INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24-25, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Licensure Programs. Based on the findings of the on-site inspection, Drug and Alcohol Treatment 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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704.11(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 employee #16 received the minimum of six hours of HIV/AIDS training within the regulatory timeframe.Employee #16 was hired as a counselor on September 9, 2019 and was due to have the communicable disease trainings no later than September 9, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #16 is scheduled for the 6 hours HIV/AIDS training on April 26/27 2021. The Quality Management Officer is responsible for oversight and will validate the training is successfully completed.
Full compliance will be achieved on April 27, 2021. |
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.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #4's record.Employee #4 was hired as a counselor on December 15, 2003 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2020 through December 31, 2020. Employee #4's employee record only documented 21 hours of annual training for the training year reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a result of the licensing inspection we have created a Training Oversight Committee comprised of our Quality Management Officer and Outreach Coordinator. They will be responsible for approving/scheduling/tracking/validating attendance at appropriate trainings.
This process will be reviewed weekly in the Quality Assurance Meeting.
Full compliance achieved April 7, 2021 and reviewed by the CEO. |
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 the review of client records, the facility failed to document an completed informed and voluntary consent to release information form in seven out of seven client records reviewed, as the form did not include a dated client signature. Client #1 was admitted on September 23, 2020 and was still active at the time of the inspection. The four consent to release information forms dated September 23, 2020 were to a family member, probation, government agency, and the funding source. Client #2 was admitted on August 4, 2020 and was still active at the time of the inspection. The four consent to release information forms dated August 4, 2020 were to a family member, probation, government agency and the funding source. In addition, a consent form dated November 16, 2020 was to another treatment facility. Client #3 was admitted on December 2, 2020 and was still active at the time of the inspection. The five consent to release information forms dated December 2, 2020 were to a family member, funding source, two government agencies and another treatment facility. Client #4 was admitted on May 5, 2020 and was discharged on October 1, 2020. The three consent to release information forms dated May 5, 2020 were to a government agency, probation and the funding source. In addition, a consent form dated June 22, 2020 was to another treatment facility. Client #5 was admitted on June 30, 2020 and discharged on September 14, 2020. A consent form dated July 21, 2020 was to a government agency. A second form dated August 31, 2020 was to an attorney.Client #6 was admitted on June 3, 2020 and discharged on November 9, 2020. The four consent forms dated June 3, 2020 were to a funding source, government agency, family member and an attorney.Client #7 was admitted on May 22, 2020 and discharged on October 30, 2020. Four consent forms dated May 22, 2020 were to two government agencies, funding source and a family member. An additional consent form dated June 24, 2020 was to an attorney.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Agency was under the belief that verbal consent was approved under DDAP as it was under every other oversight body.
- Beginning Monday April 26, 2021 all new patients will have to report to the Agency to sign all necessary consents.
- We will use mailings to get appropriate signatures in extreme cases when the patient, due to emergent situations, is unable to come to the Agency.
- We are also investigating Docu-sign and our EMR as vehicles for getting releases signed remotely.
- Currently all active patients are being asked to report in person to the Agency to sign all releases; they are being contacted by their Primary Counselor; the Quality Management Officer is in charge of oversight of the process; the process will be complete by May 17, 2021. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of all of their client rights in seven out of seven records reviewed..These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client Rights will be added to our EMR and our clinical staff will have all active patients sign, documenting they reviewed them.
The Quality Management Officer will be responsible for the oversight of the implementation of it be added to our EMR. Our Intake Coordinator will be responsible for maintaining compliance with this standard. Full compliance by April 26, 2021. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document frequency of counseling services on the client's treatment plan in seven out of seven records reviewed. Client #1 was admitted on September 23, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was dated September 29, 2020.Client #2 was admitted on August 4, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was dated August 18, 2020.Client #3 was admitted on December 2, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was dated December 3, 2020.Client #4 was admitted on May 5, 2020 and was discharged on October 1, 2020. The comprehensive treatment plan was dated May 13, 2020.Client #5 was admitted on June 30, 2020 and discharged on September 14, 2020. The comprehensive treatment plan was dated July 2, 2020.Client #6 was admitted on June 3, 2020 and discharged on November 9, 2020. The comprehensive treatment plan was dated June 10, 2020.Client #7 was admitted on May 22, 2020 and discharged on October 30, 2020. The comprehensive treatment plan was dated May 29, 2020.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Quality Management Officer (QMO) will provide a training on frequency of counseling services and the documentation on the patients treatment plan. This training will take place April 15, 2021 in the weekly clinical staff meeting.
Clinical supervisors will be responsible for the ongoing oversight of maintaining compliance in this standard.
This standard will also be a focal point of the quarterly case file reviews facilitated by the QMO.
Full compliance - April 15, 2021. |