INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Conewago Place 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 the Staffing Requirements Facility Summary Report (SRFSR) and eight personnel records, the facility failed to document that the one counselor met the qualification for the position.
Employee #5, who was hired as a counselor on September 25, 2023 and was still employed in that position at the time of the inspection. Employee #5 did not meet the qualification requirements to be a counselor. At the time of the hire, the employee did not have a qualifying degree or full certification as an addiction ' s 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.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/14/2024 Employee #5 is no longer employed by Conewago Place. Firetree shall ensure that all credentials for future clinical staff hires are verified and meet all relevant regulations and requirements for that position.
To ensure that all clinical staff meet the minimum requirements for the position of counselor or counselor assistant, Firetree HR recruiter will verify candidates degree, as well as clinical experience prior to the scheduling of an interview for the position. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for not following their policy on when history and physicals are completed in three out of seven records reviewed. The facility ' s policy and procedures manual states that history and physicals are completed within forty-eight hours of admission. Additionally, the facility failed to follow their policy on when treatment plans are updated in four out of seven records reviewed. The facility ' s policy and procedures manual stated that the initial treatment plan update is completed at fifteen days and then every thirty days thereafter.
Client #1 was admitted on May 29, 2024 and was still active at the time of the inspection. The history and physical was due no later than May 31, 2024; however, it was not completed until June 1, 2024. A comprehensive treatment plan was completed on June 4, 2024 and the next update was due no later than June 19, 2024; however, it was not completed until June 25, 2024.
Client #3 was admitted on June 5, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on June 11, 2024 and the next update was due no later than June 26, 2024; however, it was not completed until June 30, 2024.
Client # 4 was admitted on November 22, 2023 and discharged on January 22, 2024. The history and physical was due no later than November 24, 2023; however, it was not completed until November 25, 2023.
Client #5 was admitted on September 6, 2023 and discharged on November 6, 2023. A comprehensive treatment plan was completed on September 12, 2023 and the next update was due no later than September 26, 2023; however, it was not completed until October 10, 2023.
Client #6 was admitted on October 18, 2023 and discharged on December 18, 2023. The history and physical was due no later than October 20, 2023; however, it was not completed until October 21, 2023.
Client #7 was admitted on January 31, 2024 and discharged on April 1, 2024. A comprehensive treatment plan was completed on February 6, 2024 and the next update was due no later than February 21, 2024; however, it was not completed until March 6, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/10/2024 the Clinical staff were retrained in the areas of treatment plans as well as discharge summaries. The areas that were covered in the training included content of the treatment plans and discharge summaries as well as the due dates of each treatment plan and discharge summary. The specific due dates covered for the treatment plans was the initial treatment plan update is due at fifteen days and then due every thirty days thereafter. In regards to the content covered for the due dates for the discharge summary, staff was trained that the discharge summary is due no later than five days after discharge as per policy. To ensure future compliance, treatment plans and discharge summaries will be audited on a monthly basis by the Firetree compliance team to ensure they are completed in the proper time frame.
On 7/11/2024 the facility nurse met with the facility medical director to review adherence to the company policy that all history and physicals must be completed within forty-eight hours of admission. To ensure future compliance the history and physical dates will be reviewed by the compliance team during chart audits on a monthly basis.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that annual written individual staff performance evaluations, were reviewed and signed by the employee per the facility ' s policy and procedure manual in one out of two applicable personnel records reviewed. The facility ' s policy and procedure manual states that the annual job performance evaluations are completed annually based on the employee ' s date of hire.
Employee #7 was hired on October 22, 2020 as a counselor and is still in that position at the time of the inspection The annual work performance was due no later than October 22, 2023; however, it was not completed until July 6, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
During the time frame that Employee #7 annual evaluation was due to be completed there were some adjustments being made to the company's evaluation forms and the corrections were not completed at the time the evaluation was due. As of 7/15/2024 the adjustments have been made and the new evaluations forms are now available to all facilities in the company's KRONOS system. To ensure compliance with the annual evaluations due dates, the KRONOS system will notify the employee when their annual self-evaluations are due. Once the employee completes their self-evaluation the KRONOS system will notify the Facility Director that the annual evaluation is due to be completed for each employee. |
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 obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included missing name of the person, agency or organization to whom disclosure is made in one out of seven records reviewed.
Client #1 was admitted on May 29, 2024 and was still active at the time of the inspection. A release of information form was signed and dated on May 29, 2024 that did not include the name of the person, agency or organization to whom disclosure is made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/10/2024 the Clinical Staff received retraining on informed and voluntary consents for the disclosure of information. Training included specifics in regards to informed and voluntary consents especially in the areas of specific information that could be released for an informed and voluntary consent as well as the name of person, agency or organization to whom disclosure is made. To ensure future compliance consents will be reviewed during monthly chart reviews completed by the Firetree compliance team. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of the client records, the facility failed to ensure that verbal orders from the physician or other medical professional authorized by State and Federal law to prescribe medication was authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication within 3 business days from the time the order was given in three out of seven records reviewed.
Client #1 was admitted on May 29, 2024 and was still active at the time of the inspection. A verbal order was placed by the physician on June 12, 2024. The written documentation from the physician was due no later than June 17, 2024; however, the physician did not sign the order until June 20, 2024.
Client # 4 was admitted on November 22, 2023 and discharged on January 22, 2024. A verbal order was placed by the physician on December 1, 2023. The written documentation from the physician was due no later than December 6, 2023; however, the physician did not sign the order until December 13, 2023. A verbal order was placed by the physician on December 7, 2023. The written documentation from the physician was due no later than December 12, 2023; however, the physician did not sign the order until December 13, 2023. A verbal order was paced on December 22, 2023. The written documentation from the physician was due no later than December 27, 2023; however, the physician did not sign the order until December 29, 2023.
Client #5 was admitted on September 6, 2023 and discharged on November 6, 2023. A verbal order was placed from the physician on September 7, 2023. The written documentation from the physician was due no later than September 12, 2023; however, the physician did not sign the order until September 19, 2023. A verbal order was placed by the physician on October 12, 2023. The written documentation was due no later than October 17, 2023; however, the physician did not sign the order until October 21, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On 7/11/2024 the facility nurse reviewed with the facility medical director the requirement that all verbal orders for medication must be have written authentication within 3 business days from the time the order was given. To ensure future compliance all verbal orders will be reviewed by the compliance team during monthly chart audits to ensure written authentication has be completed within the required time frame. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection on July 8, 2024, the facility failed to ensure that drugs for external use were stored separately from oral drugs as there was tubes of cream stored with the oral medication in the medication cart.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/8/2024 all topical medications were reorganized to store oral medications away from topical medication utilizing a partition and proper labelling. To ensure future compliance that no topical medication is stored with oral medication the facility director will complete weekly checks of the medication cart. |