INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Step by Step Support, 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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704.11(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 staff records, the facility failed to document TB/STD and/or HIV/AIDS training within the required timeframes in two of three staff records.
Staff #1 was hired as the project/facility director on October 6, 2020. HIV/AIDS and TB/STD training was due to be completed by October 6, 2022. There was no documentation of TB/STD training in staff record #1.
Staff #4 was hired as support staff on January 15, 2021. TB/STD and HIV/AIDS training was due to be completed by January 15, 2023. There was no documentation of TB/STD or HIV/AIDS training in staff record #4.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the June 23, 2022 annual licensing inspection.
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Plan of Correction
Project Director will request verification that Staff #1 and $4 will enroll in the next available TB/STD training offered through the DDAP training management system on Staff #1 has already completed HIV/AIDS training and TB/STD training was completed June 27, 2023. Staff #4 completed their HIV/AIDS training through the patrain.org site on
June 30, 2023 .TB/STD training was completed on June 27, 2023. The clinical director will implement that all new staff will have verification of TB/STD and HIV/AIDS training.
Project Director will review training certificates to ensure that all training has been completed by the 60-day deadline. |
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.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates at least every sixty days in two of four client records.
Client #1 was admitted on December 6, 2022 and is currently an active client. A treatment plan was documented on December 6, 2022. Treatment plan updates were due to be completed by February 6, April 6 and June 6, 2023. One treatment plan update was documented on April 20, 2023.
Client #4 was admitted on January 10, 2023 and discharged on March 14, 2023. A treatment plan was documented on January 10, 2023. A treatment plan update was due to be completed by March 10, 2023. There was no treatment plan update documented in client record #4.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the July 30, 2021, February 9, 2022 and June 23, 2022 onsite licensing inspections.
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Plan of Correction
As of 6/23/2023, the client's individual counselor will be responsible for ensuring treatment plan reviews and updates are completed within the 60 day time frame. The clinical director will conduct chart reviews at least twice per month to ensure all proper documentation is completed within the appropriate time frames. |
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.
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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 treatment plan updates was submitted and approved by the Department for the July 28 - 30, 2021, February 9, 2022 and June 23, 2022 on-site licensing inspections. Treatment plan updates were again found to be a deficiency in the June 7, 2023 on-site licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The plan of correction for treatment plan updates was submitted and approved by the Department for the July 28-30, 2021, February 9, 2022, and June 7, 2023 inspections. The project director will review the approved plans of correction and ensure they are being followed via monthly chart audits of staff and client records. These audits will take place on an ongoing basis.
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