INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 26-28, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Three Rivers Youth 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 document that each counselor met the educational qualifications for the position of counselor in two of three applicable records.Staff #3, who was hired as a counselor on July 10, 2015, did not meet the educational requirements to be a counselor. Staff #3 previously qualified as a fully certified addiction counselor. At the time of the inspection, the certification was expired. Staff #4, who was hired as a counselor on October 16, 2023, did not meet the educational requirements to be a counselor. The transcripts provided did not verify the degrees were obtained. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Three Rivers Youth will follow agency policies and protocols related to staff qualifications at hire. It is required that employees submit all required documentations prior to hiring included but not limited to degrees and certifications. In addition staff must submit any updated certifications related to employment requirements and state/county regulations. The Director will follow-up monthly with staff and Human Resources to ensure certifications are updated. Also, Director will meet with staff bi-weekly for supervision to monitor the training progress towards certifications or degrees.
Staff #3--has renewed his certification and it expires 2/8/26.
Staff #4--Has a Bachelor's of Science in Psychology based on transcripts with more than a 1 year clinical work experience. Also, TRY is awaiting degree from staff--a Master's of Art in Marriage and Family Therapy. It is expected for Staff #4 to submit copy of degree by 4/30/24. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the Staff Development program, the facility failed to provide an overall training plan developed from an assessment of staff training needs for training year July 1, 2023- June 30, 2024.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Three Rivers Youth maintains program training plans and agency-wide training plans. The treatment program submitted a training plan for each of it's staff for 2023-24. The Director will work closely with the Vice President of Operations/Quality Assurance to update the agency-wide training plan that includes all trainings for entire staff during July 1,2023-June 30, 2024. The agency-wide training plan will be updated by 4/30/24. The Director will meet with the TRY Executive Team to ensure agency-wide training plans are updated on a monthly basis for all staff. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the Staff Development program, the facility failed to complete an annual evaluation of the overall training plan for training year July 1, 2022- June 30, 2023.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Three Rivers Youth maintains annual evaluations of training plans for programs and and agency-wide. The treatment program submitted an annual evaluation of training plan for each of it's staff for 2022-23. The Director will work closely with the Vice President of Operations/Quality Assurance to update the agency-wide evaluation of training plan for the entire staff during July 1,2022-June 30, 2023. The agency-wide training plan will be updated by 4/30/24. The Director will meet with the TRY Executive Team to ensure agency-wide training plans are updated on a monthly basis for all staff. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of the facility's policy and procedure manual, the project director failed to provide a procedure for how the project plans to address the security and release of electronic records. Electronic client records were implemented in July 2023, but the procedure was not updated.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Three Rivers Youth implemented an electronic record system in July 2023. As a result, TRY will update polices and procedures related to electronic records to include but not limited to usage, confidentiality and security protocols by 5/1/24. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment in three of four applicable records.Client #5 was admitted on October 18, 2023, and discharged on December 18, 2023, due to non-compliance. There was no termination letter in Client #5's record.Client #6 was admitted on January 11, 2023, and discharged on April 7, 2023, due to non-compliance. There was no termination letter in Client #6's record.Client #7 was admitted on August 8, 2022, and discharged on March 31, 2023, due to non-compliance. There was no termination letter in Client #7's record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Three Rivers Youth adheres to § 709.33. Notification of termination. (a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
Client #5-7 files had warning letters to discharge if no contact was made for non-compliance and against agency advise. However, the staff should include a termination letter once the case is discharged as well. The Director will meet the staff during bi-weekly supervisions to reiterate the policies and procedures for discharges. Also, the Director will add discharge planning to agenda on team meeting on 4/24/24. The Director and quality assurance team will randomly review files monthly to address any deficiencies. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document disclosure of treatment methods to the client in five of five applicable records.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Three Rivers Youth will adhere to
709.91. Intake and admission. (b) Intake procedures shall include documentation of: (1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
TRY will include client handbook that has the intake procedures for admission, treatment, completion and discharge to client files with client signatures by 5/1/24. Each client is given a copy of the handbook but a copy is not kept in client file. In addition, client contracts are signed during the intake process and kept in files which include criteria for admission, treatment, completion and discharge. Based on the files reviewed 4 of the 5 files had client contracts.
The Director will reiterate during bi-weekly supervisions the need to ensure all clients have contracts signed and in client files. The Director will add client records and intake and admission to agenda during the staff meeting on 4/24/24. The Director and Quality Assurance Team will randomly review files monthly to limit deficiencies. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included project policies in five of five applicable records.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Three Rivers Youth will adhere to
709.91. Intake and admission. (b) Intake procedures shall include documentation of: (2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following: (i) Project policies.
TRY will include client handbook that has the intake procedures for orientation to client files with client signatures by 5/1/24. Each client is given a copy of the handbook but a copy is not kept in client file. TRY will include a statement for clients to sign acknowledging policies have been reviewed during the orientation phase of service delivery. The statement will be added by 5/1/24.
The Director will reiterate during bi-weekly supervisions the need to ensure all clients have contracts signed and in client files. The Director will add client records, intake and admission, orientation and policies to agenda during the staff meeting on 4/24/24. The Director and Quality Assurance Team will randomly review files monthly to limit deficiencies.
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709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included hours of operation in five of five applicable records.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Three Rivers Youth will adhere to
Intake and admission:
709.91. Intake and admission. (b) Intake procedures shall include documentation of: (2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following: (ii) Hours of operation.
TRY will include client handbook that has the intake procedures for orientation with hours of operation to client files with client signatures by 5/1/24. Each client is given a copy of the handbook but a copy is not kept in client file.
The Director will reiterate during bi-weekly supervisions the need to ensure all clients have client handbooks signed and in client files. The Director will add client records, intake, admission and orientation to agenda during the staff meeting on 4/24/24. The Director and Quality Assurance Team will randomly review files monthly to limit deficiencies.
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709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included services provided in five of five applicable records.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Three Rivers Youth will adhere to Intake and admission:
709.91. Intake and admission. (b) Intake procedures shall include documentation of: (2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following: (iv) Services provided.
TRY will include client handbook that has the intake procedures for orientation with services provided in client files with client signatures by 5/1/24. Each client is given a copy of the handbook but a copy is not kept in client file. In addition, client contracts are signed during the intake process and kept in files which include services provided. Based on the files reviewed 4 of the 5 files had client contracts.
The Director will reiterate during bi-weekly supervisions the need to ensure all clients have client handbooks signed and in client files. The Director will add client records, intake, admission and orientation to agenda during the staff meeting on 4/24/24. The Director and Quality Assurance Team will randomly review files monthly to limit deficiencies.
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