INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14, 2019 of ADAPPT Outpatient Treatment Services by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, ADAPPT Outpatient Treatment Services 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) 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.
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Observations
Based on a review of personnel records, it was discovered that that Employee #4, whom was hired as a counselor on 11/12/18, did not meet the experience requirements to be a counselor. At the time of the hire, the employee had a Bachelor's Degree in Criminal justice, but did not have 1 year counseling experience
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
As of 2/7/19, Employee Martinez is receiving weekly supervision from Treatment Supervisor, which is documented. Employee Martinez is acting as a Counselor's Assistant. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the facility director in employee #1's employee record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/23/19, DDAP Examining Officer was emailed verification of Facility Director's training hours.
Facility Director will maintain copies of certificates or agendas for all trainings attended during the next licensing year. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions could not be seen or heard outside the counseling rooms. The group session taking place in Group Room #1 could be heard from outside the group room and inside Group Room #2
These findings were reviewed with facility staff during the licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 1/23/19, an additional sound machine was purchased and placed into Group Room #2 to ensure confidentiality in Group Room #1. |
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
The facility failed to ensure that fire drills were done at different times of the day. All of the fire drills for the 2018 year were conducted between 10:30 and 10:45.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 1/23/19, fire drill requirements were reviewed with staff. All future fire drills will be monitored by Facility Director to ensure different times throughout the day/evening. |
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 the review of seven client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records reviewed, #6, and #7.
Client #6 was admitted on March 8, 2018 and was discharged on September 9, 2019. There was documentation that an email report was sent on March 15, 2018 to the SIP program manager; however, there was no consent to release information form signed by the client prior to disclosure.
Client #7 was admitted on January 25, 2018 and was discharged on July 27, 2018. There was documentation that an email report was sent on February 23, 2018 to the SIP program manager; however, there was no consent to release information form signed by the client prior to disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/23/19, this Citation was reviewed with all staff. SIP consent form has been added to intake packet to ensure compliance. Facility Director is conducting random file audits to ensure compliance on an ongoing basis. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of seven client records and the project's policies and procedures, the facility failed to develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights in seven of seven client records reviewed.
In addition to retaining civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment. Additionally the clients have the following rights:
The right to inspect their own records.
Facility staff may limit access to their records if determined to be detrimental.
The right to appeal a decision limiting access to their records.
The right to request the correction of inaccurate information in the record.
The right to submit rebuttal data or memoranda to their own records.
The Project's policies and procedures did not include that clients have the right to submit rebuttal data or memoranda to their own records.
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Plan of Correction
On 1/23/19, this Citation was reviewed with all staff. Clients Rights, Rules and Responsibilities was revised to include all 6 points identified in regulations. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a complete record of services, progress notes, aftercare plan, discharge summary and follow up plan in client records 1,2,3,4,5,6 and 7.
Client #1 was admitted on 9/14/18 and was active at the time of inspection. The client record did not contain documentation of complete record of service or progress notes for group sessions.
Client #2 was admitted on 1/4/18 and was active at the time of inspection. The client record did not contain documentation of complete record of service or progress notes for group sessions.
Client #3 was admitted on 3/15/18 and was discharged on 7/24/18. The client record did not contain documentation of progress notes for group sessions,discharge summary and follow up plan.
Client #4 was admitted on 3/19/18 and was discharged on 7/20/18. The client record did not contain documentation of progress notes for group sessions and follow up plan
Client #5 was admitted on 2/27/18 and was discharged on 9/12/18. The client record did not contain documentation of complete record of service, progress notes for group sessions,discharge summary and follow up plan.
Client #6 was admitted on 3/8/18 and was discharged on 9/9/19. The client record did not contain documentation of progress notes for group sessions,discharge summary and follow up plan.
Client #7 was admitted on 1/25/18 and was discharged on 7/27/18. The client record did not contain documentation of a complete record of services, progress notes for group sessions, after-care plan, discharge summary and follow up plan.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 1/23/19, this Citation was reviewed with all staff.
Beginning on 1/23/19, Facility Director will complete weekly, random file checks to verify record of service and matching documentation for services rendered. Facility Director will also review aftercare plans, discharge summaries and ensure follow up contact is made, all of which will be tracked by the Director. |
709.14(b)(1) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
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Observations
Based on a review of administrative documentation, and conversation with facility staff during the licensure inspection conducted on January 15, 2019, the facility was unable to provide verification that they had submitted documentation to notify the department within 90 days of change in ownership.
During the licensure inspection conducted May 8, 2018, the facility staff indicated that they had just been taken over by another company. They had not filed any documentation at that time. However, because 90 days had not yet passed since the change in ownership, they were not yet out of compliance with the regulation and were advised to submit the forms within the 90 day period.
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Plan of Correction
The Project Director shall complete and submit the Ownership and Business Management Form to the Department of Drug and Alcohol Programs within thirty (30) of Plan of Correction approval.
Completion date 3/31/19
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