INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Fayette County Drug and Alcohol Commission, 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:
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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 of personnel records, the facility failed to document direct observation of a counselor assistant with a high school diploma for the first three months of employment in one of one applicable staff record.Employee #6 was hired as a counselor assistant on March 25, 2024, and was still in this position at the time of the inspection.Supervision notes from date of hire until time of inspection did not include documentation of direct observation during counseling sessions with clients.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
As of July 15, 2024, the Facility Director and Treatment Supervisor will ensure that FCDAC is in compliance with 704.9 regarding supervision of an employee that is classified as a counselor assistant. In order to comply with 704.9 the in addition to weekly supervision with the counselor assistant, the Treatment Supervisor will conduct direct observation of any client services that are conducted by the counselor assistant for the next three months. In the event that the Treatment Supervisor cannot observe a session, the Facility Director or a counselor who meets the qualifications in § 704.6 or § 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor) will conduct the observation. These observations of the counselor assistant will be documented and reviewed by the Treatment Supervisor. As long as no concerns are identified with the counselor assistant this direct observation supervision will end on October 10,2024 and for the remaining 9 months, the counselor assistant will be permitted counsel clients under the close supervision of the lead of the Treatment Supervisor. |
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 seven records reviewed. Client #1 was admitted on September 26, 2023, and discharged on December 18, 2023. A release of information form to bill insurance for services was not documented in the record. Facility staff confirmed billing had occurred.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
On July 10, 2024, the Facility Director and Treatment Supervisor met to develop a plan to ensure that FCDAC is in compliance with 709.28(c) regarding confidentiality regarding obtaining informed and voluntary consent by each client who receives Outpatient Treatment. A check list was developed that both clerical and treatment staff will be required to follow to ensure that the correct consents are obtained at time of admission. The Treatment Supervisor will ensure the compliance with this process is occurring through monthly quality assurance checks. |
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 information in one of two discharged records.The facility's policy and procedure manual states follow-up contact is to be completed for successful discharges within 30 days.Client #2 was admitted on January 22, 2024, and discharged on May 22, 2024. Follow-up was not completed until June 26, 2024.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
As of July 10,2024, the Facility Director and Treatment Supervisor will ensure that FCDAC is in compliance with 709.93(a)(11) Licensure Client records. The aforementioned staff met with the Lead Clerical staff and discussed the process of documentation of the 30 day follow up letters that are sent to clients that are successfully discharged from FCDAC. To ensure compliance with these regulations, FCDAC has identified a staff member that will create a discharge report from our EHR system on the first business day of each month to collect the dates of the successful discharges from the prior month. The staff member will prioritize the follow up letters based on the discharge dates and will send them out accordingly. If the follow up date occurs over a weekend, then the staff member will send the letters on the following business day. The Treatment Supervisor will ensure that compliance with this process is occurring through monthly quality assurance checks. |