INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Counseling Solutions of the Lehigh Valley, LLC 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 six personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one applicable employee received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee #2 was hired as the clinical supervisor on May 19, 2021 and was due to have the communicable disease training no later than May 19, 2022. However, 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 reviewed with facility staff during the licensing process.
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Plan of Correction
The project Director will ensure Employee #2 has completed the required HIV/AIDS training. This contractor has already provided proof of registration to attend the DDAP-approved HIV/AIDS training on 12/15/2022. This will be prevented in the future by ensuring all contractors are scheduled within 12 months of the hire date for all required trainings by Project Director. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of six personnel records, the facility failed to demonstrate that a sufficient number of staff persons had CPR certification and First Aid training as only one staff member was certified in CPR between May 2022 and the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has confirmed that at least two additional contractors on staff have completed First Aid / CPR certifications. This will be prevented in the future by ensuring all contractors are CPR/First Aid certified within 6 months of their hire date. Subsequently, schedule an annual CPR/First Aid training for all contractors. |
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 seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in four records reviewed.
Client #1 was admitted on February 26, 2022 and was active at the time of the inspection. The record contained documentation that personally identifying information was released to the Department of Human Services on April 7, 2022, June 11, 2022, and July 5, 2022, with no client signed consent to release information form signed by the client.
Client #2 was admitted on April 21, 2022 and was active at the time of the inspection. The record contained documentation that personally identifying information was released to the Department of Human Services on April 11, 2022, June 11, 2022, and July 6, 2022, with no client signed consent to release information form signed by the client.
Client #4 was admitted on April 21, 2022 and was discharged August 13, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on April 21, 2022, with no client signed consent to release information form signed by the client.
Client #6 was admitted on March 10, 2022 and was discharged on July 12, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on April 6, 2022, with no client signed consent to release information form signed by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project Director has implemented that all admissions moving forward complete a consent to release information to the Department of Human Services is completed by the assessor. Each counselor will ensure that each active client has a consent for NHS by 10/7/2022. This will be prevented in the future by ensuring all new intakes include this consent as a standard and will be reviewed by our Clincal Supervisor during case reviews. |
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 seven client records, the facility failed to include documentation of all the required client rights, including that client have the right to appeal a decision limiting access to their records to the director, in three records.
Client #1 was admitted on February 26, 2022 and was active at the time of the inspection.
Client #3 was admitted on May 10, 2022 and was active at the time of the inspection.
Client #7 was admitted on December 14, 2021 and was discharged on March 29, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has confirmed that all versions of the Client's Rights are up to date and include all required information: That each client has the right to appeal a decision limiting access to their records to the director, in three records. Our Administrative Assistant will remove all previous versions of the Client's Rights copies from the intake packets and replace them with the updated versions. Our counselors will review that all current clients have an updated reviewed and signed version of the client's rights by 10/7/2022 |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of seven client records, the facility failed to include documentation of a psychosocial evaluation in four records reviewed.
Client #1 was admitted on February 26, 2022 and was active at the time of the inspection.
Client #2 was admitted on April 21, 2022 and was active at the time of the inspection.
Client #3 was admitted on May 10, 2022 and was active at the time of the inspection.
Client #5 was admitted on May 28, 2022 and was discharged on August 24, 2022.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure that every assessment and admission has a psychosocial summary note which will include an overall evaluation of the client's history and current clinical observation at the time of that initial visit. This will be confirmed by the Clinical Supervisor during the orientation session following each admission of every new client. |
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 seven client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of seven applicable records reviewed.
Client #2 was admitted on April 21, 2022 and was active at the time of the inspection. The treatment and rehabilitation plan was completed on April 21, 2022 and a treatment plan update was due to be completed by June 21, 2022; however, the next treatment plan update was not completed until July 12, 2022.
Client #3 was admitted on May 10, 2022 and was active at the time of the inspection. The treatment and rehabilitation plan was completed on May 10, 2022 and a treatment plan update was due to be completed by July 10, 2022; however, the next treatment plan update was not completed until August 13, 2022.
Client #6 was admitted on March 10, 2022 and was discharged on July 12, 2022. A treatment plan update was completed on April 27, 2022 and another treatment plan update was due to be completed by June 27, 2022; however, no treatment plan updates were completed prior to the client ' s discharge.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will complete supervision with each counselor by 10/7/2022 to ensure that all review our policy of treatment plan update completion every 60 days. This will be prevented in the future by ensuring all counselors review each clients' documentation during case review with the Clinical Supervisor. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of seven client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include documentation that the clients received case consultations in two of six records reviewed.
Client #4 was admitted on April 21, 2022 and was discharged August 13, 2022.
Client #7 was admitted on December 14, 2021 and was discharged on March 29, 2022.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Clinical Supervisor will complete supervision with each counselor by 10/7/2022 to ensure that all review our policy of case consultation completion every 90 days. This will be prevented in the future by ensuring all counselors review all clients' documentation during the case review with the Clinical Supervisor. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of client records, the facility failed to follow their written client follow-up policy in three of four applicable records reviewed.
Client #4 was admitted on April 21, 2022 and was discharged August 13, 2022. The client record did not contain documentation of follow up information with the client within 7 days of discharge.
Client #5 was admitted on May 28, 2022 and was discharged on August 24, 2022. The client record did not contain documentation of follow up information with the client within 7 days of discharge.
Client #7 was admitted on December 14, 2021 and was discharged on March 29, 2022. The client record did not contain documentation of follow up information with the client within 7 days of discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will complete supervision with the Administrative Assistant by 10/7/2022 to review our policy of follow-up completion within 7 days of unsuccessful discharge and within 6 months for successful discharges. This will be prevented in the future by completing a monthly QA review of discharged cases by the Project Director. |