INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 1, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Caron Outpatient 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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704.11(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 four personnel records, the facility failed to ensure that staff received at least four hours of TB/STD in one record reviewed.Employee # 2 was hired by the facility as the Facility Director on April 8, 2019 and has remained in that position. The employee was due to have the TB/STD training no later than April 8, 2021, and the Plan of Correction from a previous citation indicated it would be completed by November 2021. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection. This is a repeat citation from the August 31, 2021 licensure renewal inspection. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director attended TB/STD training on 2/4/22. Her training certificate is available upon request. The Director of Training monitors completion of mandatory trainings on a quarterly basis. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of four personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the facility director.Employee # 2 was hired by the facility as the Facility Director on April 8, 2019 and has remained in that position. The facility's training year that was reviewed was from July 1, 2020 through June 30, 2021. Employee # 2's employee record only documented 2.5 hours of training for the period reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director was reminded of the annual training requirements and has already completed 11 training hours for the current training year which ends on June 30, 2022. The Training Director is monitoring completion of the required training hours on a quarterly basis to ensure the Facility Director obtains the required 12 hours. |
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 four personnel records, the facility failed to ensure that personnel records contained a reviewed and signed annual written staff performance evaluation in two records reviewed. Employee # 2 was hired by the facility as the Facility Director on April 8, 2019 and has remained in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by July 19, 2021 but was not signed by the employee until November 2, 2021.Employee #3 was hired by the facility as the Clinical Supervisor on June 15, 2020 and has remained in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by July 19, 2021 but was not signed by the employee until January 28, 2022.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All supervisors and directors will be re-educated on the requirement to complete annual performance evaluations for their employees within 30 days of the employee's annual hire date anniversary. The Director of Employment/Recruitment will monitor the completion of performance evaluations on a monthly basis to ensure compliance. |
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 ensure that individual treatment and rehabilitation plans included documentation of the proposed type of support services in three records reviewed.Client # 1 was admitted on October 14, 2021 and discharged on December 29, 2021. The individual treatment and rehabilitation plan signed by the client on October 14, 2021 did not include the proposed type of support services.Client # 2 was admitted on December 8, 2021 and discharged on January 27, 2022. The individual treatment and rehabilitation plan signed by the client on December 8, 2021 did not include the proposed type of support services.Client # 7 was admitted on November 8, 2021 and was active at the time of the inspection. The individual treatment and rehabilitation plan signed by the client on November 23, 2021 did not include the proposed type of support services.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counseling staff were re-educated on the requirements for inclusion of support services in patient treatment plans on 2/4/22.
The Executive Director of the program will conduct monthly medical record audits to ensure treatment plans include support services as required. |