INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5 - 6, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, PA Treatment and Healing 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
A review of personnel records was conducted on August 28, 2019 at the PA Treatment and Healing Scranton facility. During the review, it was discovered that employee #1 did not have an annual individual training plan.
Employee #1 was hired as the project director on June 3, 2019 and was still in the position as of the date of the onsite inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility failed to have an annual individual training plan in employee #1 personnel record. The employee and the HR Manager will complete and annual individual training plan and have it in the employee file as required. The project director as well as the facility director will continue to monitor this standard for ongoing compliance. In addition, the HR manager will create a spreadsheet with annual dates relating to but not limited to employee annual training plan(s). This tracking system will be updated on a monthly basis to be shared with all D&A supervisory level staff to ensure ongoing compliance.
The facility/agency is in compliance with this standard as of 10/2/2019 |
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 seven client records on September 5-6, 2019 and the policy and procedures manual on August 26-27, 2019, the facility failed to ensure that the client had been made aware of their client rights in client record #'s 1, 2, 3, 4, 5, 6 and 7. In addition, the facility's client rights policy failed to include all parts of the client rights regulation. In both the client record documentation and the policy and procedures manual, the project failed to include that a client may not be discriminated against based on color, marital status and handicap.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document that they may not discriminate against color, marital status, or handicap in their client rights policy.
The project director will update and review the policy and procedures manual and document in the client rights that PA Treatment and Healing D&A services may not discriminate against color, marital status, or handicap. This update will occur and be shared with all D&A staff on 10/4/19. On this date, the revised policy will be reviewed with all counselors by the project director and or facility director with all counselors who will monitor that written acknowledgment by the clients that they have been notified of these rights by 10/8/19. The project director and facility director will conduct weekly and monthly chart audits to ensure this standard is met on an ongoing basis.
The facility is in compliance with this standard as of 10/08/2019
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709.92(a) 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:
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Observations
Based on a review of seven client records on September 5-6, 2019, the facility failed to follow their policy and procedures manual timeline for developing the master treatment plan with the client in client records #3, 4 and 7. The "Coordination of Outpatient Drug & Alcohol Treatment Services" section of the policy and procedures manual states "it is the clinical staff person's responsibility to develop the Preliminary Treatment Plan with the client during the Intake Session and the Master Treatment Plan with fifteen (15) days of the date of the Intake Session."
Client #3 was admitted on June 28, 2019 and was still active at the time of the inspection. Intake was completed on June 28, 2019 and the master treatment plan was completed on September 3, 2019.
Client #4 was admitted on July 18, 2019 and was still active at the time of the inspection. Intake was completed on July 18, 2019 and the master treatment plan was completed on August 8, 2019.
Client #7 was admitted on August 6, 2019 and was still active at the time of the inspection. Intake was completed on August 6, 2019 and the master treatment plan was completed on August 30, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on a review of client records #3, 4 and 7. The facility failed to follow their policy and procedures manual timeline for developing the master treatment plan.
The facility director will review the policy and procedures manual timeline for developing the master treatment plan with all counselors during supervision. The facility director and project director will ensure compliance with this regulation through ongoing supervision and quality reviews of client files that will occur on a bi-weekly basis to ensure ongoing compliance as it relates to this standard.
The facility will be in compliance with standard as of 10/2/2019. |