INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Christian Counseling Associates of Western Pennsylvania LLC 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of staff records, the facility failed to ensure that staff persons received at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in one of three records.
Staff #6 was hired as a Counselor on July 20, 2022 and is still in the position. The TB/STD training was due to be completed within the first year of employment, by July 20, 2023. Staff #6 record did not contain documentation of a completed TB/STD training at time of review.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 5, 2023 annual licensing renewal inspections.
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Plan of Correction
Clinical Supervisor will ensure Staff #6 will complete TB/STD training by 6/7/24. Clinical Supervisor will review in Supervision meeting. Staff #6 already knows what TB/STD to take. Onboarding will include new hire registering for this training. Clinical Supervisor will hold Counselor accountable and document it in Supervision documentation. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs and staff interview, the facility failed to conduct unannounced fire drills at least once a month.
No fire drills were conducted from April 2023 through December 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review fire drill logs monthly in Supervision meeting and will add it as an agenda item to the Supervision meeting agenda. Facility will be in compliance by 5/31/24. This deficiency will be corrected by team leader conducting and documenting monthly fire drills and verifying monthly fire drill at bi-weekly Group Supervision meetings with Clinical Supervisor. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative information, the facility failed to provide an annual report for 2023 which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable. Facility staff confirmed that an annual report had not been completed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 5, 2023 annual licensing renewal inspections.
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Plan of Correction
Project Director will create annual report by 5/31/24. Clinical Supervisor will review this item in Executive Supervision meetings. Project Director and Clinical Supervisor will hold annual DDAP Preparation meeting and ensure presence of annual report. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of facility records and staff interview, the facility failed to ensure that the project director prepared annually, updated and signed a written manual delineating project policies and procedures.
The facility staff were unable to produce an annually updated and signed written manual for 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will ensure that the policy and procedure manual is signed indicating any changes for this next inspection year. Project Director and Clinical Supervisor will review this item in next Executive Supervision meeting by or by 5/31/24. To ensure this deficiency does not recur, Project Director will review this deficiency in annual DACCA meeting. |
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 staff records, the facility failed to ensure personnel records included an annual written individual staff performance evaluation in one of two records.
Staff #6 was hired as a Counselor on July 20, 2022 and is still in the position. Staff #6 was due to receive an annual written individual staff performance evaluation on July 20, 2023. Staff #6 ' s record did not contain an annual written individual staff performance evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will ensure completion of missing annual review by 5/31/24. Annual reviews will be incomplete if written performance evaluations are missing. Bamboo HR annual review checklist will be updated to prevent recurrence. |
709.28 (c) 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.
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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 three of six records.
Client #2 was admitted the outpatient level of care on October 6, 2023 and was active at time of review. Client #2's record did not contain an informed and voluntary consent from the client for the disclosure of information for the client's funder. The facility staff confirmed billing had been occurring since admission.
Client #3 was admitted the outpatient level of care on December 28, 2023 and was active at time of review. Client #3's record did not contain an informed and voluntary consent from the client for the disclosure of information for the client's funder. The facility staff confirmed billing had been occurring since admission.
Client #4 was admitted the outpatient level of care on July 6, 2023 and was discharged February 10, 2024. Client #4's record did not contain an informed and voluntary consent from the client for the disclosure of information for the client's funder. The facility staff confirmed billing had occurred throughout the client ' s time at the facility.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 5, 2023, May 4, 2022, and May 28, 2021 annual licensing renewal inspections.
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Plan of Correction
Informed and Voluntary consent forms have been added to intake procedure. Clinical Supervisor will audit chart for presence of this consent form prior to approving discharge of client and at case consultation meetings to ensure non-recurrence. Facility will be in full compliance by 5/31/24. |
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 client records, the facility failed to ensure treatment and rehabilitation plans shall be reviewed and updated at least every sixty days in two of six records.
Client #1 was admitted to the outpatient level of care on November 28, 2023 and was active at the time of review. Client #1's record contained a treatment plan dated January 17, 2024. The next updated treatment plan was due no later than March 17, 2024. Client #1 ' s treatment plan was not updated until April 3, 2024.
Client #2 was admitted to the outpatient level of care on October 6, 2023 and was active at the time of review. Client #2's record contained a treatment plan dated December 22, 2023. The next updated treatment plan was due no later than February 22, 2024. Client #2's treatment plan was not updated until March 26, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor will be required to send treatment plan updates to Clinical Supervisor for approval. Clinical Supervisor will audit charts, with the help of the Quality Assurance department to ensure non-recurrence. Facility will be in full compliance by 5/31/24/. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for an informed and voluntary consent was submitted and approved by the Department for the May 28, 2021, May 4, 2022, and April 5, 2023 annual licensing inspections. Informed and voluntary consent forms were again found to be a deficiency in the April 23, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Informed and voluntary consent forms have been added to the intake procedure. Project Director will hold staff accountable via disciplinary procedures if these forms are not completed to ensure non-recurrence. Clinical Supervisor will review the importance of these forms in Supervision. Facility will be in full compliance by 5/31/24. |