INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of two applicable personnel records, the facility failed to provide a mechanism to provide feedback on a completed training in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated that staff are to complete the conference report section on the Conference Request Form within five working days after their training.
Staff #2 was hired on November 2, 2019, has been in the role of facility director since November 1, 2021, and was still in this position at the time of inspection. The facility was unable to provide feedback collected from trainings Staff #2 had participated in.
Staff #3 was hired on March 13, 2006, has been in the role of counselor since September 14, 2012, and was still in this position at the time of inspection. The facility was unable to provide feedback collected from trainings Staff #3 had participated in.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Training feedback will become part of the overall training plan for the year. This section will be added where staff will provide feedback on completed training. Facility Director will monitor completion of training feedback annually. |
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 four of six client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in records for client #1, #2, #4, and #6.
Client #1 was admitted on April 14, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on June 22, 2022. A treatment and rehabilitation plan update was due no later than August 22, 2022 however, a treatment and rehabilitation plan update did not occur until August 26, 2022. A treatment and rehabilitation plan was developed on October 20, 2022. A treatment and rehabilitation plan update was due no later than December 20, 2022 however, a treatment and rehabilitation plan update did not occur until January 5, 2023.
Client #2 was admitted on April 21, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on August 11, 2022. A treatment and rehabilitation plan update was due no later than October 11, 2022 however, there was no documentation of a treatment plan update in the client record at the time of the inspection.
Client #4 was admitted on April 25, 2022 and discharged on September 23, 2022. A treatment and rehabilitation plan was developed on June 10, 2022. A treatment and rehabilitation plan update was due no later than August 10, 2022 however, a treatment and rehabilitation plan update did not occur until August 16, 2022.
Client #6 was admitted on May 3, 2022 and discharged on August 26, 2022. A treatment and rehabilitation plan was developed on June 9, 2022. A treatment and rehabilitation plan update was due no later than August 9, 2022 however, a treatment and rehabilitation plan update did not occur until August 12, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Community Counseling policy states that Electronic Treatment plans shall be reviewed and updated at least every 60 days.
IT Staff will create a database report alerting clinicians that their client's treatment plans are due 14 days (46 day) before treatment plan is due. The report will be sent out to the primary clinician of the client and Facility Director. The Facility Director will monitor the database on a weekly basis. During the Drug & Alcohol weekly meeting and individual supervision, treatment plan report will be reviewed with D&A staff to insure clinicians are following the treatment plan review policy.
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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 five of five applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a case consultation must occur every ninety days.
Client #1 was admitted on April 14, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than July 18, 2022, however a case consultation was not documented in the client record until August 3, 2022.A case consultation was due to occur no later than November 3, 2022, however a case consultation was not documented in the client record until December 21, 2022.
Client #2 was admitted on April 21, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than July 21, 2022, however a case consultation was not documented in the client record until August 3, 2022.
A case consultation was due to occur no later than November 3, 2022, however a case consultation was not documented in the client record until December 21, 2022.
Client #3 was admitted on April 21, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than July 21, 2022, however a case consultation was not documented in the client record until August 3, 2022.
A case consultation was due to occur no later than November 3, 2022, however a case consultation was not documented in the client record until December 7, 2022.
Client #4 was admitted on April 25, 2022 and discharged on September 23, 2022. A case consultation was due to occur no later than July 25, 2022, however a case consultation was not documented in the client record until August 24, 2022.
Client #6 was admitted on May 3, 2022 and discharged on August 26, 2022. A case consultation was due to occur no later than August 3, 2022, however a case consultation was not documented in the client record until August 24, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Community Counseling agency's policy is that case consults are to be conducted at least every 90 days within the first year of continuous D&A services, and annually after one continuous year of service. Director of D&A Services will review aftercare plan status on a weekly basis.
IT Staff will create a data base to alert counselors at 60 days to complete a case consult. The Facility Director will monitor the data base on a weekly basis. During the Drug & Alcohol weekly meeting and individual supervision, case consults will be completed with D&A staff to insure clinicians are following case consult policy.
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