INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15, 2022 through December 16, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Sobriety Solutions Pennsylvania 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on an administrative review, the facility failed to present a completed plan documenting the qualifications and training of staff to the Department licensing representatives at the time of the project's site visit.
The facility was unable to produce a fully completed Staffing Requirements Facility Summary Report, which documents staff qualifications and trainings, after multiple attempts at technical assistance by the Department licensing representative.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical officer, Assistant Clinical Director and HR representative will follow facility Policies and Procedures and will provide qualifications and training of staff to be presented to Department licensing representative at time of project's site visit. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure that all clinical supervisors participated in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position in one of one applicable personnel record reviewed.
Employee # 2 was hired as a clinical supervisor on July 5, 2022. There was no documentation in the record of monthly meetings with their supervisor as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Clinical Officer is to provide formal, documented supervision for at least one hour of direct observation conducted by the Chief Clinical Officer once a month at minimum to focus on the development on the staff member's clinical and supervisory skills. Monthly supervision notes will demonstrate that close supervision is occurring. All supervision meetings will be documented and will meet once a month at minimum.
The Chief Operations will meet with the Chief Clinical Officer quarterly to ensure this policy is followed. |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of personnel records, the facility failed to ensure that a counselor assistant was supervised by a full-time clinical supervisor or counselor in one of three applicable personnel records reviewed.
Employee # 5 was hired as a counselor assistant on May 7, 2022. There were no supervision notes in the record to document that the employee was being supervised by a full-time clinical supervisor or counselor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Assistant Clinical Director who meets regulation requirements under 704.6(b)(1) as a clinical supervisor is to provide formal, documented supervision for at least one hour of direct observation. This shall be conducted by the Assistant Clinical Director. Weekly supervision notes will demonstrate that close supervision is occurring. Weekly notes will also provide reference to charts and will demonstrate that at least one hour per week of direct observation is being completed.
The Chief Operations Officer will meet with the Chief Clinical Officer and Assistant Clinical Director quarterly to ensure this policy is followed. |
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 the counselor assistant was given a written semiannual performance evaluation based upon measurable performance standards in two of two applicable personnel records reviewed.
Employee # 5 was hired as a counselor assistant on May 7, 2022. A semiannual performance evaluation was due no later than November 7, 2022 ; however, there was no documentation of the semiannual performance evaluation at the time of inspection.
Employee # 7 was hired as a counselor assistant on June 10, 2022. A semiannual performance evaluation was due no later than December 10, 2022 ; however, there was no documentation of the semiannual performance evaluation at the time of inspection.
This is a repeat citation from the October 22, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Clinical Officer working with the Assistant Clinical Director have compelted a semi annual assessment form specific to counselor assistants. This will be conducted by the Chief Clinical Officer and Assistant Clinical Director every six months in effort to assess counselor assistants needs and goals.
The current counselor assistants (#5 and #7) have been assessed so that the facility is within compliance. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an annual written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor in four of seven personnel records reviewed.
Employee # 1 was hired as the Project Director on November 11, 2019. There was no current individual training plan documented in the record at the time of the inspection.
Employee # 5 was hired as a counselor assistant on May 7, 2022. There was no current individual training plan documented in the record at the time of the inspection.
Employee # 6 was hired as a counselor assistant on August 25, 2022. There was no current individual training plan documented in the record at the time of the inspection.
Employee # 7 was hired as a counselor assistant on June 10, 2022. There was no current individual training plan documented in the record at the time of the inspection.
This is a repeat citation from the January 24, 2020, October 21, 2020, and October 22, 2021 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The individualized training form in place includes required training's as well as employee and supervisor recommendations. This training plan will be reviewed bi-annually by direct supervisor (Assistant Clinical Director) to identify any training not completed or scheduled for the duration of the year. All employee training plans including those in the deficiency have been completed.
New employee onboarding forms will also include the individualized training plan that will be checked by the Chief Operations Officer and HR Representative to ensure its completion upon hiring. The HR Representative and Chief Clinical Officer will also be completing a bi-annual check of all employee records for specified forms including the annual training plan. |
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, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in four of four applicable personnel records reviewed.
Employee # 1 was hired as the Project Director on November 11, 2019 and was due to have HIV/AIDS and TB/STD training no later than November 11, 2021. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
Employee # 8 was hired as the director of admissions on October 22, 2018 and was due to have HIV/AIDS and TB/STD training no later than October 22, 2020. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
Employee # 9 was hired as the office manager on March 19, 2019 and was due to have HIV/AIDS and TB/STD training no later than March 19, 2021. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
Employee # 10 was hired as a tech on July 15, 2018 and was due to have HIV/AIDS and TB/STD training no later than July 15, 2020. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
This is a repeat citation from the January 30, 2018, January 24, 2020, October 21, 2020, and October 22, 2021 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Sobriety Solutions has developed an in-house TB/STD and HIV/AIDS Training courses.
Going forward the training will be completed for all staff as part of onboarding for new employees. and will be completed annually by clinical staff and every two years for non clinical staff. Chief Operations Officer and Chief Clinical Officer will be monitoring completion of staff trainings on a monthly basis, any employees found to be out of compliance will be notified and scheduled for missing trainings. HR representative will house staff training records to be regularly updated as needed. All staff including those in deficiency will have these trainings completed by 2/10/2023. |
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.
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Observations
Based on a review of personnel records, the facility failed to provide adequate CPR certification to a sufficient number of staff persons, so that at least one person trained in CPR is onsite during the project's hours of operations.
The facility provided documentation of current CPR certification for two staff members. Neither of the two staff members who are certified in CPR were on-site on December 16, 2022 while the inspection was being conducted.
This is a repeat citation from the October 21, 2020 and October 22, 2021 annual licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff members will complete First Aid/CPR training. HR Representative and Chief Clinical Officer will assess training needs twice a year (every 6 months). It was found that during the site visit on 12/16/22, there was a staff member on site with active CPR training, however, moving forward all new staff will complete First Aid/CPR training within 6 months of hire date and training assessment will take place every 6 months |
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 personnel records, the facility failed to ensure that the project director completed at least 12 clock hours of training during the facility's October 1, 2021 through September 30, 2022 training year.
Employee # 1 was hired as the Project Director on November 11, 2019. The personnel record documented 0 hours of training during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Pursuant to 704.11(d)(2), Project/Director identified as the same individual, has an updated training plan including required 12 clock hours of required trainings to be completed no later than 2/10/2023.
The required trainings identified in 704.11(d)(2) will be completed each training year between October 1 and November 30 the following year. |
704.12(a)(5) LICENSURE Partial Hosp Ratio
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that the partial hospitalization program had a minimum of one Full Time Equivalent (FTE) counselor for every ten clients.
The FTE is determined by dividing the total number of hours counselors devoted to their clients (24) by the project workweek (40) = 0.6. Then, to obtain the overall ratio, the total number of clients on the partial hospitalization caseload (12) is divided by the FTE (0.6) = 20 or 20:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CCO met with clinical staff to discuss clients, case loads including Partial and Outpatient clients as well as time spent. CCO updates the staffing spreadsheet to reflect changes in FTE client/staff and client/counselor to be within compliance pursuant to 709.12(a)(5). CCO will monitor level of care changes and ratios to ensure Sobriety Solutions remains withing staffing compliance ratios. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in three of five applicable personnel records reviewed.
Employee # 5 was hired as a counselor assistant on May 7, 2022. There was no documentation of training in the use of fire extinguishers at the time of the inspection.
Employee # 6 was hired as a counselor assistant on August 25, 2022. There was no documentation of training in the use of fire extinguishers at the time of the inspection.
Employee # 7 was hired as a counselor assistant on June 10, 2022. There was no documentation of training in the use of fire extinguishers at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CFO/HR Director will ensure that all personnel are registered in our online learning information system within one week of their hire date. Within that system, each employee will be assigned the "Fire Safety Course" which includes a video entitled "Fire Extinguisher Training Video". This video is required to complete the Fire Safety Course. Documentation of completion will be maintained within the employee's personnel record within two weeks of hire date as stated in policies and procedures and staff orientation. All employees listed in the deficiency shall complete training no later that 3/1/2023. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in three of five applicable personnel records reviewed.
Employee # 5 was hired as a counselor assistant on May 7, 2022. There was no documentation of training to perform assigned tasks during emergencies at the time of the inspection.
Employee # 6 was hired as a counselor assistant on August 25, 2022. There was no documentation of training to perform assigned tasks during emergencies at the time of the inspection.
Employee # 7 was hired as a counselor assistant on June 10, 2022. There was no documentation of training to perform assigned tasks during emergencies at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CFO/HR Director will provide emergency training to all personnel within 5 days of hire date which will include a review of emergency procedures and the individual employee's responsibility during an emergency. Documentation of this training and the employee's understanding will be maintained within the employee's personnel record. Employees in the deficiency will completed no later that 2/17/2023 |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on an administrative review, the project failed to ensure that the project director annually updated and signed the written manual delineating the project's policies and procedures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Sobriety Solutions Policies and Procedures were reviewed and signed by project director on 1/13/2023. CCO and HR representative will review Policies and Procedures annually which will be reviewed and signed no later than 11/30 of the calendar year. |
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 client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in five of thirteen applicable client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within three visits but no later than 30 days from admission.
Client # 1 was admitted to the partial hospitalization activity on November 4, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than November 18, 2022; however, the individual treatment and rehabilitation plan was not completed until November 30, 2022.
Client # 2 was admitted to the partial hospitalization activity on November 3, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than November 28, 2022; however, the individual treatment and rehabilitation plan was not completed until December 11, 2022.
Client # 8 was admitted to the outpatient activity on September 20, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than October 14, 2022; however, the individual treatment and rehabilitation plan was not completed until November 23, 2022.
Client # 12 was admitted to the outpatient activity on May 23, 2022 and was discharged on November 8, 2022. The individual treatment and rehabilitation plan was due to be completed no later than June 23, 2022; however, the individual treatment and rehabilitation plan was not completed until July 1, 2022.
Client # 13 was admitted to the outpatient activity on June 2, 2022 and was discharged on October 17, 2022. The individual treatment and rehabilitation plan was due to be completed no later than July 2, 2022; however, the individual treatment and rehabilitation plan was not completed until July 13, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer and Assistant Clinical Director held a policies and procedures meeting and training regarding treatment planning standards per the company P&P. Timelines were reviewed for treatment planning to be completed withing the first 3 sessions not to exceed 30 days. Clinical staff was trained to complete documentation if the timelines are not met and circumstances explaining why timelines were unable to be met. The CCO will audit the client records to ensure continued compliance. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities for the project's 2021 fiscal year.
This is a repeat citation from the January 24, 2020, October 21, 2020, and October 22, 2021 annual licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO and CFO have interviewed four independent certified public accounting firms and received one proposal. One additional independent certified public accounting firm will be interviewed, and two additional proposals will be obtained. Once all proposals are received, the preferred firm will be selected no later than March 1, 2023. After the selection is made, an engagement letter will be signed and field work of an audit of the facility for the fiscal year ended December 31, 2021 will begin based upon availability of the selected firm. It is our intention to have a completed audit by May 31, 2023. The selected independent certified public accounting firm or any future independent certified public accounting firm will be contractually engaged to prepare annual audits within six months of the conclusion of the previous fiscal year.
The CFO will request an exception to Title 28, Chapter § 709.25 Fiscal Management requirement of the Standards for Licensure of Freestanding Treatment Facilities for the fiscal years ended December 31, 2019 and December 31, 2020 due to the time and financial burden compliance would incur. In the event that the exception request is not granted, the CFO will engage the services of an independent certified public accountant to prepare an audit of the fiscal years ended December 31, 2019 and December 31, 2020.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee in one of one applicable personnel record reviewed.
Employee # 1 was hired as the Project Director on November 11, 2019. There was no annual performance evaluation documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CEO met with Project Director/CCO for annual evaluation from 1/13/22 completed 1/13/2023. Form was reviewed and signed by CEO and Project Director. Project Director will again be evaluated in March, 2023 and will be evaluated annually every March going forward. The CFO/HR Director will ensure compliance with the annual evaluation and will maintain a copy of the signed evaluation in the employee's personnel record. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form in two of fourteen client records reviewed.
Client # 5 was admitted to the partial hospitalization activity on June 23, 2022 and was discharged on July 10, 2022. The release of information form to a family member was signed and dated by the client on June 23, 2022; however, the form failed to document the name of the person, agency, or organization to whom the disclosure would be made.
Client # 9 was admitted to the outpatient activity on July 11, 2022 and was still active at the time of the inspection. The release of information form to a family member was signed and dated by the client on June 23, 2022; however, the form failed to document the name of the person, agency, or organization to whom the disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CCO met with admission and clinical staff to review policies regarding confidentially and release of confidential information. Staff was made aware that specific names need to be on the release of information document including contact phone number. Staff was made aware that no document shall be in client's chart with incomplete releases. Releases will be signed by client and staff. The CCO will audit the client records to ensure continued compliance. Clients records in deficiency have been updated. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review client records, the facility failed to document the purpose of the disclosure on release of information forms in eight of fourteen records reviewed.
Client # 1 was admitted to the partial hospitalization activity on November 4, 2022 and was still active at the time of the inspection. The release of information form to a lab was signed and dated by the client on November 4, 2022, but the form did not document the purpose of the disclosure.
Client # 4 was admitted to the partial hospitalization activity on August 26, 2022 and was discharged on September 19, 2022. The release of information form to a lab was signed and dated by the client on August 26, 2022, but the form did not document the purpose of the disclosure.
Client # 5 was admitted to the partial hospitalization activity on June 23, 2022 and was discharged on July 10, 2022. The release of information form to a lab was signed and dated by the client on June 23, 2022, but the form did not document the purpose of the disclosure.
Client # 7 was admitted to the partial hospitalization activity on November 3, 2021 and was discharged on December 1, 2021. The release of information form to a lab was signed and dated by the client on November 3, 2021, but the form did not document the purpose of the disclosure.
Client # 8 was admitted to the outpatient activity on September 20, 2022 and was still active at the time of the inspection. The release of information form to a lab was signed and dated by the client on August 26, 2022, but the form did not document the purpose of the disclosure.
Client # 9 was admitted to the outpatient activity on July 11, 2022 and was still active at the time of the inspection. The release of information form to a lab was signed and dated by the client on June 23, 2022, but the form did not document the purpose of the disclosure.
Client # 11 was admitted to the outpatient activity on April 25, 2022 and was discharged on August 12, 2022. The release of information form to a lab was signed and dated by the client on March 14, 2022, but the form did not document the purpose of the disclosure.
Client # 12 was admitted to the outpatient activity on May 23, 2022 and was discharged on November 8, 2022. The release of information form to a lab was signed and dated by the client on May 23, 2022, but the form did not document the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client charts were reviewed (Clients 1, 4, 5, 7, 8, 9, 11, 12). These charts were compared to client charts (Clients 2, 3, 6, 10, 13, 14). It was found that clients in compliance did not have releases for a lab as these forms were removed from intake process. Clients out of compliance were found to have releases for labs that were not signed as this was no longer part of the intake process. Incomplete releases for labs were removed from client charts and will not appear in future admission charts. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client record reviewed.
Client # 7 was admitted on November 3, 2021 and was administratively discharged on December 1, 2021. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Pursuant to 709.33(a)(b) and Sobriety Solutions' policies and procedures, clinical staff were met with and trained on documentation regarding an individual's involuntary discharge including reason for termination of treatment. Within this documentation, client shall have an opportunity to appeal and request reconsideration of a decision terminating treatment. The CCO will audit the client records to ensure continued compliance. The facility shall send a determination of involuntary discharge letter to the client within 7 days of discharge date which will include contact information notifying the individual that they have an opportunity to request reconsideration of a decision terminating treatment. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client record reviewed.
Client # 7 was admitted on November 3, 2021 and was administratively discharged on December 1, 2021. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Pursuant to 709.33(a)(b) and Sobriety Solutions' policies and procedures, clinical staff were met with and trained on documentation regarding an individual's involuntary discharge including reason for termination of treatment. Within this documentation, client shall have an opportunity to appeal and request reconsideration of a decision terminating treatment. The CCO will audit the client records to ensure continued compliance. The facility shall send a determination of involuntary discharge letter to the client within 7 days of discharge date which will include contact information notifying the individual that they have an opportunity to request reconsideration of a decision terminating treatment. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, facility failed to assure that clients received the required counseling services according to the individual treatment and rehabilitation plan in two of six client records reviewed.
Client # 6 was admitted to the partial hospitalization activity on July 19, 2022 and was discharged on September 1, 2022. The individual treatment and rehabilitation plan, dated August 5, 2022, indicated the client was to receive two individual therapy sessions per week. The client's record of service and progress notes indicated that the client had received one individual session per week from August 7, 2022 through August 27, 2022.
Client # 7 was admitted to the partial hospitalization activity on November 3, 2021 and was discharged on December 1, 2021. The individual treatment and rehabilitation plan, dated November 9, 2022, indicated the client was to receive two individual therapy sessions per week. The client's record of service and progress notes indicated that the client had received one individual session per week from November 21, 2021 through November 27, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer and Assistant Clinical Director held a policies and procedures meeting and training regarding treatment planning standards per the company P&P. Pursuant to 709.82 (c), clinical staff will follow treatment plans identifying client will be met with twice a week for individual sessions. Clients in the partial program are required to have two individual sessions a week. In the event that a session is missed, a missed session note will be completed under Progress Notes explaining in detail why a client was not met with for a second weekly session. The CCO will audit the client records to ensure continued compliance. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to assure that clients admitted to the partial hospitalization program received individual counseling services at least twice a week in four of six applicable client records reviewed.
Client #1 was admitted to the partial hospitalization activity on November 4, 2022 and was still active at the time of inspection. The client's record of service and progress notes indicated that the client had received one individual session per week from November 13, 2022 through December 3, 2022.
Client #2 was admitted to the partial hospitalization activity on November 3, 2022 and was still active at the time of inspection. The client's record of service and progress notes indicated that the client had received one individual session for the week of November 6, 2022 through November 12, 2022, no individual sessions for the week of November 13, 2022 through November 19, 2022 and one individual session per week from November 20, 2022 through December 3, 2022.
Client #3 was admitted to the partial hospitalization activity on November 10, 2022 and was still active at the time of inspection. The client's record of service and progress notes indicated that the client had received no individual sessions for the week of November 20, 2022 through November 26, 2022 and one individual session for the week of November 27, 2022 through December 3, 2022.
Client #5 was admitted to the partial hospitalization activity on June 23, 2022 and was discharged on July 10, 2022. The client's record of service and progress notes indicated that the client had received one individual session for the week from July 3, 2022 through July 9, 2022.
Client #6 was admitted to the partial hospitalization activity on July 19, 2022 and was discharged on September 1, 2022. The client's record of service and progress notes indicated that the client had received one individual session per week from July 24, 2022 through August 27, 2022.
Client # 7 was admitted to the partial hospitalization activity on November 3, 2021 and was discharged on December 1, 2021. The client's record of service and progress notes indicated that the client had received one individual session for the week of November 21, 2021 through November 27, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer and Assistant Clinical Director held a policies and procedures meeting and training regarding treatment planning standards per the company P&P. Pursuant to 709.82(d)(1), clinical staff will follow DDAP regulation, policies and procedures and treatment plan identifying client in the Partial Program will be met with twice a week for individual session. Clients in the partial program are required to have two individual sessions a week. In event that a session is missed, a missed session note will be completed under Progress Notes explaining in detail why a client was not met with for a second weekly session. The CCO will audit the client records to ensure continued compliance. |
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 review and update treatment and rehabilitation plans at least every sixty days in three of five applicable client records reviewed.
Client # 10 was admitted to the outpatient activity on September 2, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 26, 2022 and an update was due no later than November 26, 2022; however, the update was not completed at the time of the inspection.
Client # 12 was admitted to the outpatient activity on May 23, 2022 and was discharged on November 8, 2022. The individual treatment and rehabilitation plan was completed on July 15, 2022 and an update was due no later than September 15, 2022; however, the update was not completed until November 8, 2022.
Client # 13 was admitted to the outpatient activity on June 2, 2022 and was discharged on October 17, 2022. The individual treatment and rehabilitation plan was completed on July 13, 2022 and an update was due no later than September 13, 2022; however, the update was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer and Assistant Clinical Director held a policies and procedures meeting and training regarding treatment planning and treatment plan update standards per the company P&P pursuant to 709.92(b). Clinical staff were trained on procedure to complete a treatment plan update, which shall not exceed 60 day intervals. Assistant Clinical Director is charged with chart reviews. A reminder notice will be set up in the EMR system to alert staff that a treatment plan update is due. Client #10 was discharged successfully from treatment on 1/5/2023. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that clients received the required counseling services according to the individual treatment and rehabilitation plan in five of seven client records reviewed.
Client # 9 was admitted to the outpatient activity on July 11, 2022 and was still active at the time of inspection. The individual treatment and rehabilitation plan, dated July 14, 2022, indicated the client was to receive one individual therapy session per week. The client's record of service and progress notes indicated that the client had received no individual sessions for the weeks of July 24, 2022 through July 30, 2022, August 7, 2022 through August 13, 2022, August 21, 2022 through August 27, 2022 and November 13, 2022 through December 3, 2022.
Client # 10 was admitted to the outpatient activity on September 2, 2022 and was still active at the time of inspection. The individual treatment and rehabilitation plan, dated September 26, 2022, indicated the client was to receive one individual therapy session per week. The client's record of service and progress notes indicated that the client had received no individual sessions for the weeks of October 2, 2022 through October 15, 2022 and no individual sessions for the weeks of November 6, 2022 through the time of the inspection.
Client # 11 was admitted to the outpatient activity on April 25, 2022 and was discharged on August 12, 2022. The individual treatment and rehabilitation plan, dated April 27, 2022, indicated the client was to receive one individual therapy session per week. The client's record of service and progress notes indicated that the client had received no individual sessions for the weeks of May 15, 2022 through May 21, 2022 and May 29, 2022 through June 18, 2022.
Client # 12 was admitted to the outpatient activity on May 23, 2022 and was discharged on November 8, 2022. The individual treatment and rehabilitation plan, dated July 15, 2022, indicated the client was to receive one individual therapy session per week. The client's record of service and progress notes indicated that the client had received no individual sessions for the weeks of July 31, 2022 through August 6, 2022, August 28, 2022 through September 10, 2022 and October 2, 2022 through October 8, 2022.
Client # 13 was admitted to the outpatient activity on June 2, 2022 and was discharged on October 17, 2022. The individual treatment and rehabilitation plan, dated July 13, 2022, indicated the client was to receive one individual therapy session per week. The client's record of service and progress notes indicated that the client had received no individual sessions for the week of August 7, 2022 through August 13, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer and Assistant Clinical Director held a policies and procedures meeting and training regarding treatment planning standards per the company P&P. Pursuant to 709.92(c) clinical staff will follow DDAP regulation, policies and procedures and treatment plan identifying client in the IOP program will be met with once a week for individual session. Clients in the IOP program are required to have one individual session per week. In the event that a session is missed, a missed session note will be completed under Progress Notes explaining in detail why a client was not met with for a second weekly session. The CCO will audit the client records to ensure continued compliance. |
709.93(a)(11) 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:
(11) Follow-up information.
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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 # 11 was admitted to the outpatient activity on April 25, 2022 and was discharged on August 12, 2022. The client record did not document follow-up information as of the date of the inspection.
Client # 12 was admitted to the outpatient activity on May 23, 2022 and was discharged on November 8, 2022. The client record did not document follow-up information as of the date of the inspection.
Client # 13 was admitted to the outpatient activity on June 2, 2022 and was discharged on October 17, 2022. The client record did not document follow-up information as of the date of the inspection.
Client # 14 was admitted to the outpatient activity on August 31, 2022 and was discharged on November 1, 2022. The client record did not document follow-up information as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CEO and CCO met with staff members from the Outreach Department regarding Sobriety Solutions P&P pursuant to 709(a)(11). The Outreach Department is charged with follow up contact with discharged clients. Outreach staff will continue to log outreach calls in the internal client tracking system for client follow ups post discharge. The CCO will audit the client records to ensure continued compliance. |
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 administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe was submitted and approved by the Department for the January 1, 2018, January 24, 2020, October 21, 2020, and October 22, 2021 annual licensing inspections. Failing to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe was again found to be a deficiency in the December 15, 2022 through December 16, 2022 licensing inspection.
A plan of correction for failing to provide adequate CPR certification to a sufficient number of staff persons, so that at least one person trained in CPR is onsite during the project's hours of operations was submitted and approved by the Department for the October 21, 2020, and October 22, 2021 annual licensing inspections. Failing to provide adequate CPR certification to a sufficient number of staff persons, so that at least one person trained in CPR is onsite during the project's hours of operations was again found to be a deficiency in the December 15, 2022 through December 16, 2022 licensing inspection.
A plan of correction for failing to document an annual written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor was submitted and approved by the Department for the January 24, 2020, October 21, 2020, and October 22, 2021 annual licensing inspections. Failing to document an annual written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor was again found to be a deficiency in the December 15, 2022 through December 16, 2022 licensing inspection.
A plan of correction for failing to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities was submitted and approved by the Department for the January 24, 2020, October 21, 2020, and October 22, 2021 annual licensing inspections. Failing to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities was again found to be a deficiency in the December 15, 2022 through December 16, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CCO and COO will review deficiencies with each department head identifying each area in the POC. Each department head will be responsible for training and updating their staff. CCO, COO and HR will continuously review the POC to ensure that POCs are being addressed and corrected. Leadership team meets monthly and review of POC is now a standing meeting agenda item to ensure compliance with all POCs. |