INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 28, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Jefferson Outreach Drug and Alcohol Program Central 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records and the Staffing Requirement Facility Summary Report, the facility failed to ensure a sufficient number of staff persons were certified in CPR and trained in first aid during the project ' s hours of operation.
The facility provided CPR certification and first aid training documentation for employee #2. The facility's hours of operation are Monday through Friday from 9:00 am to 5:00pm; however, employee #2 reported they only work at this facility for 2.5 hours per week.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The insufficient number of staff certified in CPR for this program was primarily due to staff shortages. This will be corrected once new staff are hired and the management team will ensure all staff working in the program have the required CPR certifications in their files prior to the next licensing review. A checklist will be used to track completed certifications and trainings for all staff.
Current staff who were not CPR certified for the licensing review will be signed up for the next available CPR training to ensure all present staff are in compliance with this regulation. This deficiency will be corrected by 03/31/2024 depending on when the next cycle of CPR trainings are offered.
|
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the January 2023 through October 2023 fire drill logs, the facility failed to conduct an unannounced fire drill at least one time a month.
There was no documentation of fire drills being conducted during the months of July 2023 through October 2023.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Due to insufficient staffing present at the facility, fire drills were not conducted on a monthly basis. Moving forward management will conduct fire drills monthly and document on the fire drill log as usual operational practice. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in six of seven client records reviewed.
Client #2 was admitted on February 17, 2023 and was discharged on June 5, 2023. The comprehensive treatment plan was completed on March 8, 2023 and the first update was due no later than May 8, 2023; however, the update was not completed prior to discharge.
Client #3 was admitted on July 9, 2022 and was discharged on June 29, 2023. A treatment plan update was completed on March 17, 2023 and the next update was due no later than May 17, 2023; however, the update was not completed prior to discharge.
Client #4 was admitted on October 13, 2022 and was discharged on May 31, 2023. A treatment plan update was completed on February 16, 2023 and the next update was due no later than April 16, 2022; however, the update was not completed prior to discharge.
Client #5 was admitted on March 18, 2023 and was active at the time of inspection. The comprehensive treatment plan was completed on April 10, 2023, and the first update was due no later than June 10, 2023; however, the update was not completed at the time of inspection.
Client #6 was admitted on August 3, 2020 and was active at the time of inspection. A treatment plan update was completed on June 15, 2023, and the next update was due no later than August 15, 2023; however, the update was not completed at the time of inspection.
Client #7 was admitted on March 5, 2021 and was active at the time of inspection. A treatment plan update was completed on May 17, 2023, and the next update was due no later than July 17, 2023; however, the update was not completed at the time of inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Due to insufficient staffing, treatment services and required documentation were not completed in a timely manner in accordance with state regulations.
The Executive Director and Clinical Supervisor will continue to actively recruit a candidate to fill the open counselor position to be able to provide treatment services as required for all patients engaged in treatment. This will correct the portion of the deficiency due to shortage of staff.
In the interim, patients who have been awaiting services will be discharged from the program as of 1/8/2024 and referred to another provider for treatment services instead of waiting for the position to be filled as that timeline is undetermined at this time. The patients will be provided a list of referral sites and the program will provide any documentation needed for the transfer of care to an identified provider if a release of information is completed by the patient. This will correct the other portion of the deficiency in that patients re-engage in treatment services with another provider after an extended pause due to insufficient staffing with our program. This corrective action item will be completed by the clinical supervisor and assistance from a certified recovery specialist.
When a candidate is hired for the counseling position in this program, previous patients may contact the program to re-engage in services again by completing the intake process as a new patient.
The Executive Director and Clinical Supervisor will work collaboratively on the recruitment, hiring, and training of new staff for the position of counselor. In addition, the clinical supervisor will oversee all clinical and administrative activities in the program to ensure that compliance with all regulations are in place and adequate staffing is available. Regular monitoring of compliance with regulations and regular oversight of the program will occur by the Executive Director and Clinical Supervisor as a way to prevent this from occurring in the future or minimize the effect that this has on patient care and responsibilities.
|
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in five of seven client records reviewed.
Client #2 was admitted on February 17, 2023 and was discharged on June 5, 2023. The individual treatment plan, dated March 8, 2023, indicated the client was to receive three individual counseling sessions per month. The client's record of service and progress notes documented the client had received only two individual sessions during the month of May 2023.
Client #4 was admitted on October 13, 2022 and was discharged on May 31, 2023. The treatment plan update, dated February 16, 2023, indicated the client was to receive three individual counseling sessions per month. The client's record of service and progress notes documented the client had received only one individual session during the month of April 2023 and that there were no individual counseling sessions provided during the month of May 2023.
Client #5 was admitted on March 18, 2022 and was active at the time of inspection. The treatment plan update, dated April 10, 2023, indicated the client was to receive one individual counseling session weekly. The client's record of service and progress notes showed the client did not receive any individual counseling sessions since July 10, 2023.
Client #6 was admitted on August 3, 2020 and was active at the time of inspection. The treatment plan update, dated June 15, 2023, indicated the client was to receive three individual counseling sessions per month. The client's record of service and progress notes showed the client did not receive any individual counseling sessions since July 10, 2023.
Client #7 was admitted on March 5, 2021 and was active at the time of inspection. The treatment plan update, dated May 17, 2023, indicated the client was to receive one individual counseling session per month. The client's record of service and progress notes showed the client did not receive any individual counseling sessions since July 10, 2023.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Due to insufficient staffing, treatment services and required documentation were not completed in a timely manner in accordance with state regulations.
The Executive Director and Clinical Supervisor will continue to actively recruit a candidate to fill the open counselor position to be able to provide treatment services as required for all patients engaged in treatment. This will correct the portion of the deficiency due to shortage of staff.
In the interim, patients who have been awaiting services will be discharged from the program as of 1/8/2024 and referred to another provider for treatment services instead of waiting for the position to be filled as that timeline is undetermined at this time. The patients will be provided a list of referral sites and the program will provide any documentation needed for the transfer of care to an identified provider if a release of information is completed by the patient. This will correct the other portion of the deficiency in that patients re-engage in treatment services with another provider after an extended pause due to insufficient staffing with our program. This corrective action item will be completed by the clinical supervisor and assistance from a certified recovery specialist.
When a candidate is hired for the counseling position in this program, previous patients may contact the program to re-engage in services again by completing the intake process as a new patient.
The Executive Director and Clinical Supervisor will work collaboratively on the recruitment, hiring, and training of new staff for the position of counselor. In addition, the clinical supervisor will oversee all clinical and administrative activities in the program to ensure that compliance with all regulations are in place and adequate staffing is available. Regular monitoring of compliance with regulations and regular oversight of the program will occur by the Executive Director and Clinical Supervisor as a way to prevent this from occurring in the future or minimize the effect that this has on patient care and responsibilities.
|
711.92(f) LICENSURE Couns. Prov.- Reg & Sched.
711.92. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis.
|
Observations
Based on a review of client records, the facility failed to provide counseling on a regular and scheduled basis in three of seven client records reviewed.
Client #5 was admitted on March 18, 2022 and was active at the time of inspection. The client's record indicated that no individual counseling sessions were provided since July 10, 2023.
Client #6 was admitted on August 3, 2020 and was active at the time of inspection. The client's record indicated that no individual counseling sessions were provided since July 10, 2023.
Client #7 was admitted on March 5, 2021 and was active at the time of inspection. The client's record indicated that no individual counseling sessions were provided since July 10, 2023.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Due to insufficient staffing, treatment services and required documentation were not completed in a timely manner in accordance with state regulations.
The Executive Director and Clinical Supervisor will continue to actively recruit a candidate to fill the open counselor position to be able to provide treatment services as required for all patients engaged in treatment. This will correct the portion of the deficiency due to shortage of staff.
In the interim, patients who have been awaiting services will be discharged from the program as of 1/8/2024 and referred to another provider for treatment services instead of waiting for the position to be filled as that timeline is undetermined at this time. The patients will be provided a list of referral sites and the program will provide any documentation needed for the transfer of care to an identified provider if a release of information is completed by the patient. This will correct the other portion of the deficiency in that patients re-engage in treatment services with another provider after an extended pause due to insufficient staffing with our program. This corrective action item will be completed by the clinical supervisor and assistance from a certified recovery specialist.
When a candidate is hired for the counseling position in this program, previous patients may contact the program to re-engage in services again by completing the intake process as a new patient.
The Executive Director and Clinical Supervisor will work collaboratively on the recruitment, hiring, and training of new staff for the position of counselor. In addition, the clinical supervisor will oversee all clinical and administrative activities in the program to ensure that compliance with all regulations are in place and adequate staffing is available. Regular monitoring of compliance with regulations and regular oversight of the program will occur by the Executive Director and Clinical Supervisor as a way to prevent this from occurring in the future or minimize the effect that this has on patient care and responsibilities.
|
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in four of four applicable client records reviewed.
Client #1 was admitted on April 23, 2018 and was discharged on January 27, 2023. There was no follow=up information documented in the record at the time of the inspection.
Client #2 was admitted on February 17, 2023 and was discharged on June 5, 2023. There was no follow=up information documented in the record at the time of the inspection.
Client #3 was admitted on July 9, 2022 and was discharged on June 29, 2023. There was no follow=up information documented in the record at the time of the inspection.
Client #4 was admitted on October 13, 2022 and was discharged on May 31, 2023. There was no follow=up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Due to insufficient staffing, follow up information was not completed in a timely manner in accordance with state regulations.
Moving forward an identified staff will be responsible for completing the required follow up contact to patients following their discharge from the program. This identified staff will also document these contacts and place in patient chart.
Clinical leadership will complete audit procedure for all patients discharged from the program and ensure the follow up is completed. |
711.93(c)(2)(iv) LICENSURE Signature Client/Guardian
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(iv) The dated signature of the client or guardian.
|
Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in one of seven client records reviewed.
Client #5 was admitted on March 18, 2023 and was active at the time of inspection. There was evidence of billing to the funding source; however, the funding source's release of information form did not include the dated signature of the client. Additionally, there was a release of information form to an emergency contact signed by a witness that did not include the dated signature of the client.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All counseling staff will be provided a checklist to ensure required tasks are completed during intake and annual evaluation (e.g., patient signature, date, initials, or other areas that are important for completion of forms). Clinical leadership will conduct patient chart audits to ensure documentation contains all required elements for regulatory purposes and communicate that to staff in order to prevent this citation from occurring in the future.
The client record where the deficiency was located has since been discharged from the program on 1/8/2024. |