INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 2, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Colonial House, Inc. 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 ensure that one counselor assistant was given a semiannual performance evaluation.
Employee #4 was hired as a counselor assistant on June 28, 2021 and had not received an evaluation at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A performance evaluation for this employee will be completed by new Inpatient Clinical Supervisor on June 1,2022. The employee has begun the Supervision that is required for her position as Counselor Assistant with new Inpatient Clinical Supervisor on 05/04/2022. Another performance evaluation will be completed by Inpatient Clinical Supervisor on 11/04/2022. Executive Director and HR Manager will ensure completion of such required evaluations. |
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 five personnel records, the facility failed to ensure that two counselor assistants were counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #4 was hired as a counselor assistant on June 28, 2021. Employee #4 has an associate degree in human services and may only counsel clients under the close supervision of a trained counselor or clinical supervisor for the first nine months from date of hire until March 28, 2022. Employee #4 did not receive close supervision from date of hire until March 28, 2022.
Employee #5 was hired as a counselor assistant on January 31, 2022. Employee #5 has a high school diploma and may only counsel clients under the direct observation of a trained counselor or clinical supervisor for the first three months of employment. Employee #5 did not receive direct observation supervision from date of hire until the time of the inspection.
The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Employee #4 has a new Clinical Supervisor and began Close Supervision with said Supervisor for 9 months effective 05/04/2022. Weekly close supervision will be provided to employee #4 by Inpatient Clinical Supervisor from 05/04/2022 to 02/04/2023, at which time Employee #4 will be promoted to Counselor, as applicable. Oversight of compliance with these supervision requirements will be provided by Executive Director and HR Manager.
Employee #5 has a new Clinical Supervisor and has begun Direct Observation supervision on 05/04/2022. Employee #5 will remain under Direct Observation by Clinical Supervisor and Lead Counselor until 08/04/2022, at which time Employee #5 will be dropped to Close Supervision for 9 months, until 05/04/2023. Oversight of compliance with these supervision requirements will be provided by Executive Director and HR Manager. |
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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that two employees received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #6 was hired as a direct support professional on July 19, 2019 and was due to have the communicable disease trainings no later than July 19, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #7 was hired as a direct support professional on May 8, 2019 and was due to have one communicable disease training no later than May 8, 2021. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Under the suggestion of new Executive Director, CHI has purchased the Relias Online Training Management System, which will be implemented by 07/01/2022. Relias includes the required 6 hours of HIV/AIDS training and 4 hours of TB/STD training. Employee #6 will be required to complete both trainings by 08/01/2022. Employee #7 will be required to complete TB/STD training by 08/01/2022. HR manager will be responsible for assignment of trainings in Relias system during onboarding process and for all current employees to be in compliance with required trainings. HR manager and Executive Director, along with the Managers and Supervisors, will ensure direct support professionals in their departments complete trainings as scheduled and required by the training management system. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation according to the facility's policy and procedures timeframe of within 72 hours of admit in three out of seven records reviewed.
Client #1 was admitted on January 17, 2022 and was discharge on February 21, 2022. Client #1 had a psychosocial evaluation documented on February 16, 2022.
Client #2 was admitted on November 9, 2021 and was discharged on December 12, 2021.
The client record did not contain documentation of a psychosocial evaluation.
Client #3 was admitted on November 18, 2021 and was discharged on December 15, 2021.
The client record did not contain documentation of a psychosocial evaluation.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
New Inpatient Clinical Supervisor met with all Clinical Staff on 05/04/2022 following the inspection. Policy regarding the completion of psychosocial evaluations was reviewed. All active clinical charts were audited and a psychosocial evaluation was found in all active charts. A new QA sheet was added to the front of each active chart to aid clinical staff in guiding clinical documentation requirements and deadlines throughout a client's treatment stay. Clinical Supervisor and Lead Counselor will be reviewing all active charts on a weekly basis for compliance with completion of psychosocial evaluations and clinical impressions. Executive Director will provide guidance to Clinical Supervisor regarding oversight as necessary. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 client records, the facility failed to document a case consultation in three out of three records reviewed.
Client #1 was admitted on January 17, 2022 and was discharge on February 21, 2022.
Client #2 was admitted on November 9, 2021 and was discharged on December 12, 2021.
Client #3 was admitted on November 18, 2021 and was discharged on December 15, 2021.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
New Inpatient Clinical Supervisor met with all Clinical Staff on 05/04/2022 following the inspection. Policy regarding the completion of case consultations was reviewed. All active clinical charts were audited and a case consultation was found in charts of individuals who had been in treatment at least 60 days. Clinical Supervisor reviewed with clinical staff that an client who discharges before 60 days still requires a case consultation, per policy stating that a client will have at least one case consultation throughout their treatment stay. The discussion clarified some misconceptions by clinical staff. A new QA sheet was added to the front of each active chart to aid clinical staff in guiding clinical documentation requirements and deadlines throughout a client's treatment stay. Clinical Supervisor and Lead Counselor will be reviewing all active charts on a weekly basis for compliance with completion of case consultations. Executive Director will provide guidance to Clinical Supervisor regarding oversight as necessary. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide an aftercare plan in one out of three applicable records reviewed.
Client #2 was admitted on November 9, 2021 and was discharged on December 12, 2021.
The client record did not contain documentation of an aftercare plan.
The finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
New Inpatient Clinical Supervisor met with all Clinical Staff on 05/04/2022 following the inspection. Policy regarding the completion of a client's aftercare plan was reviewed. All discharged charts for the month of April 2022 were audited and an Aftercare Plan was found in all discharged charts for that month. Clinical staff was reminded that a client required an aftercare plan regardless of discharge type. This clarified some misconceptions by the clinical team. A new QA sheet was added to the front of each active chart to aid clinical staff in guiding clinical documentation requirements and deadlines throughout a client's treatment stay. Staff was reminded an Aftercare Plan must be completed before the day of discharge and a copy provided to the client. In the case of a client leaving against facility advice without an aftercare plan, staff was instructed to
place an aftercare plan in the chart regardless and indicate they were unable to complete it and why. Clinical Supervisor and Lead Counselor will be auditing all active charts weekly and will advise clinical staff to begin completion of an aftercare plan as a client approaches their discharge date. Executive Director will provide guidance to Clinical Supervisor regarding oversight as necessary. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a discharge summary in two out of three applicable records reviewed.
Client #2 was admitted on November 9, 2021 and was discharged on December 12, 2021.
The client record did not contain documentation of a discharge summary.
Client #3 was admitted on November 18, 2021 and was discharged on December 15, 2021.
The client record did not contain documentation of a discharge summary.
The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
New Inpatient Clinical Supervisor met with all Clinical Staff on 05/04/2022 following the inspection. Policy regarding the completion of discharge summaries was reviewed. All discharged charts were audited for the month of April 2022 and a discharge summary was found. Clinical staff was reminded that discharge summaries must be completed on all discharging clients, regardless of type of discharge. This clarified misconceptions by clinical staff. A new QA sheet was added to the front of each active chart to aid clinical staff in guiding clinical documentation requirements and deadlines throughout a client's treatment stay. Clinical Supervisor and Lead Counselor will be reviewing all discharged charts at time of discharge to ensure compliance with completion of discharge summaries. Executive Director will provide guidance to Clinical Supervisor regarding oversight as necessary. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 client records, the facility failed to document a follow up in three out of three applicable records reviewed.
Client #1 was admitted on January 17, 2022 and was discharge on February 21, 2022.
Client #2 was admitted on November 9, 2021 and was discharged on December 12, 2021
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Client #3 was admitted on November 18, 2021 and was discharged on December 15, 2021.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
New Inpatient Clinical Supervisor met with all Clinical Staff on 05/04/2022 following the inspection. Policy regarding follow up with client being completed within 7 days of discharge was reviewed. All discharged clinical charts were audited for the month of April 2022 and a follow up call progress note was found to be documented in all discharged charts. A new QA sheet was added to the front of each active chart to aid clinical staff in guiding clinical documentation requirements and deadlines, including making a follow up call to the discharged client within 7 days after discharge. Clinical Supervisor and Lead Counselor will review discharged charts prior to storing them to ensure a follow up call was made and documented. Executive Director will provide guidance to Clinical Supervisor regarding oversight as necessary. |