INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5-6, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Care & Addiction Recovery Services 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(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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to supervise the one counselor assistant by a full-time clinical supervisor or counselor who meets the qualifications.
Employee #7 was hired April 3, 2023 as a Counselor Assistant and was still employed in this position at the time of the inspection. Supervison of this employee was being performed by the Facility Director.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Supervision of the counselor assistant at CCARS has been shifted to a qualified counselor to be in compliance with DDAP regulations. Clinical staff have been retrained by the Director on the qualifications of any counselor providing this type of supervision going forward. Facility Director will be responsible to make sure any current or future counselor assistant will be supervised by a qualified counselor. Facility to be in full compliance as of 9/7/23. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on February 2, 2022, and was due to have the communicable disease trainings no later than February 2, 2023. There was no documentation in the personnel file of the completion of the four-hour TB/STD trainings as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
CCARS Director retrained all staff on the necessity of completing all required trainings within the mandated timeframes set by DDAP regulations. Staff understand that their position may be in jeopardy if found to not be in compliance going forward. Director will check in with all staff at regular clinical and staff meetings to ensure ongoing compliance. Employee #4 completed TB/STD (4 hr) training from DDAP on 9/29/23. Documentation was placed in the personnel file of employee #4. Facility in full compliance on 9/29/23. |
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 provide a complete client record, which is to include follow-up information in two out of four applicable discharged record reviews.
Client #6 was admitted on October 7, 2022, and was discharged on June 23, 2023. The facility's policy notes that a follow-up contact must occur within sixty days of discharge. Client #6's follow-up contact was to occur by August 23, 2023; however, a follow-up letter was not completed until September 5, 2023.
Client #8 was admitted on October 6, 2022 and was discharged on April 27, 2023. There was no documentation of a follow-up information in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CCARS experienced a change in some staff positions recently. New staff, as well as all other staff were retrained by the Director regarding the importance of sending a follow up letter within 60 days following discharge and then documenting this follow-up in client's record, as per CCARS policy. Client #8 had no documentation of a follow-up letter in client record. A follow-up letter has now been sent and documentation noted in client file.
Office Manager and Director will provide random audit of discharged files to ensure ongoing compliance regarding CCARS's follow up procedure. Facility to be in compliance by 9/18/23.
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