INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 21, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection,Victory Treatment Group 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(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor met both the educational and experiential qualifications for the position.
Employee #2 was hired on November 5, 2024, as the clinical supervisor and was still in that position at the time of the inspection. There was no documentation in the employee's personnel record to verify that they attained three years of clinical experience in a health or human service agency which includes one year of working directly with the chemically dependent person for a person with a qualifying Bachelor's Degree.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On March 1, 2025 the clinical supervisor was removed from this role.
The Executive Director will ensure that future hires or anyone who is to be promoted to this role, will have verified that they attained three years of clinical experience in a health or human service agency which includes one year of working directly with the chemically dependent person for a person with a qualifying Bachelor's Degree. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
It was observed by DDAP staff that the fire escape stairs from the second and third floors were covered with snow.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will ensure that there are no future obstructions of exits for the stairways, hallways and exits from rooms and from the residential facility. All staff were reminded that stairways, hallways and exits from rooms and from the residential facility must be unobstructed at all times. During the facility rounds process, the behavioral health tech on duty will make sure that there are no obstructions, this will be monitored by the Executive Director.
The snow was removed immediately after it was observed with the DDAP staff from the fire escape stairs outside.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure three employees received the required training in the use of the fire extinguishers upon employment.
Employee #1 was hired on November 5, 2024, for the position of facility director and was still in that position at the time of the inspection. There was no documentation in the personnel record to verify completion of a fire extinguisher training.
Employee #2 was hired on November 5, 2024, for the position of clinical supervisor and was still in that position at the time of the inspection. There was no documentation in the personnel record to verify completion of a fire extinguisher training.
Employee #1 was hired on November 5, 2024, for the position of counselor and was still in that position at the time of the inspection. There was no documentation in the personnel record to verify completion of a fire extinguisher training.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff will complete the required training in the use of the fire extinguishers upon employment.
The Executive Director will ensure that all staff will complete this required training within the first week of hire. All staff who did not have this training have completed it effective March 20, 2025. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in five out of seven records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within seventy-two hours of admission.
Client #1 was admitted on January 6, 2025, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than January 9, 2025; however, it was not completed until January 29, 2025.
Client #3 was admitted on November 22, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than November 25, 2024; however, it was not completed until December 19, 2024.
Client #4 was admitted on November 27, 2024, and discharged on December 25, 2024. A comprehensive treatment plan was due no later than November 30, 2024; however, it was not completed until December 3, 2024.
Client #6 was admitted on November 13, 2024, and discharged on January 29, 2025. A comprehensive treatment plan was due no later than November 16, 2024; however, it was not completed until November 19, 2024.
Client #7 was admitted on December 30, 2024, and discharged on January 31, 2025. A comprehensive treatment plan was due no later than January 2, 2025; however, it was not completed until January 31, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The treatment plan guidelines established by the facility's policy and procedures manual were rereviewed with all clinical staff on 2/24/2025. It is the primary counselor's responsibility to ensure that a comprehensive treatment plan is created within 72 hours.
The facility's Executive Director will ensure that the treatment plans are being created within 72 hours of a client's admission date. The Executive Director will conduct periodic chart reviews to ensure that this timeline is being followed. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of four applicable records reviewed.
Client #3 was admitted on November 22, 2024, and was still active at the time of the inspection. A treatment plan was completed on December 19, 2024, and the next update was due no later than January 19, 2024; however, the subsequent updated treatment plan was dated February 20, 2025.
Client #6 was admitted on November 13, 2024, and was discharged January 29, 2025. A treatment plan was completed on November 19, 2024, and the next update was due no later than December 19, 2024; however, the subsequent updated treatment plan was dated January 20, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The treatment plan update timeline was rereviewed with all clinical staff to ensure that all updates are done according to the regulatory timeframe. All clinical staff met on 2/24/2025 to discuss this timeframe.
The facility's Executive Director will ensure that the treatment plan updates are being completed in the accurate timeframe by completing periodic chart reviews.
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 ensure a complete client record, in five of five applicable client records, 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: case consultation notes.
Client #1 was admitted on January 6, 2025, and was and was still active at the time of the inspection. The client record did contain documentation of a case consultation note, dated February 10, 2025; however, it contained only one signature for people in attendance.
Client #2 was admitted on November 26, 2024, and was and was still active at the time of the inspection. The client record did contain documentation of a case consultation note, dated January 24, 2025; however, it contained only one signature for people in attendance.
Client #3 was admitted on November 22, 2024, and was and was still active at the time of the inspection. The client record did contain documentation of a case consultation note, dated February 20, 2025; however, it contained only one signature for people in attendance.
Client #6 was admitted on January November 13, 2024, and was discharged on January 29, 2025. The client record did contain documentation of a case consultation note, dated January 20, 2025; however, it contained only one signature for people in attendance.
Client #7 was admitted on January December 20, 2024, and was discharged on January 31, 2025. The client record did contain documentation of a case consultation note, dated January 31, 2025; however, it contained only one signature for people in attendance.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical team met on 2/24/2025 to discuss signature requirements for case consults. Case consultations must be signed by at least two clinical staff persons who were in attendance. The counselor who is documenting the case consultation will ensure to obtain the signature from at least one other staff member in attendance.
The Executive Director will conduct periodic chart reviews to ensure that a case consultation consists of at least 2 signatures from clinical staff members. |