INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on June 14, 2022 through June 15, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Consortium was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors who have not functioned for 2 years as a supervisor in the provision of clinical services completed a Department-approved core curriculum in clinical supervision in two of two applicable personnel records reviewed.
Employee #5 was hired as a clinical supervisor on November 6, 2021 and did not have clinical supervision experience prior to being hired. There was no documentation of the 30-hour DDAP sponsored clinical supervision training, or a department approved clinical supervision training on file at the time of the inspection.
Employee #7 was hired as a clinical supervisor on December 13, 2021 and did not have clinical supervision experience prior to being hired. There was no documentation of the 30-hour DDAP sponsored clinical supervision training, or a department approved clinical supervision training on file at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Division Director will revise external hiring and internal promotion practices for the position of Clinical Supervisor. The revision will require that candidates show documented proof of completing a core curriculum in clinical supervision approved by DDAP. This change in process will be monitored by the TSS Director. 06/28/2022
The Program Managers will ensure that Employees #5 and #7 complete a DDAP approved clinical supervision curriculum. The Division Director will monitor this assignment. 08/30/2022
|
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.
|
Observations
Based on a review of personnel records, the facility failed to provide documentation of an individual training plan developed with input from both the employee and the supervisor in one of seventeen personnel records reviewed.
Employee #1 was hired as the Project Director on December 3, 2001. The individual training plan for the current training year was not completed as of the date of inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The TSS Director will request and file a copy of the Annual Training Plan for the Project Director for the year 2022 and moving forward, each subsequent year prior to the submission deadline. The Division Director is responsible to monitor this activity. |
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.
|
Observations
Based on the review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics within the regulatory timeframe in one of three applicable personnel records reviewed.
Employee #10 was hired as a counselor on May 24, 2021 and was due to receive the minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than May 24, 2022; however, there was no documentation of completion of HIV/AIDS or TB/STD training at the time of inspection.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The Program Managers will ensure that all staff obtain the DDAP approved training for (6) hours of HIV/AIDS and (4) hours of TB/STD training before the end of their first year of employment. The Division Director will monitor and review for compliance during supervision. The Division Director will assist the Program Managers with locating and arranging fees for the above training. Employee # 10 will complete the DDAP required (6) HIV/AIDS and (4) TB/STD. |
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.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director during the facility's January 2021 through December 2021 training year in one of one applicable personnel records reviewed.
Employee #1 was hired as the Project Director on December 3, 2001. The personnel record documented 7.2 hours of annual training during the training year reviewed.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The Project Director will complete (12) hours of training annually in areas such as
The TSS Director will request and file copies of all trainings completed by the Project Director. The Division Director will include the monitoring of training compliance with the monitoring of program employee's training compliance. The Division Director will send and automatic bi-monthly training reminder via Outlook calendar to the Project Manager and all program staff.
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors during the facility's January 2021 through December 2021 training year in four of six applicable personnel records reviewed.
Employee #9 was hired as a counselor on September 10, 2018. The personnel record documented 9.5 hours of annual training during the training year reviewed.
Employee #11 was hired as a counselor on August 31, 2020. The personnel record documented 18.25 hours of annual training during the training year reviewed.
Employee #13 was hired as a counselor on January 14, 2019. The personnel record documented 13.75 hours of annual training during the training year reviewed.
Employee #14 was hired as a counselor on November 8, 2002. The personnel record documented 6.25 hours of annual training during the training year reviewed.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The Division Director will send and automatic bi-monthly training reminder via Outlook calendar to the Project Manager and all program staff. 07/12/2022
During the Counselor's monthly supervision meetings, the Clinical Supervisors will review and document training hour's status for each counselor. During the Clinical Supervisor's monthly supervision meetings, the Program Manager's will review and document the status of training hours of the supervisors and their team of counselors. During the Program Manager's monthly supervision meetings, the Division Director will review and document the status of training hours for the Program Manager's and their teams. 07/05/2022
|
704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on a review of the Staffing Requirement Facility Summary Report, the facility failed to ensure that the Full-Time Equivalent (FTE) counselor caseload for counseling in outpatient programs did not exceed 35 active clients as two clinical supervisors and two counselors exceeded the FTE counselor caseload.
The counselor FTE is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee #5 was hired as a clinical supervisor on November 6, 2021. Their ratio calculation was as follows: 15/37.50= .4(FTE); 15/.4= 37.5 which equals a client/counselor ratio of 37:1.
Employee #6 was hired as a clinical supervisor on May 5, 2022. Their ratio calculation was as follows: 15/37.50= .4(FTE); 15/.4= 37.5 which equals a client/counselor ratio of 37:1.
Employee #13 was hired as a counselor on January 14, 2019. Their ratio calculation was as follows: 18.75/37.50= .5(FTE); 18/.5= 36 which equals a client/counselor ratio of 36:1.
Employee #14 was hired as a counselor on November 18, 2002. Their ratio calculation was as follows: 30/37.50= .8(FTE); 30/.8= 37.5 which equals a client/counselor ratio of 37:1.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
?Due to recent staff retirements the program had (2) vacant FTE Counselor positions at the time of this review. Both positions were posted in May 2022 and (1) interview was completed.
On 06/21/2022 one additional FTE Counselor position was added to the staff roster and the budget.
One of the three vacant positions will be filled as of 07/05/2022. The caseloads for FTE #13, #14, Clinical Supervisors, will be adjusted to meet the ratio requirements and then transitioned to the new FTE Counselors upon hire.
The FTE Counselors, #5, and #6 will be adjusted to meet the regulation for counselor caseload ratios. Clients who have been in treatment over (1) year, will no longer be included in the billing requirement of (3) clinical services monthly, unless it is indicated clinically via assessments, drug screens, or client requests. 07/12/2022
The Admissions Supervisor will be responsible for ensuring appropriate caseload assignments during the admissions assignment process.
Program Managers will be responsible to review all caseloads monthly and ensure that counselor/client ratios are in compliance with regulations The Division Director is responsible to monitor for compliance of these assignments. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on a physical plant inspection, the facility failed to have hot water under pressure in all non-residential facility bathrooms. There was no running hot water under pressure, in the community bathroom's, which are located on the first and second floor.
This is a repeat citation from the February 5, 2021 and June 24, 2021 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facilities Director is responsible to correct and maintain the appropriate water pressure throughput the facility. The Facilities Director and his team will shut off the incoming water supply for the entire building, after services on a Saturday, and drain the building. The team will then cut away any bad shut off valves and faucets and replace them with new ones. This will allow the shut off valves to be opened all the way to increase the pressure. The water pressure in all areas of the facility will be checked by the Facilities Director bi-monthly and any issues with appropriate functioning will be addressed accordingly. The Division Director is responsible to monitor compliance with this process.09/10/2022 |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that the fire extinguisher, located in the management office area, was inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection tag was October 2020.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The Facilities manager is responsible to ensure that all Fire Extinguishers in the building are expected and approved annually. The Fire Extinguisher tagged October 202 will be inspected by 07/12/2022. Moving forward, the Facilities Director will escort the inspector to each of the extinguishers in the building to ensure none are overlooked. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
|
Observations
Based on an administrative review, the facility, which is publicly funded, failed to complete and make available to the public a 2021 annual report which is to include, but is not limited to, a statement disclosing the names of officers, directors, and principal shareholders, when applicable.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Licensing & Clinical Training Director is responsible to make available, in a timely manner, the annual audit report, which includes, but is not limited to a statement of disclosing the names of officers and principal shareholders. The 2021 audit completion is expected by 8/31/2022, Due to the following holiday week, the notice of availability for the 2021 audit will be posted by 09/15/2022. This expectation will be monitored by the Division Director. |
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.
|
Observations
Based on an administrative review, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The acquisition of the accounting firm we previously used caused a number of issues which were out of our control.
Presently, the auditors are moving through the 2021 audit as quickly as possible and expect to have it completed by August 31.2022. Our 2022 audit will be completed timely as we do not expect this unique set of circumstances to reoccur. The Consortium's VP / CFO is responsible to ensure timely receipt of the annual audit. The Division Director will monitor this process for compliance. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
|
Observations
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of physical or sexual assault by staff or a client.
On August 26, 2021, there was an act of physical aggression from a client towards a counselor that was not reported to the Department within 3 business days.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All Internal, Significant, and Unusual Incident Reports completed by staff or clients will be forwarded to the Administrative Supervisor for review and determination of the level of reporting required. The Administrative Supervisor will ensure that all incidents meeting the Unusual Incident Reporting levels are completed in the DDAP IR Reporting System within (3) business days of the incident. The Administrative Supervisor will also print a copy of the submitted report and file it in the client's medical record. The Division Director is responsible for monitoring this activity for compliance. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Based on a review of patient records, the facility failed to document that each patient received an average of 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hours of which shall be individual psychotherapy, in three of seven patient records reviewed.
Patient #1 was admitted on October 13, 2021 and was active at the time of inspection. The patient record documented 2.5 hours of group psychotherapy for the month of March 2022; however, none of the hours were individual psychotherapy hours.
Patient #2 was admitted December 10, 2019 and was active at the time of inspection. The patient record documented 2 hours of psychotherapy for the month of September 2021 and 2 hours and 5 mins of psychotherapy for the month of October 2021.
Patient #6 was admitted on January 21, 2020 and was discharged on May 12, 2022. The patient record documented 15 mins of psychotherapy for the month of August 2021.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Counselor is responsible to utilize the service attendance tracker to ensure that all members on their case list receive an average of 2.5 hours of psychotherapy during their first two years of treatment, with at least one (1) of those hours being individual psychotherapy each month. The Clinical Supervisor is responsible to review the service attendance weekly and discuss any concerns during supervision with the counselor. The Program Managers are required to monitor weekly compliance with this requirement, and assist the clinical team to meet the expectations. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to transfer patient files, which is to include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient in two of two applicable patient records reviewed.
Patient #4 was admitted on February 27, 2020 and was transferred out on March 29, 2022. The patient record did not document that the receiving narcotic treatment program was notified of the date of admission of the patient.
Patient #5 was admitted on November 23, 2020 and was transferred out on September 18, 2021. The patient record did not document that the receiving narcotic treatment program was notified of the date of admission of the patient, medical and psychosocial summaries, urinalysis reports or summary, exception requests, and current status of the patient.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical staff that facilitate clinic to clinic transfers are responsible to obtain client consent on the Transfer Release form. The release will list all required transfer documents. The required documents will be copied from the client's medical record and faxed to the receiving clinic. The packet will be filed in the client's medical record accompanied by proof of the client's admissions to the receiving clinic and fax transmission sheets. If the transfer packet is forwarded via secured email, the secured email page containing to who the information was sent, the clinic name, date, and time will be filed in the client's medical record. The Clinical Supervisor is responsible to review this process for each transfer and ensure compliance with the regulations. The Program Manager is responsible to monitor the process for compliance. The Division Director will facilitate documentation training on 06/29/2022. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to document the results of all annual physical examinations given by the narcotic treatment program, which is to include an annual reevaluation by the narcotic treatment physician in one of four applicable patient records reviewed.
Patient #4 was admitted on February 27, 2020 and was discharged on March 29, 2022. There was no annual physical examination given by the narcotic treatment program documented in the patient record prior to discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Nurse Manager is responsible for scheduling the Annual Physical appointments for the doctors and notifying the clinical team each month of the appointments for the following month. The Nurse Manager is responsible to place the appointment message reminder in the AMS system as well as provide the appointment sip to the clients. The Nurse Manager is responsible to place the clients on hold for the day of their scheduled Annual Physical appointments. If the client presents after the scheduled appointment time, the Nurse Manager will send the client to be seen for the appointment according to the availability of the doctor on site that day. If the client presents after the doctor leaves for the day, the Nurse Manager will place the client on hold for the following day. The Division Director is responsible to monitor compliance of this requirement. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
|
Observations
Based on a review of patient records, the facility failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and was reviewed, dated, and signed by the medical director in three of four applicable patient records reviewed.
Patient #2 was admitted on December 10, 2019 and was active at the time of inspection. There was no annual evaluation of the patient's status documented in the client record at the time of inspection.
Patient #4 was admitted on February 27, 2020 and was discharged on March 29, 2022. The annual evaluation of the patient's status was completed by the counselor on March 3, 2022; however, the evaluation was not reviewed, dated, and signed by the medical director.
Patient #6 was admitted on January 21, 2020 and was discharged on May 12, 2022. The annual evaluation of the patient's status was completed by the counselor on January 3, 2022; however, the evaluation was not reviewed, dated, and signed by the medical director.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Nurse Manager is responsible for scheduling the Annual Physical appointments for the doctors and notifying the clinical team each month of the appointments for the following month. The Counselor of Record is responsible to use the email notification as a reminder to schedule the Annual Evaluation service and submit to the form to the doctor prior to the client's appointment date for the doctor's review and signature. The Clinical Supervisor is responsible to review and sign the submissions and ensure that all Annual Evaluations for the upcoming appointments are accounted for and forwarded to the doctor's attention for review and signature. The Annual Evaluation for client #2 will be completed and forwarded to the doctor for review and signature by 07/11/2022. The Program Manager is responsible to monitor this process for compliance. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
|
Observations
Based on review of the facility's unusual incident reports, the facility failed to notify the Department within 48 hours of a death or serious injury due to trauma, suicide, medication error or unusual circumstances.
On September 3, 2021, the facility was notified of the offsite death of a patient; however, there was no documentation that the incident was reported to the Department within 48 hours.
On September 10, 2021, the facility was notified of the offsite death of a patient; however, there was no documentation that the incident was reported to the Department within 48 hours.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
- The Administrative Supervisor will ensure that all Unusual Incident Reporting on client deaths are completed in the DDAP IR Reporting System within (3) business days of the incident. The Administrative Supervisor will also print a copy of the submitted report and file it in the client's medical record. The Division Director is responsible for monitoring this activity for 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.
|
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 three of seven client records reviewed.
Client #1 was admitted on October 13, 2021 and was still active at the time of inspection. A treatment plan update was completed on November 18, 2021, and the next update was due no later than January 18, 2021; however, the update was completed on March 31, 2022.
Client #4 was admitted on February 27, 2020 and was discharged on March 29, 2022. A treatment plan update was completed on September 16, 2021, and the next update was due no later than November 16, 2021; however, the update was completed on December 7, 2021.
Client #6 was admitted on January 21, 2020 and was discharged on May 12, 2022. A treatment plan update was completed on March 9, 2022, and the next update was due no later than May 9, 2022; however, the update was completed on May 12, 2022.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
? Counselors and Clinical Supervisors will be required to view their trackers every Friday for documentation due the following week. Counselors will place dosing members on hold for the following week to complete the Treatment Plan Updates identified as due for that week. If the member presents for group, the Treatment Plan will be completed after the end of the group. If the member cannot stay after group, the counselor will notify the clinical supervisor who will excuse the member form the group and complete the Treatment Plan Update service with the member. The member will be informed that they are not permitted to return to group until the Treatment Plan Update service is completed. The counselor and/or clinical supervisor will update the tracker after this service is completed. The Program Manager is responsible to ensure this process is followed by each counselor and clinical supervisor. This process will be reviewed weekly by the Program Manager. The Division Director will facilitate documentation training on 06/29/2022 for all clinical staff. The Division Director is responsible to ensure compliance of all staff involved in this process.
In reference to Client # 6: The treatment Plan was not late. According to the AMS Dosing report, this client was absent from treatment after May 5, 2022 until she was discharged on May 12, 2022.
|
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.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include follow-up information, in three of three applicable client records reviewed.
Client #5 was admitted on November 23, 2020 and was discharged on September 28, 2021.
Client #6 was admitted on January 21, 2020 and was discharged on May 12, 2022.
Client #7 was admitted on November 3, 2021 and was discharged on January 20, 2022.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Counselor of Record is responsible to submit the 30 day follow up notice to the Care Manager for their team. The Care Manger is responsible to mail out the follow up letter and submits the copy to the member's chart. The Clinical Care Manager is responsible to ensure all documents and outreach attempts related to the discharge process is completed prior to closing out the discharge process. The Program Manager is responsible to ensure this process is followed for all discharges. The Division Director is responsible to monitor for 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.
|
Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for providing hot water under pressure were submitted and approved by the Department for the February 5, 2021 and June 24, 2021 annual licensing inspections. Not having hot water under pressure was again found to be a deficiency in the June 15, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The current Division Director and Facilities Director were not in these positions during the time tis deficiency was cited the the department and unaware of the citation. Since being made aware of the deficiency, the plan to correct the hot water pressure, as stated above in P197 is as follows;
The Facilities Director is responsible to correct and maintain the appropriate water pressure throughput the facility. The Facilities Director and his team will shut off the incoming water supply for the entire building, after services on a Saturday, and drain the building. The team will then cut away any bad shut off valves and faucets and replace them with new ones. This will allow the shut off valves to be opened all the way to increase the pressure. The water pressure in all areas of the facility will be checked by the Facilities Director bi-monthly and any issues with appropriate functioning will be addressed accordingly. The Division Director is responsible to monitor compliance with this process. |