INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors and lead counselors who have not functioned for 2 years as a supervisor in the provision of clinical services completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed.
Employee #3 was hired as a clinical supervisor on July 18, 2022. The employee's resume did not indicate there was 2 years of clinical supervision experience prior to being employed. There was no documentation of a Department-approved clinical supervision core curriculum training on file at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon review, the program discovered an updated resume was not presented to auditor. Please see accompanying current resume which shows over 5 years of supervisory experience. Additionally, the program sees immense value in the Core Curriculum Clinical Supervisor training. Employee #3 registered for a DDAP approved Clinical Supervisor training with registration receipt 5/30/23. Clinical Supervisor will complete the Core Curriculum-Supervisor Training and receive certification by July 31, 2023. Training certificate will be uploaded to Employee #3 personnel file for future inspections. Moving forward, any newly hired Lead Counselors or Clinical Supervisors who have not functioned for 2 years as a supervisor in the provision of clinical services will complete the Core Curriculum Clinical Supervisor training within 2 years of hire date. This will be tracked by the Facility Director annually and upon hire of new staff. |
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 personnel records and the Staffing Requirement Facility Summary Report, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in two of six personnel records reviewed.
Employee #5 was hired as clinical support staff on March 6, 2000. The HIV/AIDS and TB/STD trainings were due to be completed no later than March 6, 2002; however, the HIV/AIDS training was not completed until September 15, 2021 and there was no documentation of the TB/STD training at the time of inspection.
Employee #6 was hired as clinical support staff on April 15, 2019. The HIV/AIDS and TB/STD trainings were due to be completed no later than April 15, 2021; however, the HIV/AIDS training was not completed until September 15, 2021 and there was no documentation of the TB/STD training at the time of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The staff found to be outstanding in TB/STD training were longstanding employees. Due to turnover across all levels of management within the last 2 years and the tenure of each employee, this training was missed for Employees #5 and #6.
Employees #5 and #6 registered for the TB/STD training on July 14, 2023 but have been wait listed. Clinical Supervisor will monitor the DDAP training calendar and re-register employees #5 and #6 for TB/STD training if necessary. Due to wait list issues, we plan to complete these trainings by 9/30/23. Clinical Supervisor has now implemented an employee training tracker that includes hire dates, DDAP required training titles and timelines. The training tracker was implemented 5/22/2023. Clinical Supervisor will review the training tracking system with the Facility Director during monthly supervision meetings. The training tracker will also be reviewed with Project Director on a quarterly basis in order to ensure compliance with all training requirements. If any staff look to be missing training deadlines, they will be pulled from the schedule until they meet training requirements. Further, the agency's Quality Management Committee which includes Project Director/COO, Clinical Director, Director of Operations, Facility Director, Human Resources, and Director of Clinical Support Services will monitor training completion and address |
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 personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that a sufficient number of staff persons were certified in CPR and trained in first aid during the facility's hours of operation.
The facility did not provide documentation that any employee had current CPR certification. The facility's hours of operation are Monday through Tuesday from 8:30am to 6:00pm and Wednesday through Friday from 8:30am to 5:00pm and there were no employees that had current CPR certification coverage for the hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor completed CPR/First Aid training on May 27, 2023. Program Counselor completed CPR/First Aid training on June 6, 2023. The training of these two staff now satisfied the requirement to have "a sufficient number of staff persons so that at least one person trained is onsite". However, for added precaution, remaining staff (clinical support/front desk) will complete CPR/First Aid training no later than August 31, 2023.
Clinical Supervisor has now implemented an employee training tracker that includes hire dates, DDAP required training titles including CPR/First Aid, and timelines. The training tracker was implemented 5/22/2023. Clinical Supervisor will review the training tracking sheet with the Facility Director during monthly supervision meetings. Project Director will review compliance with training completion dates on a quarterly basis. If any staff look to be missing training deadlines, they will be pulled from the schedule until they meet training requirements. Additionally, the executive team including CEO, COO, CHRO and Chief Compliance Officer now review status of CPR completion on a monthly rotation. Missing or late CPR dates will be identified and addressed directly with management and staff.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on review of the May 2022 through April 2023 fire drill logs, the facility failed to conduct an unannounced fire drill at least one time a month as there was no fire drill conducted during the month of December 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon investigation, the missing December 2022 fire drill was found to be due to staff turnover. The person responsible for administering unannounced fire drills left the organization in December. The month ended before a new person was assigned to conduct fire drills for the site.
The program has now established a back-up employee to run fire drills in the event the person typically responsible is out for an extended time. Persons responsible include Clinical Support Staff with Clinical Supervisor as back up and Facility Director as third back up.
Clinical Supervisor reviewed this monthly fire safety requirement with the clinical support staff during the group supervision meeting on June 1, 2023. Clinical Supervisor will monitor monthly fire drill completion through the training tracker. The training tracker will be reviewed monthly with the Facility Director during supervision meetings. Further, the agency's Quality Management Committee (which includes Project Director/COO, Direction of Operations, Chief Compliance Officer, Clinical Director and Facility Director) will review Fire Drill completion on a monthly basis to ensure timely completion.
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709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made to on a consent form in two of seven client records reviewed.
Client #4 was admitted on September 30, 2022 and was discharged on November 30, 2022. A release of information form was signed and dated by the client on September 30, 2022 and the consent form documented " insurance " as the name of the person, agency, or organization to whom the disclosure was made to.
Client #5 was admitted on November 2, 2022 and was discharged on January 23, 2023. A release of information form was signed and dated by the client on November 2, 2022 and the consent form did not include a name of the person, agency, or organization to whom the disclosure would be made to.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #4 and Client #5 have been discharged and consent forms end-dated/inactive. These consent forms were the first completed by the counselor so this issue was identified to be caused by a training/education issue.
Clinical Supervisor retrained counselor and support staff on confidentiality procedures including proper informed consent completion. This training took place on June 8, 2023. Further, the Clinical Supervisor will monitor monthly through client chart audits. Any deficiencies identified will be addressed with the staff and consent form corrected.
Clinical Supervisor will also partner with the agency Clinical Director, Director of Clinical Support Services and the Clinical Performance Improvement Committee to conduct random quarterly chart reviews which will focus on accurate and timely completion of consent forms. The chart review findings will be presented to the Quality Management Committee on a monthly basis. If deficiencies are identified the committee will recommend and enforce corrective action.
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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 client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in two of three applicable client records reviewed.
Client #2 was admitted on January 6, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on February 1, 2023, and the first update was due no later than April 1, 2023; however, the update was completed on April 11, 2023.
Client #3 was admitted on January 11, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on February 1, 2023, and the first update was due no later than April 1, 2023; however, the update was completed on April 5, 2023.
This is a repeat citation from the May 24, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon review it was discovered that the citation was repeated due to supervisor missing submission dates.
Facility Director reviewed treatment plan submission timeline requirements with clinical supervisor and program counselors during group supervision on June 1, 2023.
The program has now implemented a new tracker which will monitor treatment plan submissions through a spreadsheet to ensure plans are submitted prior to the 60-day timeline. In order to avoid this being a repeat finding in future, the tracker will now be reviewed with Facility Director on a monthly basis in order to ensure timely completion. As a further layer of oversight, the tracker will also be reviewed with the Project Director, Clinical Director and Quality Management Committee to ensure additional oversight. Staff who are found to be out of compliance will be held accountable in conjunction with HR.
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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 client records, the facility failed to a maintain a complete client record on an individual, which is to include case consultation notes, in four of four applicable client records reviewed.
Client #1 was admitted on November 30, 2022 and was active at the time of inspection. A case consultation note was completed and signed by the clinician on January 11, 2023; however, the note did not document the case had been discussed with any other staff members.
Client #2 was admitted on January 6, 2023 and was active at the time of inspection. A case consultation note was completed and signed by the clinician on January 18, 2023; however, the note did not document the case had been discussed with any other staff members.
Client #3 was admitted on January 11, 2023 and was active at the time of inspection. There was no documentation of a case consultation note in the client record at the time of the inspection.
Client #5 was admitted on November 2, 2022 and was discharged on January 23, 2023. A case consultation note was completed and signed by the clinician on December 5, 2022; however, the note did not document the case had been discussed with any other staff members.
This is a repeat citation from May 24, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon review, the program found that the Clinical Supervisor misunderstood the case consultation and previously thought that the submission of the case consult note by the clinician satisfied the regulation. Clinical Supervisor has been re-trained as of 5/22/2023 and effective immediately, will be completing monthly case consultation notes in collaboration with the counselors.
It is now understood this is a team approach to monitoring client progress.
Effective immediately, the Clinical Supervisor will complete monthly client case consultation notes during employee supervision meetings. Monitoring of case consultation notes will be tracked through the documentation tracking tool. This tracking tool will be overseen by the Facility Director. The tracking tool will also be presented quarterly to the Project Director and Quality Management Committee to ensure compliance.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include follow-up information, in two of four applicable client records reviewed.
Client #4 was admitted on September 30, 2022 and was discharged on November 30, 2022. There was no follow-up information in the record at the time of the inspection.
Client #5 was admitted on November 2, 2022 and was discharged on January 23, 2023. There was no follow-up information in the record at the time of the inspection.
This is a repeat citation from the May 17, 2021 and May 24, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon Project and Facility Director's review, it was found that the Clinical Supervisor did not effectively monitor the discharge tracking and follow-up post discharge. This procedure was reviewed with the Clinical Supervisor and counselors during group supervision on 5/24/2023.
Clinical supervisor will continue to review discharge follow-up procedures with counselors and support staff during group and individual supervision. Counselors will contact clients within seven (7) days of discharge and document the outreach. Counselors will also mail a hard copy of the agency discharge/re-engagement letter to the client within seven (7) days of discharge.
Effective immediately, the Clinical Supervisor will monitor completion of follow up contacts while processing all discharges. Monitoring of follow up information will be tracked through the documentation tracking tool. This tracking tool will be overseen by the Facility Director. The tracking tool will also be presented quarterly to the Project Director and Quality Management Committee to ensure compliance.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for failing to document follow-up information in the client record were submitted and approved by the Department for the May 24, 2022 and May 17, 2021 annual licensing inspections. Failing to document follow-up information was again found to be a deficiency in the May 16, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Facility Director failed to ensure actions were taken to adequately address repeat citations from the previous year's inspection. Facility Director has implemented a formal warning for the repeat citation with staff. Clinical Supervisor will review in team meetings and individual supervisions citations and steps to be taken to address regulation requirements. Clinical Supervisor and Facility Director will continue to monitor progress made towards corrective action plan deadlines to ensure compliance with regulations.
The facility plans to review all current and former plans of correction with the support of the agency compliance department. The Facility Regional Director and Clinical Supervisor will collaborate with the Chief Compliance Officer to monitor the plans of correction on a quarterly basis.
The Facility Regional Director and Clinical Supervisor will also partner with the agency's internal Clinical Performance Improvement Committee to conduct spot client chart reviews to monitor compliance.
The agency executive team is committed to improvement and will review program status on a regular basis during Quality Management Committee meetings. The meetings include COO/Project Director, Clinical Director, Director of Operations, Human Resources, Chief Compliance Officer, Director of Clinical Support Services and Facility Director. If a problem with compliance is identified, staff will be held accountable and/or pulled from schedule. The agency's approach to monitoring these specific citations at an executive level will ensure citations do not occur again. |