INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 3, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Casa de Consejeria Drug and Alcohol Counseling Program, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the April 2020 through April 2022 fire drill logs, the facility failed to identify, on each fire drill log, either which exit route was used, the amount of time it took for evacuation or whether the fire alarm/smoke detector was operative. The July 2020 fire drill log did not document which exit route was used. Additionally, the October 2020 fire drill log did not document whether the fire alarm/smoke detector was operative. Also, the July 2021 and February 2022 fire drill logs did not document the amount of time it took for evacuation.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will review and retrain the Administrative Assistant on the correct way to conduct a fire drill and complete the fire drill logs. This includes, but not limited to exit route used, the amount of time it took for evacuation or whether the fire alarm/smoke detector was operative. The Administrative Assistant will set monthly reminders to conduct fire drills and complete the fire drill log correctly by filling in and checking off the necessary information required after conducting the fire drill. The facility director will also set monthly check-ins and review of documents to assure its appropriate completion. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the April 2020 through April 2022 fire drill logs, the facility failed to set off the fire alarm or a smoke detector during each fire drill. The October 2020 fire drill log did not document whether the fire alarm/smoke detector was set off and operative.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will review and retrain the Administrative Assistant on the correct way to conduct a fire drill and complete the fire drill logs. This includes, but not limited to exit route used, the amount of time it took for evacuation or whether the fire alarm/smoke detector were operative. The Administrative Assistant will set monthly reminders to conduct fire drills and complete the fire drill log correctly by filling in and checking off the necessary information required after conducting the fire drill. The facility director will also set monthly check-ins and review of documents to assure its appropriate completion. |
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 the policy and procedure manual and a review of client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in two of six applicable client records reviewed. Per the facility's policy and procedure manual, the individual treatment and rehabilitation plans are to be completed within thirty days from a client's admission date. Client #1 was admitted on March 9, 2022 and was still active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed by April 8, 2022 but was not completed until April 13, 2022.Client #7 was admitted on March 3, 2021 and was discharged on November 2, 2021. The individual treatment and rehabilitation plan was due to be completed by April 2, 2021 but was not completed until April 14, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director and/or clinical supervisor will hold a staff in-service training no later than 7/15/22 regarding the following essential elements of treatment planning. Special emphasis will be made on the timeframes and the importance of completing a timely comprehensive treatment plan within the first 30 days of a client admission. Areas of review will include:
Date of admission
Date of initial treatment plan
Date of present treatment plan
Date of subsequent treatment plan
DSM-IV five (5) diagnosis
Type and frequency of treatment and rehabilitative services
Behaviorally defined problem statement
Measurable long and short term treatment goals
Proposed types of support services.
Interdisciplinary treatment approach
Consumer involvement in formulation of TX plan
Methods of treatment
Interventions are specified (Action steps are specified, and are clearly follow up in progress notes)
Consumer strengths and barriers
Statement of understanding is present on treatment plan
TX plans are signed by all treatment team members
Treatment plans are completed within policy timeframe.
The auditing team, which includes the clinical supervisor and program director, will continue to conduct random chart audits on a bi-weekly basis and ensure that treatment plans include type and frequency of treatment, rehabilitation services, and correct time frames of completion. If circumstances prevent counselors from being timely with their treatments they must reflect and provide information through progress notes or complete discharge.
The current records where the deficiencies were found were reviewed with each corresponding counselor and were advised on the deficiencies and plan of correction. |
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. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has contacted an independent public accountant who will have our 2020 financial audit completed by the date indicated above. The Executive Director will make sure to secure the commencement of future audits no later than May 31 through an engagement letter and completed by June 30. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document a dated signature of the client on release of information forms in one of seven client records reviewed.Client #5 was admitted on December 2, 2021 and was discharged on February 25, 2022. There was a release of information form to a transportation provider signed by the witness on December 2, 2021. However, the dated signature of the client was not documented on the form.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor and/or facility director will hold an in-service training to discuss timely revisions and checks of releases of information in order to prevent expiration, lapses of time while a client is active in our program, appropriate completion of whom the release is for, client and witness signatures, and dates. The training will focus on including the correct signatures with dates for the clients and witnesses. Active charts will be audited in order to rectify any ROIs out of compliance and active clients will sign a new ROI.
The in-service will also discuss essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2, including the Health Insurance Portability and Accountability Act (HIPPA) The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be disclosed, to whom specifically, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether the client has received a copy. This will be completed by 7/15/22.
Clinical staff shall continue to attend recommended Department of Health training and provide documentation in areas such as confidentiality and client recordkeeping. This will be monitored by HR on an annual basis. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of a witness on release of information forms in one of seven client records reviewed.Client #3 was admitted on March 22, 2022 and was active at the time of inspection. There were release of information forms to an emergency contact, a funding source, a primary care physician and a laboratory signed by the client on March 22, 2022. However, the dated signature of the witness was not documented on any of the forms. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor and/or facility director will hold an in-service training to discuss timely revisions and checks of releases of information in order to prevent expiration, lapses of time while a client is active in our program, appropriate completion of whom the release is for, client and witness signatures, and dates. The training will focus on including the correct signatures with dates for the clients and witnesses. Active charts will be audited in order to rectify any ROIs out of compliance and active clients will sign a new ROI.
The in-service will also discuss essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2, including the Health Insurance Portability and Accountability Act (HIPPA) The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be disclosed, to whom specifically, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether the client has received a copy. This will be completed by 7/15/22.
Clinical staff shall continue to attend recommended Department of Health training and provide documentation in areas such as confidentiality and client recordkeeping. This will be monitored by HR on an annual basis. |
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 the client the opportunity to request reconsideration of a decision terminating treatment in one of one applicable client record reviewed.Client #6 was admitted on July 19, 2021 and was administratively discharged on November 19, 2021. The termination notice provided to the client did not provide an opportunity for the client to request a reconsideration of the involuntary termination.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor was informed of the deficiency. The missing termination letter was mailed explaining the reason for the discharge and the process for reconsideration.
Review of discharge documentation and process will be conducted through an in-service no later than 7/15/2022 by the clinical supervisor and/or facility director that will ensure the policy implementation of the discharge process including termination letters during the administrative discharges.
Quality Assurance along with the clinical supervisor and/or facility director regularly audits all discharges and compliance for aftercare and termination letters in order to prevent any missed documents. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 develop and document the individual's comprehensive treatment and rehabilitation plan with the client in two of six applicable client records reviewed. Client #1 was admitted on March 9, 2022 and was still active at the time of inspection. The comprehensive treatment plan was signed and dated by facility staff on April 8, 2022 and by the client on April 13, 2022; however, there was no documentation in the record stating that the plan was developed with the client's input.Client #7 was admitted on March 3, 2021 and was discharged on November 2, 2021. The comprehensive treatment plan was signed and dated by facility staff on March 30, 2021 and by the client on April 14, 2021; however, there was no documentation in the record stating that the plan was developed with the client's input.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director and/or clinical supervisor will hold a staff in-service training no later than 7/15/22 regarding the following essential elements of treatment planning. Special emphasis will be made on the timeframes and the importance of completing a timely comprehensive treatment plan within the first 30 days of a client admission. Areas of review will include:
Date of admission
Date of initial treatment plan
Date of present treatment plan
Date of subsequent treatment plan
DSM-IV five (5) diagnosis
Type and frequency of treatment and rehabilitative services
Behaviorally defined problem statement
Measurable long and short term treatment goals
Proposed types of support services.
Interdisciplinary treatment approach
Consumer involvement in formulation of TX plan
Methods of treatment
Interventions are specified (Action steps are specified, and are clearly follow up in progress notes)
Consumer strengths and barriers
Statement of understanding is present on treatment plan
TX plans are signed by all treatment team members
Treatment plans are completed within policy timeframe.
The auditing team, which includes the clinical supervisor and program director, will continue to conduct random chart audits on a bi-weekly basis and ensure that treatment plans include type and frequency of treatment, rehabilitation services, and correct time frames of completion. Progress notes were added to client records explaining the time gaps of dates signed to each record and that the plans were reviewed and completed with the client input. |
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 a maintain a complete client record on an individual, which is to include follow-up information, in two of four applicable client records reviewed.Client #6 was admitted on July 19, 2021 and was discharged on November 19, 2021. There was no follow-up information in the record at the time of the inspection.Client #7 was admitted on March 3, 2021 and was discharged on November 2, 2021. There was no follow-up information in the record 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 clinical supervisor and/or clinical supervisor will conduct an in-service training that will review and address the follow-up information during the discharge process of every client. This in-service will include the review of our policy and focus on completing a 30-day follow-up regardless of the reason or type of discharge that is done. To eliminate and prevent deficiency, the clinical supervisor and/or facility director reviews all discharges to ensure accuracy on discharge records and all their follow-ups. The in-service training will occur no later than 7/15/2022. |