INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 26, 2024, 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 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #2's employee record.Employee #2 was hired as a counselor on May 1, 2020, and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2023, through December 31, 2023. Employee #2's employee record only documented 22.5 hours of annual training during this period. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L0083:As stated in Evolution Counseling Substance Outpatient Policy Manual under code 704.11. Counselors should receive 25 hours of training. The Project Director will meet monthly with employee #2 and track trainings, discuss upcoming trainings and review the employee's training log. The Project Director will also find a variety of appropriate trainings that focus on employee #2's clinical growth and trends in d&a. |
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 January 10, 2023, through December 12, 2023 fire drill logs, the facility failed to document the time that each fire drill was conducted. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
LP279: The Project Director had recreated the fire drill log to now add the time that each fire drill occurred. The new fire drill log now includes the month, date, time of drill, evacuation time, location of fire/event type, exit route used, alarm/smoke detector operative, number of persons in facility and problems encountered. The newly recreated fire drill log will be implemented March 2024. |
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 and an interview with the facility director, the project failed to document an annual financial audit for the fiscal year ending June 30, 2023.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
L0169: The Project Director will coordinate with the fiscal auditor to determine a deadline on when all of the necessary documentation needs completed and submitted to the auditor. The Project Director will request that the auditor submit the due date via email or on letterhead. The Project Director will also work with the Evolution Co-Owners and Administrative Specialist to submit all necessary documentation to the fiscal auditor on time.
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709.92(a) 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:
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client in two out of six applicable records.Client #4 was admitted on May 21, 2023, and was discharged on September 25, 2023. A comprehensive treatment plan was developed on June 1, 2023, it was not signed or dated by the client. Client #6 was admitted on October 4, 2023, and was discharge on February 15, 2024. A comprehensive treatment plan was developed on December 4, 2023, it was not signed or dated by the client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L1875: With the failure to obtain client signatures on multiple treatment plans, the SOS Counselor will start as of March 25th, 2024, to notify the Project Director of any treatment plans that are in need of signatures from the medical doctor, counselor and the client for all initial and updated treatment plans. The SOS Counselor will notify the Project Director via email; this allows the Project Director to reflect back on the emails during quarterly file reviews of the EMR system TherapyNotes and to address treatment plans in monthly supervisions. The SOS Counselor will also notify the Project Director of any treatment plans, initial or updated, that are being submitted to the medical doctor for review. |