff development program including an assessment of staff training needs, overall plan for addressing these needs, a mechanism to collect feedback on completed training, and an annual evaluation of the overall training plan. -705.27(4)i-ii: the evacuation and transfer of client and staff to a safe location and the assignment of staff during emergencies-709.32(c)1-6: medications used by clients including administration, drug storage areas, inspection of drug storage areas, methods for control and accountability of drugs, security of drugs, and medication errors-709.94(e): follow up policyThese findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The following policies have been created, reviewed and approved as of 04/12/24/
1. Staff Development and Training Evaluation Process Policy
2. Emergency Plan for Staff and Clients
3. Medication administration/storage.
4. Client Aftercare/Follow up reviewed and updated 4/22/24
The Project Director and Clinical Director will be responsible to review on an annual basis to ensure accurate and relevant information.
|
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.
|
Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one of seven records. Client #4 admitted on October 20, 2023 and discharge February 28, 2024. There was no consent to release information form for the funding source. Billing was confirmed in client record.These findings were reviewed with the facility staff during the licensing process.This is a repeat citation from March 15, 2023 and May 12, 2022 licensure renewal inspections.
|
Plan of Correction
The Director of Counseling will be held responsible for ensuring that ALL clinicians are not only obtaining informed consent in a timely manner, but will also be required to submit to the CEO (Project Director) results of monthly review to ensure compliance. This review will start 04/30/24.
The CCCAS policy and procedure for reporting the release of information was reviewed with all active SA clinicians on 3/20/24, and this consent will be obtained during the initial appointment. Clinicians that fail to meet this requirement will be subject to performance counseling and disciplinary action if warranted. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on a review of client records, the facility failed to document a dated signature of the client on consents to release information in two of seven records.Client #2 admitted on September 5, 2023 and discharged January 19, 2024. One release of information was unsigned by the client and stated " Therapy Portal " on the client signature line dated December 27, 2023 to a referral agency. Client #3 admitted on July 7, 2023 and discharged February 19, 2024. One release of information was unsigned by the client and had the clients name typed on signature line dated September 18, 2023 to an attorney. These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Director of Counseling will be responsible for ensuring that this requirement is met, by conducting monthly chart audits, and reporting results to the CEO, Project Director. These audits will commence 04/30/24.
All SA clinicians were advised of the importance of obtaining consent to release information on 03/20/24.
If it becomes apparent that any clinician is failing to obtain these signatures, performance counseling and disciplinary action may be taken, |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in four of seven records.Client #1 admitted on September 25, 2023 and discharged January 25, 2024. A treatment plan was completed on October 18, 2023 and the next update was due no later than December 18, 2023; however, the next update was completed on January 18, 2024. Client #2 admitted on September 5, 2023 and discharged January 19, 2024. A treatment plan was completed on September 21, 2023 and the next update was due no later than November 21, 2023; however, the next update was completed on December 7, 2023.Client #3 admitted on July 7, 2023 and discharged February 19, 2024. A treatment plan was completed on November 6, 2023 and the next update was due no later than January 5, 2024; however, the next update was completed on February 2, 2024.Client #4 admitted on October 20, 2023 and discharge February 28, 2024. A treatment plan was completed on October 26, 2023 and the next update was due no later than December 25, 2023; however, no treatment plan updates were completed before discharge.These findings were reviewed with the facility staff during the licensing process.This is a repeat citation from the March 15, 2023 annual licensure inspection.
|
Plan of Correction
Treatment Plans will be reviewed in the EHR by the Director of Counseling every 30 days, to ensure that updates are being documented in a timely fashion. This shall begin 04/30/24.
This audit information will also be provided to the CEO(Project Director).
The requirement for updated treatment plans was reviewed with all SA staff on 03/20/24.
Failure of any staff to complete treatment plans every 60 days can result in performance counseling or disciplinary action. |
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.
|
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 obtaining a consent to release information form prior to releasing information were submitted and approved by the Department for the March 15, 2023, and May 12, 2022 annual licensing inspections. Obtaining a consent to release information form was again found to be a deficiency in the March 19, 2024 licensing inspection.This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The counseling department of this agency CCCAS has experienced some unfortunate turnover, both on the Director of Counseling level and CEO, over the last two years.
In fact the most current Director of Counseling who was also Project Director and Clinical Director, was noted to have failed to provide the supervision and follow up needed, and this employment ended days before this site visit of 03/19/24.
Moving forward the CEO will remain Project Director and will directly assist and monitor care provided as well as policy implementation with the new Director of Counseling ( hired 4/15/24). In addition any new SA counselor employee orientation will include specific focus on all pertinent DDAP regulation information to ensure complete compliance with all regulations. The CEO (Project Director) shall perform random compliance checks quarterly on all DDAP Outpatient regulations to ensure compliance, with specific focus on those areas that have been repeatedly deficient, to prevent reoccurrences. |