INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 30, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lakeside NEPA 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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704.7(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 five personnel records, the facility failed to ensure one counselor met the educational qualifications for the position prior to being hired.
Employee #4 was hired on May 9, 2022 and has since left the facility. Employee #4 was hired while working toward completion of a bachelor ' s degree, it had not been completed prior to hire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with regulation 704.7(b) relating to qualifications for the position of counselor. The Facility Director will review qualifications of future candidates to ensure they meet the educational requirements for the position of counselor. Any candidate that does not meet the educational requirements of the position of counselor will be employed as a counselor assistant and must complete supervision based on educational level. The candidate will be promoted to counselor depending on clinical experience required per educational level. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drills from January 2022 to October 2022, the facility failed to set off a fire alarm or smoke detector during three unannounced fire drills.
Unannounced fire drills conducted on January 25, 2022, March 21, 2022 and April 18, 2022 did not document that a fire alarm or smoke detector was set off.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with regulation 705.28(d)(7) LICENSURE Fire Safety in setting off a fire alarm or smoke detector during three fire drills. The Director of Outreach and Marketing will conduct monthly fire drills and ensure to set off fire alarms or smoke detectors during the drills. The Facility Director will monitor monthly fire drills to ensure documentation is completed properly. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the December 16, 2021 licensing inspection.
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Plan of Correction
The facility failed to comply with regulation 709.25 Fiscal Management for completion of annual financial audit. The facility will obtain services from an independent certified public accountant to ensure the past due and future annual financial audits are completed annually reporting all activities associated with services provided. The past due annual financial audit will be submitted to The Department of Drug and Alcohol Program by February 1, 2023. All future financial audits will be completed on time and submitted when requested to The Department of Drug and Alcohol Program.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of seven 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 the purpose of disclosure in six records reviewed.
Client #1 was admitted on September 26, 2022 and was current at the time of the inspection. An informed and voluntary consent to disclose information form signed and dated by the client on September 27, 2022, for a government agency did not include the purpose of disclosure.
Client #2 was admitted on March 24, 2022 and discharged on April 6, 2022. Two informed and voluntary consent to disclose information forms signed and dated by the client on March 25, 2022, to a government agency and emergency contact did not include the purpose of disclosure.
Client #3 was admitted on May 9, 2022 and was current at the time of the inspection. Two informed and voluntary consent to disclose information forms signed and dated by the client on May 9, 2022, to a friend and another agency did not include the purpose of disclosure.
Client #4 was admitted on September 29, 2022 and was current at the time of the inspection. Four informed and voluntary consent to disclose information forms signed and dated by the client on September 29, 2022, to a legal entity, a government agency, another treatment provider and a family member did not include the purpose of disclosure.
Client #5 was admitted on February 3, 2022 and was discharged on February 16, 2022. Four informed and voluntary consent to disclose information forms signed and dated by the client on February 3, 2022, to a physician, a treatment provider, family member, and a friend did not include the purpose of disclosure.
Client #7 was admitted on August 8, 2022 and was current at the time of the inspection. An informed and voluntary consent to disclose information form signed and dated by the client on August 8, 2022, to a treatment provider did not include the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with regulation 709.28(c)(3) LICENSURE Confidentiality in obtaining an informed and voluntary consent for the disclosure of information to include the purpose of disclosure. The Facility Director conducted a staff training on 12/20/2022 to educate clinical staff to include the purpose of disclosure in the client's record of informed and voluntary consents. The Facility Director will complete monthly chart audits to ensure competency and efficiency. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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 seven client records, the facility failed to develop an individual treatment and rehabilitation plan with the client that included written documentation of proposed type of support services in five out of six applicable records reviewed.
Client #1 was admitted on September 26, 2022 and was current at the time of the inspection.
Client #3 was admitted on May 9, 2022 and was current at the time of the inspection.
Client #4 was admitted on September 29, 2022 and was current at the time of the inspection.
Client #5 was admitted on February 3, 2022 and was discharged on February 16, 2022.
Client #6 was admitted on January 11, 2022 and s discharged July 28, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with regulation 709.92(a)(3) regarding development of an individual treatment and rehabilitation plan to include support services. The Facility Director conducted a training to the clinical staff members on 12/20/2022 providing education on support services and the proper format for completing an individual treatment and rehabilitation plan. The Facility Director will complete random monthly chart audits and ensure clinical staff are including supportive services. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project including a discharge summary in one of three applicable records reviewed.
Client #5 was admitted on February 3, 2022 and was discharged on February 16, 2022. There was no documentation of a discharge summary in the client record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with regulation 709.93(a)(10) LICENSURE Client Record to include a discharge summary. The Facility Director conducted a staff training on 12/20/2022 to educate clinical staff on writing a comprehensive discharge summary. The Facility Director will complete monthly chart audits to ensure documentation is completed. |