INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Blueprints for Addiction Recovery, 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide direct observation by a trained counselor or clinical supervisor for the first 3 months of employment or for the next 9 months, under close supervision.
Employee #8 was hired on July 31, 2023 and was still employed at the time of the inspection. She requires direct observation until October 31, 2023. She had no documentation of direct observation during individual counseling sessions on August 8, 10, 15, and 29, 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The clinical supervisors immediately reviewed and amended all session notes for Employee #8 for August 8, 10, 15, and 29, 2023, to include specific documentation of direct observation by a qualified staff member.
The Clinical Supervision Policy has been updated by the Human Resources Director, to accurately reflect the expectations for direct observation and close supervision for Counselor Assistants. This updated policy outlines the specific requirements and procedures for direct observation and close supervision.
The Human Resources Director, in collaboration with the Lancaster Site Director, conducted retraining sessions for all clinical supervisors on 9/28/2023. This retraining emphasizes the frequencies, types, and requirements for both direct observation and close supervision. Supervisors will receive ongoing guidance on how to meet these requirements effectively. Additionally, this retraining focuses on enhancing supervision notes and session notes to include specific details about observed sessions and case review during close supervision, to include date, time, and content discussed. This corrective action will provide clear evidence of close supervision and direct observation.
The Human Resources Director has established a monthly auditing process, which began on 10/2/2023, for supervision notes, group/individual session notes, and other relevant documentation in Blueprints' EMR. This audit will verify the accurate and ongoing implementation of the correct levels of supervision for all counselor assistants, including Employee #8, and ensure compliance with DDAP supervision requirements.
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704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 40 clock hours of annual training required for counselor assistants for the first year of training.
Employee #14 was hired as a counselor assistant on August 26, 2022 and was still in the position as of the date of the inspection. The employee was required to have at least 40 clock hours of training by August 25, 2023; however, he only had 25 clock hours.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #14 missed the timeframe in which they could complete assigned trainings and is unable to meet the requirement at this time. The Clinical Supervisor, Human Resources Manager, and Executive Administrator were notified immediately of the citation and its implications.
On 9/22/2023, the Human Resources Director updated the Blueprints' Training Plan Policy to solidify the responsibility of creating accurate training plans that meet the requirements outlined in 704.11. This policy update includes revised completion timeframes which align with employees' position start dates.
On 9/22/2023, the Human Resources Director met with the Lancaster Site Director and Clinical Supervisors to discuss the changes to the policy, communicate assigned responsibilities, and retrain Clinical Supervisors on the above policy changes. In this meeting, it was communicated that the completion and submission of Annual Training Plans will be the responsibility of the Clinical Supervisor, with the Human Resources Director and Executive Administrator monitoring and reviewing for accuracy.
The HR Director and Executive Administrator implemented measures to conduct ongoing monitoring of supervisor's tracking of staff trainings and completed training plans. Quarterly, a meeting between Clinical Supervisors and HRD will be held to discuss training needs, training progress, and upcoming due dates.
These expectations were established between the Lancaster Site Director & Clinical Supervisor, Executive Administrator, and Human Resources Director on 9/22/2023.
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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 outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.
Client #2 was admitted on April 20, 2023 and was still active at the time of the inspection. A treatment plan update was completed on June 22, 2023 and an update was due no later than August 22, 2023; however, none was completed.
Client #4 was admitted on June 7, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on June 21, 2023 and an update was due no later than August 1, 2023; however, it was not completed until August 23, 2023.
Client #6 was admitted on January 3, 2023 and was discharged on May 31, 2023. A treatment plan update was completed on March 16, 2023 and an update was due no later than May 16, 2023: however, it was not completed until May 31, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The treatment plan updates in question were completed, though they were completed outside of the stipulated timeframe. No further steps can be taken as the issue of non-compliance was dictated by time, though a case management note explaining the error has been added to each client's treatment record.
The Site Director and Clinical Supervisor educated the clinical team during a regular clinical staff meeting on 10/3/2023 on the process and dictated timeframe requirements for complete client records, as well as to update staff on the following improvements. New expectations for IOP/OP clients that were communicated include the completion of a TPU three sessions prior to the close of the appropriate timeframe, which anticipates any possible complicating attendance concerns.
The Site Director and Clinical Supervisor augmented Blueprints' internal census to include conditional formatting to highlight client records approaching a needed treatment plan update. This functionality streamlines pre-existing internal auditing procedures for directors, supervisors, and compliance staff to ensure that any clients approaching the timeframe of a Treatment Plan Update have TPUs completed within the appropriate time. Counselors will also be able to utilize this visibility function to manage their own day-to-day tasks and, with frequent reminders from supervisory staff, will be set up for success in this regard.
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