INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 21, 2021 through October 22, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Sobriety Solutions Pennsylvania 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(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records, the facility failed to document a semiannual performance evaluation in one of one applicable counselor assistant record reviewed.
Employee # 6 was hired as a counselor assistant on January 11, 2021 and was still in that position at the time of the inspection. There was not a documented semiannual performance evaluation in the personnel record at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Clinical Officer working with the VP of Operations have developed a semi annual assessment form specific to counselor assistants. This will be conducted by the Chief Clinical Officer every six months.
The current counselor assistants have been assessed so that the facility is within compliance. |
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 maintain documentation that the bachelor level counselor assistant only counseled clients under close supervision for at least the first six months of employment in one of one applicable record reviewed.
Employee # 6 was hired as a counselor assistant on January 11, 2021 and was still in that position at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Clinical Officer is to provide formal, documented case review and an additional hour of direct observation conducted by the Chief Clinical Officer or an assigned and qualified counselor once per week to focus on the development on the Counselor Assitant's clinical skills. Weekly supervision notes will demonstrate that close supervision is occurring. Weekly notes will also provide reference to charts and will demonstrate that at least one hour per week of direct observation is being completed.
The VP of Operations will meet with the Chief Clinical Officer quarterly to ensure this policy is followed. |
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 ten personnel records, the facility failed to ensure that each employee had a training plan completed annually in three records reviewed.
Employee # 2 was hired as a counselor on January 14, 2019 and was still in that position at the time of the inspection. The most recent training plan in the record was completed on October 5, 2020.
Employee # 4 was hired on September 4, 2019 and has been a counselor since November 2, 2020. The most recent training plan in the record was completed on October 5, 2020.
Employee # 6 was hired as a counselor assistant on January 11, 2021 and was still in that position at the time of the inspection. The record contained no documentation of an individual training plan.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The individualized training form that was in use was revised to include required training's as well as employee and supervisor recommendations. This training plan will be reviewed bi-annually by direct supervisor to identify any training not completed or scheduled for the duration of the year.
New employee onboarding forms include the individualized training plan that will be checked by the VP of Operations to ensure its completion upon hiring. The VP of Operations will also be completing a bi-annual check of all employee records for specified forms including the updated annual training plan. |
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 ten personnel records, the facility failed to ensure that staff received at least four hours of TB/STD in seven records reviewed.
Employee # 1 was hired by the facility on May 7, 2018 and has been the Project and Facility Director since November 11, 2019. The employee was due to have the TB/STD training no later than May 7, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee # 2 was hired as a counselor on January 14, 2019 and was due to have the TB/STD training no later than January 14, 2020. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection. This is a repeat citation.
Employee # 4 was hired on September 4, 2019 and has been a counselor since November 2, 2020. Employee # 4 was due to have the TB/STD training by at least September 4, 2021. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee # 7 was hired as an office manager on October 22, 2018 and was due to have the TB/STD training no later than October 22, 2020. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee # 8 was hired as a tech on March 19, 2019 and was due to have the TB/STD training no later than March 19, 2021. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee # 9 was hired as a tech on July 15, 2018 and was due to have the TB/STD training no later than July 15, 2020. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee # 10 was hired as the VP of Operations on July 6, 2017 and was due to have the TB/STD training no later than July 6, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
This is a repeat citation from the October 21, 2020 licensure renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with DDAP licensing alert 1997-06 TB Training, Sobriety Solutions has developed an in-house TB/STD Training course. The training was held 11/18 for all staff. Going forward the training will be held annually for all staff and also as part of onboarding for new employees. The VP of Operations will be monitoring completion of staff trainings on a monthly basis, any employees found to be out of compliance will be notified and scheduled for missing trainings. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The project failed to ensure that a sufficient number of staff persons were trained in first aid, so that at least one person trained in these skills were onsite during the project's hours of operation. Based on the review of the Staffing Requirement Facility Summary Report and personnel records, there was no documentation of any staff member completing first aid training in ten of ten personnel records reviewed.
This a repeat citation from the October 21, 2020 licensure renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 11/15/2021, all staff members have completed First Aid/CPR training with the American Red Cross. Going forward, the VP of Operations will conduct training audits every 6 months to ensure that all current employees and new employees are meeting all training requirements. |
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 ten personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one employee ' s record.
Employee # 4 was hired on September 4, 2019 and has been a counselor since November 2, 2020. The facility's training year that was reviewed was from October 1, 2020 through September 30, 2021. Employee #4 ' s employee record only documented 18 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The VP of Operations woking with the Chief Clinical Officer have developed a training audit plan. The audits will occur every 6 months for all current and new employees. Any employee found to be out of compliance will be notified. The required trainings have been evaluated to ensure that all DDAP regulations are being met. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from October 2020 through September 2021, the facility failed to prepare alternate exit routes to be used as each drill used the same exit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The VP of Operations will conduct fire drills using alternate routes. A schedule has been created which rotates which exits to be used during a fire drill. The drill will be run by the VP of Operations on a monthly basis and will be unannounced. The VP of Operations is solely responsible for choosing when and which exit is to be used. Any issues that may arise will be addressed during monthly leadership meetings. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of fire drill logs from October 2020 through September 2021, the facility failed conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts. Eleven of the twelve fire drills were conducted during this period were on a Friday. All twelve drills occurred at either 03:00 p.m. or 03:30 p.m.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The VP of Operations will conduct fire drills using alternate routes. A schedule has been created which rotates which exits to be used during a fire drill. The drill will be run by the VP of Operations on a monthly basis and will be unannounced. The VP of Operations is solely responsible for choosing when and which exit is to be used. Any issues that may arise will be addressed during monthly leadership meetings. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
This is a repeat citation from the January 24, 2020 and October 21, 2020 licensure renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO and CFO are in the process of scheduling an audit. This audit will cover 2020 and 2021. The CEO and CFO are meeting with several different agencies over the next 30 days and will make a decision on which one will perform the audit. Once decision is made audits will be completed. Deadline for decision to be made is set for 12/15. Audits are expected to be completed by 1/31/2022. |
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
The project failed to keep disclosures of client identifying information within the limits established by 4 Pa Code 255.5 (b) in 14 of 14 records reviewed. Each record contained a signed release of information form to the funding source, which allowed for the release of treatment plans, psychological assessment, psychiatric history and assessment, results of physical exam, medical history/current status, biopsychosocial assessment, laboratory test results, employment information, legal status, family information, aftercare recommendations, discharge summary, and discharge planning.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon investigation by the VP of Operations, an error was found within the EMR that caused the updated forms to be considered "under review" and therefore not activated. This has been resolved and as per the previous POC the following changed have been made:
All clinical and admissions employees, as per the CEO, will be required to attend DDAP approved confidentiality training within 6 months. New employees will be required to attend within 6 months of hire.
The VP of Operations has worked with the EMR company to create more specific release forms which are specific to the various types of releases.
The Clinical Director will check all consents and releases during weekly clinical chart audit. Any incorrect info will be corrected within 3 business days. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The project failed to document that the client had acknowledged that they were notified that they have the right to inspect their own records, that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client, and that the reasons for removing sections shall be documented in the record in 14 of 14 client records reviewed.
This a repeat citation from the October 21, 2020 licensure renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon investigation by the VP of Operations, an error was found within the EMR that caused the updated forms to be considered "under review" and therefore not activated. This has been resolved and as per the previous POC the following changed have been made:
Client Rights form was revised to include the following:
"Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record."
This has been updated in Policy & Procedure Manual, wall hangings, Client Handbook, and the Client Acknowledgement of Rights(signed during intake).
All current clients have signed updated acknowledgement. All future clients will sign updated acknowledgement. The client rights acknowledgement is required to be signed during intake by both admitting client as well as witness.
The admissions team member who completes admission will ensure consent to client rights is signed during intake process. The Clinical Director will check to ensure that this has been done during weekly clinical chart audits. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
The project failed to document the client acknowledgement that they were notified that they have the right to appeal a decision limiting access to their records to the director in fourteen of fourteen client records reviewed.
This a repeat citation from the October 21, 2020 licensure renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon investigation by the VP of Operations, an error was found within the EMR that caused the updated forms to be considered "under review" and therefore not activated. This has been resolved and as per the previous POC the following changes have been made:
Client Rights form was revised to include the following:
"Clients have the right to appeal a decision limiting access to their records to the director"
This has been updated in Policy & Procedure Manual, wall hangings, Client Handbook, and the Client Acknowledgement of Rights(signed during intake).
All current clients have signed updated acknowledgement. All future clients will sign updated acknowledgement.The client rights acknowledgement is required to be signed during intake by both admitting client as well as witness.
The admissions team member who completes admission will ensure consent to client rights is signed during intake process. The Clinical Director will check to ensure that this has been done during weekly clinical chart audits. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
The project failed to document the client acknowledgement that they were notified that they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in 14 of 14 client records reviewed.
This a repeat citation from the October 21, 2020 licensure renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon investigation by the VP of Operations, an error was found within the EMR that caused the updated forms to be considered "under review" and therefore not activated. This has been resolved and as per the previous POC the following changes have been made:
Client Rights form was revised to include the following:
"Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records"
This has been updated in Policy & Procedure Manual, wall hangings, Client Handbook, and the Client Acknowledgement of Rights(signed during intake).
All current clients have signed updated acknowledgement. All future clients will sign updated acknowledgement.The client rights acknowledgement is required to be signed during intake by both admitting client as well as witness.
The admissions team member who completes admission will ensure consent to client rights is signed during intake process. The Clinical Director will check to ensure that this has been done during weekly clinical chart audits. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
The project failed to document the client acknowledgement that they were notified that they have the right to submit rebuttal data or memoranda to their own records in 14 of 14 client records reviewed.
This a repeat citation from the October 21, 2020 licensure renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon investigation by the VP of Operations, an error was found within the EMR that caused the updated forms to be considered "under review" and therefore not activated. This has been resolved and as per the previous POC the following changes have been made:
Client Rights form was revised to include the following:
"Clients have the right to submit rebuttal data or memoranda to their own records"
This has been updated in Policy & Procedure Manual, wall hangings, Client Handbook, and the Client Acknowledgement of Rights(signed during intake).
All current clients have signed updated acknowledgement. All future clients will sign updated acknowledgement. The client rights acknowledgement is required to be signed during intake by both admitting client as well as witness.
The admissions team member who completes admission will ensure consent to client rights is signed during intake process. The Clinical Director will check to ensure that this has been done during weekly clinical chart audits. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on a review of seven client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project including case consultation notes in four records reviewed.
Client #8 was admitted on December 14, 2020 and discharged on January 8, 2021. The client record did not contain documentation of case consultation notes.
Client #9 was admitted on May 26, 2021 and discharged on June 15, 2021. The client record did not contain documentation of case consultation notes.
Client #10 was admitted on August 16, 2021 and discharged on September 27, 2021. The client record did not contain documentation of case consultation notes.
Client #11 was admitted on March 15, 2021 and discharged on April 26, 2021. The client record did not contain documentation of case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A case consultation form was added to the EMR system. The form has been set to require two clinical signatures. The completion of the form has been added to the weekly chart checklist that is completed by the Chief Clinical Officer. |
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 seven client records, the facility failed to ensure a complete client record that included case consultation notes for four client records reviewed.
Client #1 was admitted on March 2, 2021 and discharged on August 19, 2021. The client record did not contain documentation of case consultation notes.
Client #2 was admitted on December 14, 2020 and discharged on August 12, 2021. The client record did not contain documentation of case consultation notes.
Client #3 was admitted on June 15, 2021 and discharged on August 11, 2021. The client record did not contain documentation of case consultation notes.
Client #4 was admitted on January 18, 2021 and discharged on July 16, 2021. The client record did not contain documentation of case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A case consultation form was added to the EMR system. The form has been set to require two clinical signatures. The completion of the form has been added to the weekly chart checklist that is completed by the Chief Clinical Officer. |
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 seven client records, the facility failed to ensure a complete client record included information relative to the client ' s involvement with the project to include follow-up information in four records reviewed.
Client #1 was admitted on March 2, 2021 and discharged on August 19, 2021. The client record did not contain documentation of follow-up information.
Client #2 was admitted on December 14, 2020 and discharged on August 12, 2021. The client record did not contain documentation of follow-up information.
Client #3 was admitted on June 15, 2021 and discharged on August 11, 2021. The client record did not contain documentation of follow-up information.
Client #4 was admitted on January 18, 2021 and discharged on July 16, 2021. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the end of each week a discharge report will be run by the Outreach Team. All clients discharged during that previous week will be contacted. The team member contacting the client will document how and when the attempt was made as well as the outcome of the contact. |