INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Penn Foundation 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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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 provide documentation of an individual training plan developed with input from both the employee and the supervisor in one of six personnel records reviewed.
Employee # 1 was hired as the Project Director on January 22, 2019. The individual training plan for the current training year was not completed as of the date of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The training plan for employee # 1 was completed on 10/27/2021. The Board President is responsible for completing the individual training plan for the project director annually. The facility director will complete a training chart audit annually to ensure that a training plan is present for each employee. |
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.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project director completed at least 12 clock hours of annual training during the facility's July 1, 2020 through June 30, 2021 training year in one of one applicable personnel record reviewed.
Employee # 1 was hired as the Project Director on January 22, 2019. The personnel record documented 10.25 hours of training.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/15/2021, The facility director will complete an audit of completed trainings for the project director two times per year to ensure that the project director completes 12 hours of training per year. Trainings completed outside of the My E-learning platform will be uploaded into the system. |
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 personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training during the facility's July 1, 2020 through June 30, 2021 training year in one of three applicable personnel records.
Employee #5 was hired as a counselor on January 22, 2019. The personnel record documented 24 hours of training.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/15/2021 Clinical supervisors
will complete an audit of the My E-learning account for each employee three times per year to ensure that employees are registering for and completing 25 training hours throughout the training year. Trainings taken outside of the My E-learning platform will be uploaded in the system. If the My E-learning audit shows that an employee is not making progress toward training hours at the time of the audit this will be addressed by the clinical supervisor during individual supervision. |
705.26 (1) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(1) Shall have a heating and cooling ventilation system that is adequate to maintain an indoor temperature of at least 65F in the winter. When indoor temperatures exceed 90F, mechanical ventilation such as fans or air conditioning shall be used.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all heaters were permanently mounted or installed as there was a space heater located in office #112.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The space heater was removed from the vacant office on 10/25/2021. On 10/26/2021, all staff were informed that space heaters are not permitted at any time. The clinical supervisor will conduct random office checks to ensure space heaters are not in the building. Violations of this policy will be addressed administratively by the facility director. |
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 October 2020 through September 2021 fire drill logs, the facility failed to identify, on the drill log, which exit routes were used during the drills conducted in April 2021, July 2021 and August 2021. Additionally, the facility failed to evacuate all individuals during the drills conducted in April 2021, July 2021 and August 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/1/2021, the maintenance department will conduct all fire drills. Fire drills will be documented on the fire drill log updated in January 2019, which includes all items required under this regulation. This form was redistributed to maintenance staff and the clinical supervisor on 11/1/2021 to ensure the correct form is being utilized. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to provide documentation that a written individual staff performance evaluation was developed annually, which is to include the employee signature, in personnel records in two of seven personnel records reviewed.
Employee #1 was hired as the Project Director on January 22, 2019. The annual performance evaluation was completed on June 17, 2021, but the evaluation did not include the employee signature.
Employee #3 was hired as a clinical supervisor on September 23, 2019. The annual performance evaluation for the current year was not documented in the record at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The completed annual performance evaluation for the project director was signed by the project director on 10/27/2021. The annual performance evaluation for the clinical supervisor had not been completed due to her supervisor leaving the agency recently, this was noted in the personnel record as a temporary measure. The interim supervisor completed the evaluation on 10/27/2021. Effective immediately, the facility director along with human resources staff will audit the annual performance evaluations to ensure they are signed by the employee and supervisor as well as completed in a timely manner. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form to each client's funding source prior to the disclosure of information in all seven client records reviewed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Due to COVID-19 emergency procedures verbal consent was obtained to release information to funding sources, and the Release of Information form was mailed to persons served to sign and return, per the 2020 plan of correction. Individuals did not consistently return the mailed forms. Effective, 9/1/2021 all persons served are required to come in person for their level of care assessment to ensure that Releases of Information contain a live signature. For persons enrolled in treatment services prior to 9/1/2021, the counselor or case manager will arrange for the person to come on site to sign a Release of Information form before their next scheduled appointment. Effective 11/1/2021, clinical supervisors will conduct quarterly audits to ensure compliance.
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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 the dated signature of the client on the release of information forms to each client's funding source in all seven client records reviewed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Due to COVID-19 emergency procedures verbal consent to disclose information in the client record was obtained, and the Release of Information form was mailed to persons served to sign and return, per the 2020 plan of correction. Individuals did not consistently return the mailed forms. Effective, 9/1/2021 all persons served are required to come in person for their level of care assessment to ensure that Releases of Information contain a live signature. For persons already enrolled in treatment services the counselor or case manager will arrange for the person to come on site to sign a Release of Information form before their next scheduled appointment. Effective 11/1/2021 clinical supervisors will conduct quarterly chart audits to ensure compliance. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgment by clients that they had been informed of their right to retain civil rights and liberties except as provided by statute in all seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to COVID-19 emergency procedures and services being delivered virtually, verbal consent was obtained and documents in the client record related to client rights. Effective, 9/1/2021 all persons served are required to come in person for their level of care assessment to ensure that a live signature is obtained on the acknowledgment receipt form stating that they have been informed of their right to retain civil rights and liberties except as provided by statute. Effective 11/1/2021, clinical supervisors will conduct quarterly chart audits to ensure compliance. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgment by clients that they had been informed of their right that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in all seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to COVID-19 emergency procedures and services being delivered virtually, verbal consent was obtained and documents in the client record related to client rights. Effective, 9/1/2021 all persons served are required to come in person for their level of care assessment to ensure that a live signature is obtained on the acknowledgment receipt form stating that they have been informed of their right that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion. Clinical supervisors will conduct quarterly chart audits to ensure compliance beginning 11/1/2021. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgment by clients that they had been informed of their right to inspect their own records and that the project, facility, or clinical director may temporarily remove portions of the record that are deemed to be detrimental to the client when the client is reviewing the record in all seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to COVID-19 emergency procedures and services being delivered virtually, verbal consent was obtained and documents in the client record related to client rights. Effective, 9/1/2021 all persons served are required to come in person for their level of care assessment to ensure that a live signature is obtained on the acknowledgment receipt form stating that they have been informed of their right to inspect their own records and that the project, facility, or clinical director may temporarily remove portions of the record that are deemed to be detrimental to the client when the client is reviewing the record. Effective 11/1/2021, clinical supervisors will conduct quarterly chart audits to ensure compliance. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgment by clients that they had been informed of their right to appeal a decision limiting access to their records to the director in all seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to COVID-19 emergency procedures and services being delivered virtually, verbal consent was obtained and documents in the client record related to client rights. Effective, 9/1/2021 all persons served are required to come in person for their level of care assessment to ensure that a live signature is obtained on the acknowledgment receipt form stating that they have been informed of their right to appeal a decision limiting access to their records to the director. Effective 11/1/2021, clinical supervisors will conduct quarterly chart audits to ensure compliance. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgement by clients that they had been informed of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in all seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to COVID-19 emergency procedures and services being delivered virtually, verbal consent was obtained and documents in the client record related to client rights. Effective, 9/1/2021 all persons served are required to come in person for their level of care assessment to ensure that a live signature is obtained on the acknowledgment receipt form stating that they have been informed of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records. Effective 11/1/2021, clinical supervisors will conduct quarterly chart audits to ensure compliance. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgement by clients that they had been informed of their right to submit rebuttal data or memoranda to their own records in all seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to COVID-19 emergency procedures and services being delivered virtually, verbal consent was obtained and documents in the client record related to client rights. Effective, 9/1/2021 all persons served are required to come in person for their level of care assessment to ensure that a live signature is obtained on the acknowledgment receipt form stating that they have been informed of their right to submit rebuttal data or memoranda to their own records. Effective 11/1/2021, clinical supervisors will conduct quarterly chart audits to ensure compliance. |
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 maintain a complete client record on an individual, which is to include follow-up information, in three of four applicable client records reviewed.
Client #5 was admitted on May 18, 2021 and was discharged on June 17, 2021.
Client #6 was admitted on December 4, 2020 and was discharged on February 1, 2021.
Client #7 was admitted on November 19, 2020 and was discharged on April 22, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/15/2021, support staff will conduct a follow up call within 7 days of the client's discharge from Penn Foundation Outpatient Services to determine the status of the client. Support staff will document the follow up call on the blank note form. The clinical supervisor will conduct quarterly chart audits to ensure compliance. |