INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 21, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Centre Counseling Associates 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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705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
Based on a physical plant inspection and review of the facility policy and procedure manual, the facility failed to provide a written procedure for staff and clients to follow in case of an emergency that included provisions for the evacuation and transfer of clients and staff to a safe location.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This Policy and Procedure Manual was written in 2005. During that time it has been reviewed and edited many times. The person that wrote the manual remembers writing a description for the safe evacuation of clients and staff including which exit to use, instructions where to proceed to a rally point at the building directly opposite the Centre Counseling offices, and the importance for the counselor to check that all persons are evacuated before leaving the office. This section will be retrieved from the original CD-Rom that it was saved on and included in the printed Policy and Procedure Manual. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility ' s policy manual, the facility failed to provide a written plan for the coordination of client treatment and rehabilitation services that included the written procedures for the management of treatment/rehabilitation services for clients that included a discharge summary at the conclusion of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall within 120 days update the clients file with a discharge summary that reflects his support services present during treatment and after discharge.
A notation shall be made that all clients must have included within 15 days of their discharge a written discharge summary that reflects the conditions of discharge, any relevant follow up recommendations for any support systems the client may have access to. |
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 and discussion with facility staff, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one of one record reviewed.
Client # 1 was admitted on June 1, 2023, and was still active at the time of the inspection. The record did not contain an informed and voluntary consent to disclose information to the client ' s funder; however, staff reported billing was occurring.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Within 120 days the Project Director will review this file with the client during her next session to obtain her signature to allow informed and voluntary consent to disclose relevant information to her funding source.
A notation shall be recorded in the Procedure and Policy Manual that an informed and voluntary consent must be signed at the "time of intake". This has been our standard policy but was an oversite by the Project Director. The notation will be made that no further client contact nor billing can be made until all releases are reviewed with the client and the Project Director. |
709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
Based on a review of client records and discussion with facility staff, the facility failed to have readily accessible a discharged client ' s record for a minimum of 4 years. An individual that had been a long-term client was reportedly discharged recently; however, the record was not available at the licensed facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This file was stored with the bulk of client files at an offsite storage site. Because of security reasons I have always kept all files in a locked and secure cabinet at my home office. I am only in my State College Office 2 days a week for client sessions. The rest of the time the State College office is unoccupied. The bulk of paperwork and file management is done in my home office. I personally bring all files for clients I am seeing each night in a secure conveyance that never leaves my presence.
The Project Director shall ensure that no one with the exception of the Project Director shall have any access to these files. Before each scheduled session the Project Director shall review the schedule and ensure that all relevant files are available, at hand, upon initiation of the session.
The secure storage area where the files are stored is at my home office. In the event of an unscheduled visit the files can be retrieved from this area which will take approximately 20 to thirty minutes round trip because the location is within less than a mile from my downtown office.
Upon request for any other files that have not been scheduled to be reviewed at this inspection can can be presented in a timely fashion. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of requested administrative paperwork, the facility failed to develop a recordkeeping system that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
The following materials were requested however the facility was unable to provide them during the licensing process:
The Staffing Requirement Facility Summary Report (SRFSR) which provides data of facility staff ' s credentials, dates of hire, years of experience, required dates for infectious disease training, verification of First Aid and CPR certification, annual training requirements, as well as the breakdown of the hours spent per week on active clients and the number of active clients receiving drug and alcohol treatment.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
This report was updated before the inspection as it has been for the past 15 inspections and should have been available. It was the Project Directors mistake for it not to have been presented at the time of inspection. A note will be put in the Policy and Procedure Manual that this form must be available for BDAP's yearly inspection. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to provide policies and procedures for responding to a physical assault or sexual assault by staff or a client during the licensing process.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Within 120 days the Project Director will make an addition to the Policy and Procedure Manual that succinctly describes a procedure to call the local police to investigate The situation during or immediately after the incident. A notation describing the incident shall be prepared and noted in the unusual incident ledger. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to provide policies and procedures for responding to selling or use of illicit drugs on the premises during the licensing process.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Within 120 days The Project Director will ensure that an addition will be made to the Policy and Procedure Manual that succinctly describes a procedure to call the local police to investigate The situation during or immediately after the incident. A notation describing the incident shall be prepared and noted in the unusual incident ledger. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to provide policies and procedures for responding to a death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services during the licensing process.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Within 120 days The Project Director shall ensure an addition will be made to the Policy and Procedure Manual that succinctly describes a procedure to call the local police to investigate The situation during or immediately after the incident. A notation describing the incident shall be prepared and noted in the unusual incident ledger. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to provide policies and procedures for responding to a significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day during the licensing process.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Within 120 days the Project Director shall ensure that an addition shall be made to the Policy and Procedure Manual which will describe who to call or where to obtain information on the incident, how long the facility will be closed, and an estimation when the facility will be functioning again. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to provide policies and procedures for responding to a theft, burglary, break-in or similar incident at the facility during the licensing process.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Within 120 days the Project Director shall ensure an addition will be made to the Policy and Procedure Manual that succinctly describes a procedure to call the local police to investigate The situation during or immediately after the incident. A notation describing the incident shall be prepared and noted in the unusual incident ledger.
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709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to provide policies and procedures for responding to an event at the facility requiring the presence of police, fire or ambulance personnel during the licensing process.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Within 120 days the Project Director shall ensure an addition will be made to the Policy and Procedure Manual that succinctly describes a procedure to call the local police or relevant medical responders to investigate The situation during or immediately after the incident. A notation describing the incident shall be prepared and noted in the unusual incident ledger. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to provide policies and procedures for responding to a fire or structural damage to the facility during the licensing process.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Within 120 days an addition will be made to the Policy and Procedure Manual by the Project Director that succinctly describes a procedure to call the local police, fire department or relevant medical responders to investigate the situation during or immediately after the incident. A notation describing the incident shall be prepared and noted in the unusual incident ledger. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to provide policies and procedures for responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification during the licensing process.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Within 120 days the Project Director shall ensure an addition will be made to the Policy and Procedure Manual that succinctly describes a procedure to call or inform the relevant medical responders and or organizations to investigate the situation during or immediately after the incident. A notation describing the incident shall be prepared and noted in the unusual incident ledger. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with a client that includes written documentation of short and long-term goals for treatment as formulated by both staff and client in one out of one record reviewed.
Client # 1 was admitted on June 1, 2023, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on June 1, 2023, however, there was no documentation of short and long-term goals for treatment as formulated by both staff and client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Within 120 days or until this client comes in for her next session a discussion of short and long term goals will be undertaken and the results shall be documented in the client's file. This must have been a mistake by the Project Director because this is a normal operating procedure when first engaging a new client. The Project Director will examine each new file to ensure that these notations have been addressed at the initial meeting |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with a client that includes written documentation of type and frequency of treatment and rehabilitation services in one out of one record reviewed.
Client # 1 was admitted on June 1, 2023, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on June 1, 2023, however, there was no documentation of type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall conduct a review of each new client's file to ensure these issues are notated before any further sessions can be scheduled. It shall include the type and frequency of treatment and rehabilitation services.
This particular file shall be reviewed and corrected at the next scheduled session within this client or within 120 days. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with a client that includes written documentation of proposed type of support service in one out of one record reviewed.
Client # 1 was admitted on June 1, 2023, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on June 1, 2023, however, there was no documentation of proposed type of support service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall within 120 days or until her next scheduled session work with the client to identify any support services available and document the findings in her file.
A notation of this deficiency shall be placed in the Policy and Procedure Manual and a statement shall be included that the support services available to the client should be appropriately noted for every client when the file is first opened or if there are changes during the course of treatment during the closing summary. |