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, Wellness Recovery 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor met the educational qualifications for the position in one of two applicable personnel records reviewed.
Employee #3 was hired on June 1, 2023 and was still in the position at the time of the inspection. The employee had a bachelor's degree with the required experience; however, the major was in environmental science, which is not a qualifying major.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #3, whose educational qualifications did not initially meet the requirements for the counselor position, will be provided with additional training and resources to enhance their knowledge and skills relevant to counseling. They will also be encouraged to pursue further education or obtain relevant certifications to supplement their qualifications, aligning with the DDAP requirements for the counselor position. Effective May 1st, Employee #3 will transition to the role of counselor assistant, where they can apply their existing skills while working towards meeting the necessary qualifications for the counselor position. The Clinical Director will be responsible for monitoring progress and compliance.
The Clinical and Project Director will lead a comprehensive review of all personnel records to identify any additional instances of educational qualification discrepancies. The Project Director and Clinical Director have collaborated to update the hiring procedures, ensuring alignment between candidates' educational backgrounds and the qualifications necessary for counseling positions. This updated process will involve meticulous examination of academic transcripts during the recruitment phase, utilizing the DDAP-provided list of approved training programs as a guideline for evaluation.
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709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual in three of three applicable records.
The policy and procedure manual indicates a discharge summary be completed at time of discharge.
Client #10 was admitted to detox on December 19, 2023 and was discharged on December 21, 2023. The discharge summary was due to be completed no later than December 21, 2023, however, the discharge summary was not completed until April 2, 2024.
Client #11 was admitted to detox on January 24, 2024 and was discharged on January 26, 2024. The discharge summary was due to be completed no later than January 26, 2024, however, the discharge summary was not completed until February 26, 2024.
Client #12 was admitted to detox on March 8, 2024 and was discharged on March 12, 2024. The discharge summary was due to be completed no later than March 12, 2024, however, the discharge summary was not completed until March 22, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility's Policy and Procedure manual has undergone revision to mandate that all client discharge summary documentation must be finalized by a therapist within 14 days following discharge. The clinical team has been duly informed and educated regarding this policy update. The Clinical Director will assume responsibility for monitoring both progress and compliance in this regard. Additionally, dates will be routinely reviewed during weekly chart audits and supervision meetings to ensure adherence to the established timeline. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in six of six applicable records.
Client #1 was admitted to inpatient on March 6, 2024 and was still active at the time of the inspection. The treatment plan was dated March 18, 2024.
Client #2 was admitted to inpatient on March 20, 2024 and was still active at the time of the inspection. The treatment plan was dated April 3, 2024.
Client #4 was admitted to inpatient on November 3, 2023 and discharged on December 1, 2023. The treatment plan was dated November 17, 2023.
Client #5 was admitted to inpatient on November 21, 2023 and discharged on December 18, 2023. The treatment plan was dated December 5, 2023.
Client #6 was admitted to inpatient on February 1, 2024 and discharged on February 8, 2024. The treatment plan was dated February 5, 2024.
Client #7 was admitted to inpatient on March 19, 2024 and discharged on March 21, 2024. The treatment plan was dated March 21, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Director will institute a revised documentation protocol mandating that the proposed type of support service must be clearly documented on every individual treatment care plan. This process will involve educating our clinical team on the importance of accurate and comprehensive documentation, emphasizing the critical role it plays in delivering effective and tailored support to our clients. The Clinical Director will oversee the implementation of this protocol and closely monitor compliance. Regular audits and supervision meetings will also be conducted to ensure ongoing adherence to the revised documentation standards. Through these proactive measures, we are committed to upholding the highest standards of care and ensuring that each client receives the appropriate support services outlined in their treatment plans. Documentation changes will take effect May 4th, 2024. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide verification that any work done by the client at the project is an integral part of his treatment and rehabilitation plan, in six of six applicable residential records reviewed.
There was no documentation on any treatment plan that work done by the client while in residential treatment was an integral part of treatment in the following records:
Client #1 was admitted to inpatient on March 6, 2024 and was still active at the time of the inspection.
Client #2 was admitted to inpatient on March 20, 2024 and was still active at the time of the inspection.
Client #4 was admitted to inpatient on November 3, 2023 and discharged on December 1, 2023.
Client #5 was admitted to inpatient on November 21, 2023 and discharged on December 18, 2023.
Client #6 was admitted to inpatient on February 1, 2024 and discharged on February 8, 2024.
Client #7 was admitted to inpatient on March 19, 2024 and discharged on March 21, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Director will implement a revised documentation protocol requiring that any work done by the patient during treatment be clearly documented on every individual treatment care plan, tailored to their needs, abilities, and strengths. This initiative will include comprehensive education for our clinical team, highlighting the pivotal role accurate documentation plays in providing effective and personalized support to our clients. The Clinical Director will supervise the implementation of this protocol and closely monitor compliance. Additionally, regular audits and supervision meetings will be conducted to consistently uphold the revised documentation standards. These documentation updates will be implemented starting May 4th, 2024. |