INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 7-9, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Evolution Counseling Services, 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of administrative information, the facility failed to have the clinical supervisor complete a core curriculum in clinical supervision. Employee #2 was hired as a Clinical Supervisor in May 2020. Upon hire, Employee #2 did not have the required 2 years of supervision experience. As of the inspection date, the core curriculum training has not been completed.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Clinical Supervisor, as per 704. 6(c), who does not have the required 2 years' experience or per request of DDAP, will schedule and complete core curriculum training in clinical supervision upon being hired by the facility. This will be scheduled and completed at the earliest availability of the clinical supervisor and training openings offered by DDAP (no later than 90 days upon hire which is also the initial probationary period of new employees at the facility). Clinical supervisor will process details of training availability with Project Director. Project Director will confirm scheduling during individual supervision within the first two weeks of being hired and confirm completion of training at 90 day probationary evaluation. If the clinical supervisor has not completed the core curriculum training within 90 days, the clinical supervisor will have initial probationary period extended for 90 days (no more than 180 days total) with completion of core curriculum in clinical supervision a requirement. If for some reason the clinical supervisor does not complete the core curriculum within 180 days, the individual within this position will be terminated. The facility will be in compliance by September 1, 2021. |
704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of administrative information, the facility failed to include a policy and procedure for collecting feedback on completed training.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Project Director will revise current policy titled " Staff Development Program Policy" to include a policy and procedure for collecting feedback on completed training by June 1, 2021. The revised policy will replace current policy and will be submitted as DDAP approval as required. The policy will include a plan to collect feedback. This includes an annual (January 1- December 31) review and evaluation of the overall facility plan and the following requirements:
(1) An assessment of staff training needs.
(2) An overall plan for addressing these needs.
(3) A mechanism to collect feedback on completed training.
(4) An annual evaluation of the overall training plan.
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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 administrative information, the facility failed to document an overall agency training plan for the original training year beginning in July 2020.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Project Director will revise current policy titled " Staff Development Program Policy" to include a policy and procedure by June 1, 2021. The revised policy will replace current policy and will be submitted as DDAP approval as required. The policy will include details of the overall training plan which will be completed on an annual basis for the facility as well as how the training needs will be assessed on an annual basis. This will be focused on training from 1/1 to 12/31 on an annual basis. Annual training needs will be reviewed and assessed during the employee's "Annual Employee Evaluation" review with direct supervisor. The upcoming training plan will be reviewed and signed by employee and supervisor. |
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, the facility failed to document monthly fire drills.The facility was given approval to begin services in July 2020. The fire drill log was reviewed from August 2020 to April 2021. Fire drills were not conducted for the months of August 2020, September 2020, October 2020, November 2020, December 2020, January 2021, and February 2021. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Project Director created "Fire Safety Policy" and placed in policy manual. The policy requires monthly fire drills and states:
(1) On a monthly basis, at an unannounced time during normal facility operating hours, the Project/Facility Director will place a phone call from outside the main doors of the facility requesting to speak to either Office Manager or Lead Counselor.
(2) Upon speaking to someone within the facility, notification of the fire drill would occur and description of location of the fire would be detailed. Office Manager and/or Lead Counselor will be responsible for leading the client/staff to safety as detailed in "General Safety and Emergency Procedures Policy".
(3) Project/Facility Director will track length of evacuation, exit route used, any special conditions simulated and problems encountered. This will then be documented on annual "Fire Drill Log" kept within office manager's office.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel and training records, the facility failed to ensure all personnel on all shifts are trained to perform assigned tasks during emergencies in two of two records.Employee #1 and #2 were both hired May 1, 2020. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Office Manager will assure all staff will complete training within first 7 days of employment which will include "emergency training" and "fire exiting". These will be added to facility's "Orientation Checklist" for new employee's by June 1, 2021. Completion of these trainings will be confirmed by office manager and kept within employee personnel file. Existing untrained staff will be trained on June 1, 2021. Completion of the training for the existing staff will be confirmed by Office Manager and documented within the employee's personnel files. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill log, the facility failed to document the time, the number of staff, and if the smoke detector / fire alarm was operable.The facility was given approval to begin services in July 2020. The fire drill log was reviewed from August 2020 to April 2021. The fire drill log failed to include all the required information.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. The "Fire Drill Log" will be edited by the Project Director and submitted to DDAP as requested by June 1, 2021. The edits will include all requirements of documentation of monthly fire drills as per 705.28 (d) which states: Maintain a written fire drill record including the date, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. |
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 the fire drill log, the facility failed to document if the fire alarm or smoke detector was activated during each fire drill.The facility was given approval to begin services in July 2020. The fire drill log was reviewed from August 2020 to April 2021. The facility failed to activate the fire alarm or smoke detector.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Project Director requested an alternate means to activating the fire alarms which includes DDAP approval for announcing fire alarms. The facility received approval as of 4/14/2021 and will follow requirements moving forward.
The approval states, "We have reviewed your request for an exception to the Department of Drug and Alcohol Program's Physical Plant Standards for Nonresidential Facilities, Chapter 705.28(d)(7), relative to activating a fire alarm or smoke detector during a fire drill. An exception is not needed, but approval is granted for the use of an alternate means of announcing fire drills.This alternate means of announcing fire drills is intended to alert those within the space occupied by the facility of the fire drill but will not disturb other occupants in the building.
Since the fire alarm system will not be activated during fire drills, documentation that the alarm system
is in working order must be available for review during licensing inspections. Documentation that it is working must be updated on an annual basis. |
709.22 (b) (1) LICENSURE Governing Body
§ 709.22. Governing body.
(b) The duties of the governing body include, but are not limited to, the following:
(1) Designating the position to serve as project director as the person officially responsible to the governing body either directly or indirectly.
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Observations
Based on a review of the administrative information, the facility failed to have the governing body designate the position to serve as project director.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. The governing body of the facility will complete a signed statement from the owners of Evolution Counseling Services, LLC which will designate the project director of the facility as the one who will report to governing body in all matters having to do with facility. This signed statement will be available for future DDAP reviews accompanying the policy manual. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to document a release of information that included the specific information within the parameters of 4 Pa Code 255.5 in seven of seven client records reviewed. Each client record reviewed included release of information forms for funding sources that exceeded that which is permitted by 4 Pa Code 255.5.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1.Proper completion of client paperwork will be added to facility's "Orientation Checklist" for new employee's by June 1, 2021. The topics on the "Orientation Checklist" will be reviewed and signed off on within the first 2 weeks of employment and will be monitored by the office manager. Also, each employee will be required to complete a training on confidentiality within the first year of employment. The Project Director and Clinical Supervisor will lead a review of all active and closed client records every 3 months by September 30, December 31, March 31 and June 30 of each year. During this review, releases will be reviewed for the appropriate detail as required by 709.28. Missing or incorrect information will be documented and shared with clinical supervisor then corrections will be shared and documented within 30 days with Project Director within individual supervision. Each file will have a "Client Record Review Sheet" to assist file review and documentation. |
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 client records, the facility failed to document the purpose of disclosure on the release of information form for another agency in one of seven client records.Client record #1 documented a release of information to another agency that was signed February 22, 2021. The release was missing the purpose of the disclosure.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. 1.Proper completion of client paperwork will be added to facility's "Orientation Checklist" for new employee's by June 1, 2021. The topics on the "Orientation Checklist" will be reviewed and signed off on within the first 2 weeks of employment and will be monitored by the office manager. Also, each employee will be required to complete a training on confidentiality within the first year of employment. The Project Director and Clinical Supervisor will lead a review of all active and closed client records every 3 months by September 30, December 31, March 31 and June 30 of each year. During this review, releases will be reviewed for the appropriate detail as required by 709.28. Missing or incorrect information will be documented and shared with clinical supervisor then corrections will be shared and documented within 30 days with Project Director within individual supervision. Each file will have a "Client Record Review Sheet" to assist file review and documentation. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the date on the witness signature on a release of information form for the funding source. Client #7 had a release of information signed for a funding source, but the witness signature did not include a date. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1.Proper completion of client paperwork will be added to facility's "Orientation Checklist" for new employee's by June 1, 2021. The topics on the "Orientation Checklist" will be reviewed and signed off on within the first 2 weeks of employment and will be monitored by the office manager. Also, each employee will be required to complete a training on confidentiality within the first year of employment. The Project Director and Clinical Supervisor will lead a review of all active and closed client records every 3 months by September 30, December 31, March 31 and June 30 of each year. During this review, releases will be reviewed for the appropriate detail as required by 709.28. Missing or incorrect information will be documented and shared with clinical supervisor then corrections will be shared and documented within 30 days with Project Director within individual supervision. Each file will have a "Client Record Review Sheet" to assist file review and documentation.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement the client was notified of their civil rights and that, no client may be deprived of a civil right solely by reason of treatment.Seven of seven client records reviewed did not document notification of this right.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Project Director will revise "Client Rights and Responsibilities" within the intake/consent to treatment packet to align with current facility policy and PA Code 709.30 (1) through (6). Upon revision and POC approval, Project Director will give approval for Clinical Supervisor will utilize new "Client Rights and Responsibilities" to be completed with any current and future clients moving forward which will document written acknowledgement by clients that they have been notified of those rights within the PA Code. Current clients completing this new document will be completed by June 1, 2021 or upon approval of POC (whichever comes first).
Moving forward, the Project Director and Clinical Supervisor will lead a review of all active and closed client records every 6 months by June 30 and December 31 of each year. During this review, intake/consent to treatment packets will be reviewed for completion of written acknowledgement by clients of their client rights as required by 709.30 (1) through (6). Missing or incorrect information will be documented and shared with clinical supervisor then corrections will be shared and documented within 30 days with Project Director within individual supervision. Each file will have a "Client Record Review Sheet" to assist file review and documentation.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement the client was notified they will not be discriminated against based on creed, sex, and marital status. Seven of seven client records reviewed did not document notification of this right.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Project Director will revise "Client Rights and Responsibilities" within the intake/consent to treatment packet to align with current facility policy and PA Code 709.30 (1) through (6). Upon revision and POC approval, Project Director will give approval for Clinical Supervisor will utilize new "Client Rights and Responsibilities" to be completed with any current and future clients moving forward which will document written acknowledgement by clients that they have been notified of those rights within the PA Code. Current clients completing this new document will be completed by June 1, 2021 or upon approval of POC (whichever comes first).
Moving forward, the Project Director and Clinical Supervisor will lead a review of all active and closed client records every 6 months by June 30 and December 31 of each year. During this review, intake/consent to treatment packets will be reviewed for completion of written acknowledgement by clients of their client rights as required by 709.30 (1) through (6). Missing or incorrect information will be documented and shared with clinical supervisor then corrections will be shared and documented within 30 days with Project Director within individual supervision. Each file will have a "Client Record Review Sheet" to assist file review and documentation.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement the client was notified the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. Seven of seven client records reviewed did not document notification of this right.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Project Director will revise "Client Rights and Responsibilities" within the intake/consent to treatment packet to align with current facility policy and PA Code 709.30 (1) through (6). Upon revision and POC approval, Project Director will give approval for Clinical Supervisor will utilize new "Client Rights and Responsibilities" to be completed with any current and future clients moving forward which will document written acknowledgement by clients that they have been notified of those rights within the PA Code. Current clients completing this new document will be completed by June 1, 2021 or upon approval of POC (whichever comes first).
Moving forward, the Project Director and Clinical Supervisor will lead a review of all active and closed client records every 6 months by June 30 and December 31 of each year. During this review, intake/consent to treatment packets will be reviewed for completion of written acknowledgement by clients of their client rights as required by 709.30 (1) through (6). Missing or incorrect information will be documented and shared with clinical supervisor then corrections will be shared and documented within 30 days with Project Director within individual supervision. Each file will have a "Client Record Review Sheet" to assist file review and documentation.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement the client was notified they have the right to appeal a decision limiting access to their records to the director.Seven of seven client records reviewed did not document notification of this right.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Project Director will revise "Client Rights and Responsibilities" within the intake/consent to treatment packet to align with current facility policy and PA Code 709.30 (1) through (6). Upon revision and POC approval, Project Director will give approval for Clinical Supervisor will utilize new "Client Rights and Responsibilities" to be completed with any current and future clients moving forward which will document written acknowledgement by clients that they have been notified of those rights within the PA Code. Current clients completing this new document will be completed by June 1, 2021 or upon approval of POC (whichever comes first).
Moving forward, the Project Director and Clinical Supervisor will lead a review of all active and closed client records every 6 months by June 30 and December 31 of each year. During this review, intake/consent to treatment packets will be reviewed for completion of written acknowledgement by clients of their client rights as required by 709.30 (1) through (6). Missing or incorrect information will be documented and shared with clinical supervisor then corrections will be shared and documented within 30 days with Project Director within individual supervision. Each file will have a "Client Record Review Sheet" to assist file review and documentation.
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement by the client they were notified of the right to submit memoranda to their own records. Seven of seven client records reviewed did not document notification of this right.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Project Director will revise "Client Rights and Responsibilities" within the intake/consent to treatment packet to align with current facility policy and PA Code 709.30 (1) through (6). Upon revision and POC approval, Project Director will give approval for Clinical Supervisor will utilize new "Client Rights and Responsibilities" to be completed with any current and future clients moving forward which will document written acknowledgement by clients that they have been notified of those rights within the PA Code. Current clients completing this new document will be completed by June 1, 2021 or upon approval of POC (whichever comes first).
Moving forward, the Project Director and Clinical Supervisor will lead a review of all active and closed client records every 6 months by June 30 and December 31 of each year. During this review, intake/consent to treatment packets will be reviewed for completion of written acknowledgement by clients of their client rights as required by 709.30 (1) through (6). Missing or incorrect information will be documented and shared with clinical supervisor then corrections will be shared and documented within 30 days with Project Director within individual supervision. Each file will have a "Client Record Review Sheet" to assist file review and documentation.
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709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on a review of the administrative information, the facility failed to develop a policy and procedure that includes the prompt review and identification of the causes directly or indirectly responsible for the unusual incident.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Project Director will edit the Facility Policy and Procedure "Reporting of Unusual Incidents" to include the following by June 1, 2021 or upon approval of POC (whichever comes first):
1. Upon employee documentation of an unusual incident following facility policy, the report will be provided to the Project Director and/or Clinical Supervisor within 24 hours.
2. Project Director and/or Clinical Supervisor will promptly review and identify the causes directly or indirectly responsible for the unusual incident within 24 hours. If a corrective action plan is indicated as needed, this will be created/completed within the same 24 hour review time period by the Project Director and/or Clinical Supervisor and provided to employee associated with the unusual incident for review and comprehension.
3. Project Director will monitor any questions or concerns with the plan as well as the completion of the corrective action plan. Monitoring will occur for one month at a time with review of plan and monitoring with employee and Clinical Supervisor.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of the administrative information, the facility failed to develop a policy and procedure that includes the ongoing monitoring of the corrective action plan.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Project Director will edit the Facility Policy and Procedure "Reporting of Unusual Incidents" to include the following by June 1, 2021 or upon approval of POC (whichever comes first):
1. Upon employee documentation of an unusual incident following facility policy, the report will be provided to the Project Director and/or Clinical Supervisor within 24 hours.
2. Project Director and/or Clinical Supervisor will promptly review and identify the causes directly or indirectly responsible for the unusual incident within 24 hours. If a corrective action plan is indicated as needed, this will be created/completed within the same 24 hour review time period by the Project Director and/or Clinical Supervisor and provided to employee associated with the unusual incident for review and comprehension.
3. Project Director will monitor any questions or concerns with the plan as well as the completion of the corrective action plan. Monitoring will occur for one month at a time with review of plan and monitoring with employee and Clinical Supervisor.
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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 the disclosure to the client of completion and discharge upon intake in seven of seven client records reviewed on April 8, 2021.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Project Director will work with Clinical Supervisor to create a summary of facility policy "Intake and Admission Policy" which will include the criteria for admission, treatment, completion and discharge as per 709.91 (b) (1). This summary will be shared and disclosed for review to all current and future clients. Clients will acknowledge the information has been shared and disclosed to them by signing the "Consent to Treatment". Current clients completing this new document will be completed by June 1, 2021 or upon approval of POC (whichever comes first).
Moving forward, the Project Director and Clinical Supervisor will lead a review of all active and closed client records every 6 months by June 30 and December 31 of each year. During this review, intake/consent to treatment packets will be reviewed for completion of Intake and Admission Policy summary disclosure as per 709.91 (b) (1) and (2). Missing or incorrect information will be documented and shared with clinical supervisor then corrections will be shared and documented within 30 days with Project Director within individual supervision. Each file will have a "Client Record Review Sheet" to assist file review and documentation.
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