INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 4, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure that the clinical supervisor participated in documented monthly meetings with their supervisor to discuss their duties and performance during the first 6 months in the position in one of one applicable personnel record reviewed.
Employee #3 was hired as a clinical supervisor on January 22, 2024. There was no documentation, in the record of monthly clinical supervision meetings during the months of February 2024 and March 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: Clinical supervisor will meet at a minimum of one time per month with their supervisor. Each supervision will be documented. Director will monitor to ensure supervision is occurring regularly and as required. |
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 Staffing Requirement Facility Summary Report, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one of three applicable personnel records reviewed.
Employee #2 was hired as facility director on July 19, 2021. The HIV/AIDS training and the TB/STD training was due to be completed no later than July 19, 2023; however, there was no documentation that either training was completed as of the date of the inspection.
This is a repeat citation from the May 16, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Current Facility Director took the trainings while at a former position with Pyramid but could not locate the training certificates. Facility Director will enroll in the next available HIV/AIDS and TB/STD training to bring training requirements into compliance. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all heaters are permanently mounted or installed as there was a space heater located in Room #1.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Space heater has been removed from the premises. Program Director reviewed with all program staff that space heaters are prohibited. |
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 prior to the disclosure of information in one of seven client records reviewed.
Client #2 was admitted on January 5, 2023 and was active at the time of inspection. The consent to release information form to the funding source in the record expired on February 2, 2024. There was evidence of disclosures to the funding source after the expiration of the release form; however, there was no updated consent to release information form signed by the client, in the record, prior to any of the disclosures made after February 2, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Consent to release of information process was reviewed with the clinician and addressed in supervision. Clinical supervisor will review 2 charts per month to monitor ongoing compliance to regulation. The consent that was out of compliance has been redone with the client with correct dates and is in the chart. |
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.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of six applicable client records reviewed.
Client #3 was admitted on November 7, 2023 and was discharged on March 25, 2024. The comprehensive treatment plan was completed on November 30, 2023 and an update was due no later than January 30, 2024; however, the update was not completed prior to discharge.
Client #4 was admitted on August 3, 2023 and was discharged on December 21, 2023. A treatment plan update was completed on October 13, 2023 and the next update was due no later than December 13, 2023; however, the update was not completed prior to discharge.
Client #6 was admitted on June 21, 2023 and was discharged on February 23, 2024. A treatment plan update was completed on November 8, 2023 and the next update was due no later than January 8, 2024; however, the update was not completed prior to discharge.
Client #7 was admitted on September 26, 2023 and was discharged on January 4, 2024. A treatment plan update was completed on October 26, 2023 and the next update was due no later than December 26, 2023; however, the update was completed on January 3, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan requirements have been reviewed with the clinician in supervision. Clinician will use a document tracker to monitor due dates for all treatment plans. Tracker will be reviewed in weekly supervision for ongoing compliance. Clinical Supervisor will complete 2 chart reviews per month to monitor ongoing 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.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for failing to ensure each client's treatment and rehabilitation plans are updated at least every 60 days were submitted and approved by the Department from the May 24, 2022 and May 16, 2023 annual licensing inspections. Failing to ensure treatment plans are updated at least every 60 days was again found to be a deficiency in the April 4, 2024 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Timely treatment plan submission tracking will be added to the program scorecard which will be submitted to The Quality Management Committee on a monthly basis for review. An annual review of the program will be conducted by the Clinical Process Improvement Committee. Review of results on document tracker, scorecard and CPIC will be reviewed by Facility Director and Project Director. Continued noncompliance with treatment plan standards will result in disciplinary action for staff. |