INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on June 27, 2023 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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704.9(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 all counselor assistants were 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 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.
Employee # 8 was hired as a counselor assistant on August 5, 2022. A semiannual performance evaluation was due no later than February 5, 2023; 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 and December 16, 2022 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address the non-compliance with DDAP 704.9(a), a thorough review of the current policies and procedures related to DDAP 704.9(a) will be conducted to identify any gaps or deficiencies. The Clinical Director will complete a full weekly supervision for all employees including counselor assistants. A semi-annual performance evaluation for counselor assistants will be completed by Clinical Director working collaboratively with the counselor assistants. Additionally, Clinical Director will regularly assess compliance and identify any potential issues through supervision and performance evaluations. The Clinical Director and Chief Clinical Officer will oversee and follow DDAP 704.9(a) compliance, ensuring that all corrective measures are effectively implemented, and that the organization maintains a culture of continuous improvement in regulatory adherence. Performance evaluations for counselor assistants will be completed by or before 9/1/2023. |
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 six of seven applicable 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 # 4 was hired as a counselor on February 28, 2022. 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 June 10, 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 May 1, 2023. There was no current individual training plan documented in the record at the time of the inspection.
Employee # 9 was hired as the director of admissions on October 22, 2018. There was no current individual training plan documented in the record at the time of the inspection.
Employee # 10 was hired as a tech on July 15, 2018. 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, October 22, 2021, and December 16, 2022 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
HR files for current employees will be reviewed by Chief Clinical Officer and HR representative. Chief Clinical Officer and HR representative will review employee files to identify current employees not in compliance with regulation 704.11(b)(1). Chief Clinical Officer and Clinical Director will complete individual training plans for employees 1, 4, 5, 7, 9 and 10. Regulation 704.11(b)(1) will be on the monthly leadership meeting agenda in effort to ensure compliance to this regulation. |
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 five applicable personnel records reviewed.
Employee # 1 was hired as the Project Director on November 11, 2019 and was due to have TB/STD training no later than November 11, 2021. The TB/STD training was not completed at the time of the inspection.
Employee # 4 was hired as a counselor on February 28, 2022 and was due to have TB/STD training no later than February 28, 2023. The TB/STD training was not completed at the time of the inspection.
Employee # 5 was hired as a counselor assistant on June 10, 2022 and was due to have HIV/AIDS and TB/STD training no later than June 10, 2023. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
Employee # 9 was hired as the director of admissions on October 22, 2018 and was due to have TB/STD training no later than October 22, 2020. The TB/STD training was not completed at the time of the inspection.
This is a repeat citation from the January 30, 2018, January 24, 2020, October 21, 2020, October 22, 2021 and December 12, 2022 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Sobriety Solutions will establish a new TB/STD training as the current TB/STD training was found to be one hour short of the required 4 hour training. The new training will be completed by all new employees who require this training as well as employees 1, 4, 5 and 9. Employee 5 will complete the 6 hour HIV/AIDS training pursuant to regulation 704.11(c)(1). These trainings will be completed by or before 9/1/2023. Staff TB/STD trainings and HIV/AIDS training requirements will be on the monthly leadership meeting agenda in effort to ensure compliance for regulation 704.11(c)(1). |
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 one full time staff member and two part time staff members. A CPR training was provided for a second full time staff member; however, the CPR training was not a full certification. Based on the hours of operation and the number of hours the employees work each week, there was not enough CPR certification coverage to ensure that one staff person trained in CPR is onsite during the project's hours of operation.
This is a repeat citation from the October 21, 2020, October 22, 2021, and December 16, 2022 annual licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Sobriety Solutions will conduct a companywide First Aid/CPR training to ensure there are enough staff members with an active full CPR certification. These trainings will be conducted in two-year increments. New employees who do not yet hold a valid First Aid/CPR certification will be required to have this training completed upon hire in effort to ensure compliance for regulation 704.11(c)(1). CCO and COO have valid CPR certifications and are on site 9am to 5pm Monday through Friday. Clinical Director holds a valid CPR certification and is on site 12pm to 9pm Monday through Thursday and 9am to 5pm Fridays (office closes 5pm Friday). Additionally, we will have all employees complete CPR/First Aid training by 9/1/2023 |
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 four of five applicable personnel records reviewed.
Employee # 5 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.
Employee # 6 was hired as a counselor assistant on April 25, 2023. 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 May 1, 2023. There was no documentation of training in the use of fire extinguishers at the time of the inspection.
Employee # 8 was hired as a counselor assistant on August 5, 2022. There was no documentation of training in the use of fire extinguishers at the time of the inspection.
This is a repeat citation from the December 12, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Sobriety Solutions will add employee onboarding and trainings to the monthly leadership meetings in effort to ensure that these trainings will be completed. Pursuance to 705.28(c)(4), all new employees will sign on and complete Fire Safety Training upon hire. Completion and documentation will be maintained in the employees personnel file to be reviewed in monthly employee record audit to ensure trainings are being completed. Employees 5, 6, 7 and 8 will complete this training by or before 9/1/2023. Completion certificates will be added to employee personnel record. |
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 four of five applicable personnel records reviewed.
Employee # 5 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.
Employee # 6 was hired as a counselor assistant on April 25, 2023. 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 May 1, 2023. There was no documentation of training to perform assigned tasks during emergencies at the time of the inspection.
Employee # 8 was hired as a counselor assistant on August 5, 2022. There was no documentation of training to perform assigned tasks during emergencies at the time of the inspection.
This is a repeat citation from the December 12, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Sobriety Solutions will add employee onboarding and trainings to the monthly leadership meetings in effort to ensure that these trainings will be completed. Pursuance to 705.28(d)(3), all new employees will sign on and complete tasks to be completed during emergencies training upon hire. Completion and documentation will be maintained in the employees personnel file to be reviewed in monthly employee record audit to ensure trainings are being completed. Employees 5, 6, 7 and 8 will complete this training by or before 9/1/2023. Completion certificates will be added to employee personnel record. |
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 is to 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, October 22, 2021, and December 12, 2022 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 secured an independent public accounting firm and precured a signed engagement letter on March 10, 2023. The audit has been ongoing with expectation that this will be completed on or before December 15, 2023. This firm or any future independent public accounting firm will be contractually engaged to prepare annual audits within six months of the conclusion of the previous fiscal year. |
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 records reviewed.
Client # 5 was admitted on February 1, 2023 and was administratively discharged on February 22, 2023. 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 is a repeat citation from the December 12, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer and Clinical Director reviewed policies and procedures regarding 709.33(a). Clinical Director developed a written termination of treatment template that has been instituted. A Written Termination of Treatment which include contact information notifying the individual that they have the opportunity to appeal and request reconsideration of a termination of treatment decision is to be sent within 7 days of discharge date. This document will be uploaded into the individual's chart. Weekly chart audits will be completed by Clinical Director who will review all discharges for that week to ensure termination letters were completed and sent to discharged individual. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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:
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Observations
Based on a review of client records, the facility failed to document that individual treatment and rehabilitation plans were developed with the client in three of seven applicable client records reviewed.
Client #1 was admitted to the partial hospitalization activity on May 11, 2023 and was active at the time of inspection. There was no documentation, in the record, of an individual treatment and rehabilitation plan at the time of inspection.
Client # 4 was admitted to the partial hospitalization activity on December 27, 2022 and was discharged on January 12, 2023. There was no documentation, in the record, of an individual treatment and rehabilitation plan at the time of inspection.
Client # 5 was admitted to the partial hospitalization activity on January 27, 2023 and was discharged on February 27, 2023. There was no documentation, in the record, of an individual treatment and rehabilitation plan at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will continue with weekly chart audits and will identify any issues with treatment planning. Chief Clinical Officer and Clinical Director met with clinical staff for an in house policies and procedures training on 8/4/2023 regarding treatment planning and timeframes to ensure compliance pursuant to 709.82(a). Clinical staff will identify any issues with completion of treatment planning at weekly staff meeting. Clients 1, 4 and 5 are no longer active clients and these specific deficiencies cannot be corrected. |
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 ensure that treatment and rehabilitation plans were reviewed and updated at least every sixty days in two of six applicable client records reviewed.
Client # 8 was admitted to the outpatient activity on February 21, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 18, 2023 and the first update was due no later than May 18, 2023; however, the update was not completed until June 2, 2023.
Client # 9 was admitted to the outpatient activity on March 14, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 18, 2023 and the first update was due no later than May 18, 2023; however, the update was not completed until May 23, 2023.
This is a repeat citation from the December 12, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will continue with weekly chart audits and will identify any issues with treatment planning. Chief Clinical Officer and Clinical Director met with clinical staff for an in house policies and procedures training on 8/4/2023 regarding treatment planning and treatment plan updates ensure compliance pursuant to 709.92(b). Clinical staff will identify any issues with treatment plan update at weekly staff meeting. |
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, October 22, 2021, and December 16, 2022 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 June 27, 2023 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, October 22, 2021 and December 16, 2022 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 June 27, 2023 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, October 22, 2021 and December 16, 2022 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 June 27, 2023 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, October 22, 2021 and December 16, 2022 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 June 27, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CCO and COO met with department heads regarding deficiencies needing to be addressed. Each department will make these an agenda items for their weekly staff meetings. COO, CCO, HR will continue to review POC to ensure compliance with regulations. Leadership team will meet monthly at leadership meeting and review POC which is a standing agenda item and identify any issues per report from each department head. |