INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18-19, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Rehabilitation Services 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on two applicable employee personnel records reviewed, the facility failed to provide documentation of close supervision for one counselor assistant with a bachelor ' s degree.
Employee # 8 was hired as a bachelor ' s level counselor assistant on April 24, 2023 and was still in this position at the time of the inspection. Based on a review of employee # 8's personal record there was no documentation of close supervision documented during the weeks of April 30-May 6 and May 7-May 13, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective at the time of this plan, the Clinical Director will conduct and document close supervision sessions on a weekly basis starting with the hire date of any clinical team members. These close supervision sessions will take place regardless of the team member having a caseload of active clients. These notes will be documented and filed in the newly hired team member's personnel file.
The Clinical Director will be responsible for ensuring the completion of the supervision sessions and documentation. The Executive Director will be responsible for oversight of the filing of completed supervision records. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to keep cooking and eating utensils in a clean and enclosed area. Cooking utensils were being stored hanging in an open area in the kitchen.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All kitchen utensils will now be stored in a plastic container with a closing lid. This procedure will override the recommendation from the health inspection visits which have advised that utensils can be stored hanging on a utensil rack.
This will be adhered to by the facility cook and will be overseen for compliance by the Kitchen Supervisor.
This plan of correction became effective on 9/19/23 |
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 one of eight client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client record # 5.
Client # 5 was admitted on June 8, 2023 and was still active at the time of the inspection. Progress notes indicated that an interpreter was used for individual therapy sessions, however, there was no informed and voluntary consent from the client for the disclosure of information for the interpreter in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A consent form has been developed which will serve as the informed consent documentation in cases where an interpreter is needed for communication with the client. This form indicates the name of the client, name of the interpreter, and an indication that the consent will govern the discussion of client information within individual and family therapy sessions.
This document was completed with Client #5 and the form will be used for any client needing translation services for individual events or ongoing therapy.
The consent will be maintained in the client record in the corresponding section with other confidentiality release forms.
The Clinical Director will check for the completion of this form during internal file audits. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on one of one applicable client record reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment.
Client # 2 was admitted on December 1, 2022 and discharged on December 22, 2022. There was no documentation in the client record notifying the client in writing of termination from the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When the determination has been made for the unsuccessful discharge of a client due to lack of treatment progress, program noncompliance which presents a risk to the safety of clients or staff, or a scheduled court hearing where the recommendation is made for an unsuccessful discharge from treatment, the client will be notified, in writing of the reasons for the recommendation and the opportunity to request reconsideration. This form will be signed by the client. If the client refuses to sign the document, this will be indicated on the form and the signed or unsigned document will be maintained in the client file.
Adherence to this policy will be maintained by the Clinical Director following a client record audit prior to the effective discharge date. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on three of eight client records reviewed, the facility failed to provide a complete client record to include information relative to the client ' s involvement with the project that included individualized group therapy progress notes. The group therapy notes reviewed did not include a comment relative to each individual ' s response or participation in the group session.
Client #5 was admitted on June 8, 2023 and was still active at the time of the inspection.
Client #7 was admitted on September 14, 2023 and was still active at the time of the inspection.
Client #8 was admitted on July 20, 2023 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/20/23, all group therapy notes must include a hand-written section under the "A" section of the DAP note. Group notes documenting the same group session may contain an identical description of the session topic. The assessment will be hand-written to ensure individuality of notes between clients in the same session.
Adherence to this policy will be maintained by the Clinical Director. |