INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 31, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tradition House 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(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 six personnel and training records on October 31, 2017, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two personnel records reviewed.
Employee # 3 was hired as a counselor on November 12, 2007 and promoted to Lead Counselor on October 27, 2014. Employee # 3 only completed 18.75 clock hours of annual training for the January to December 2016 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure that employee #3 completes her full 25 clock hours of annual training for the present year. Program Director will review policy regarding training hours with the lead counselor. Human Resource Coordinator will monitor employee files quarterly to ensure compliance with mandated trainings. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation during the physical plant tour for the licensing inspection on October 31, 2017, the facility failed to ensure that counseling sessions could not be heard outside of the counseling room in two separate counselor offices.
During the tour, a counselor on the second floor and a counselor in the basement area conducted sessions with the door to their office open. Conversations between the counselor and the client could be clearly heard by this licensing specialist, staff members, and anyone else in the vicinity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff was re-educated on ensuring confidentiality of clients while in the counselors office on November 8, 2017 during clinical meeting. Clinical staff will utilize sound machines and ensure their doors are closed during individual sessions etc. Program Director and Lead Counselor will monitor weekly to ensure compliance. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 eight client records on October 31, 2017, the facility failed to document that the individual treatment and rehabilitation plan was developed with the client in one of eight client records reviewed.
Client #5 was admitted to treatment on August 14, 2017 and was discharged on September 22, 2017. The client's individual treatment and rehabilitation plan was developed on August 18, 2017 but was never signed by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff were retrained on completion of treatment plans and treatment plan reviews during clinical meeting on November 8,2017. Counselors will ensure updates are being completed and reviewed and signed off with the client, within the required time frame. Lead Counselor and Program Director will complete monthly chart audits to ensure compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of eight client records on October 31, 2017, the facility failed to document that treatment and rehabilitation plans were updated every 30 days in four of eight client records, as required.
Client #2 was admitted to treatment on July 11, 2017. The comprehensive treatment plan was developed on July 25, 2017 and the update was completed on October 6, 2017.
Client #3 was admitted to treatment on August 18, 2017. The comprehensive treatment plan was developed on August 25, 2017 and the update was completed on October 31, 2017.
Client #6 was admitted to treatment on July 13, 2017. The comprehensive treatment plan was developed on July 31, 2017 and the updated treatment plan dated August 24, 2017 was not signed by the client.
Client #7 was admitted to treatment on January 31, 2017 and was discharged on May 9, 2017. The comprehensive treatment plan was developed on February 8, 2017 and the only updated treatment plan was dated March 6, 2017. A treatment plan was due on April 6, 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed regulations for tx plans and tx plan reviews with clinical staff on November 8,2017, during clinical staff meeting. Discussed importance of meeting required time lines. Program Director and Lead Counselor will monitor progress and compliance with tx plan and tx plan reviews during monthly chart audits. |