INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 14, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Caron Counseling Services 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the 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 a written individual training plan for each employee in the required time frame, appropriate to that employee's skill level in one out of ten employee records reviewed.
Employee #7 was hired on September 30, 2024 as a counselor and was still in the position as of the date of the inspection. The plan is dated November 12, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Supervisor of Training and Education re-educated leadership on the time-frame requirements of an employee individual training plan on 12/2/24. New employees typically complete their individual training plan during New Employee Orientation, which is expected to be completed within the first 30 days of employment. To ensure that the completion of the individual training plan is not missed, the completion of the individual training plan will be added to the New Employee Onboarding Checklist. This is an internal document which helps leaders track completion of all new employee orientation and onboarding tasks and due dates. The Learning Management Software Administrator will track completion of employee individual training plans on a monthly basis, and will send reminders to leaders as needed. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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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. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in three out of seven client records reviewed.
Client #3 was admitted on March 7, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on March 7, 2024 with no type or frequency identified.
Client #4 was admitted on September 10, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 11, 2024 with no frequency identified.
Client #7 was admitted on April 22, 2024 and discharged on September 11, 2024. A comprehensive treatment plan was developed on June 22, 2021 with no frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will re-educate clinicians on individual and treatment rehabilitation plan requirements, specifically that the plan must include written documentation of type and frequency of treatment and rehabilitation services. This education will be provided during Clinical Supervision by 12/13/24. The Clinical Supervisor will do chart audits monthly to ensure that individual and treatment rehabilitation plans include type and frequency of treatment and rehabilitation services. The Clinical Supervisor will report progress to the Quality Committee on a quarterly basis. |
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 five out of seven records reviewed.
Client #2 was admitted on March 15, 2024 and was still active at the time of the inspection. A treatment plan update was completed on July 5, 2024 and an update was due no later than September 5, 2024; however, none was not completed until September 9, 2024.
Client #3 was admitted on March 7, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 7, 2024 and an update was due no later than May 7, 2024; however, it was not completed until July 29, 2024.
Client #5 was admitted on February 8, 2024 and was discharged on June 20, 2024. A comprehensive treatment plan was completed on February 8, 2024 and the next update was due no later than April 9, 2024; however, it was completed on April 15, 2024.
Client #6 was admitted on March 21, 2024 and was discharged on October 9, 2024. A treatment plan update was completed on May 17, 2024 and the next update was due no later than July 17, 2024; however, it was not completed until August 16, 2024.
Client #7 was admitted on April 22, 2024 and was discharged on September 11, 2024. A treatment plan update was completed on June 18, 2024 and an update was due no later than August 18, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will re-educate clinicians on individual and treatment rehabilitation plan requirements, specifically that plans must be reviewed and updated at least every 60 days. This education will be provided during Clinical Supervision by 12/13/24. The Clinical Supervisor will do chart audits monthly to ensure that individual and treatment rehabilitation plans are updated at least every 60 days. The Quality Analyst will do quarterly chart reviews and will report progress to leadership. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in six out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 60 days.
Client #1 was admitted on July 3, 2024 and was still active at the time of the inspection. A case consultation was completed on August 28, 2024; and the next one was due no later than October 28, 2024; however, it was not completed until November 11, 2024.
Client #2 was admitted on February 10, 2023 and was still active at the time of the inspection. A case consultation was completed on July 5, 2024 and the next one was due no later than September 5, 2024; however, it was not completed until September 9, 2024. Additionally, another case consultation was due by November 9, 2024; however, none was completed.
Client #3 was admitted on March 7, 2024 and was still active at the time of the inspection. A case consultation was due no later than May 7, 2024; however, it was not completed until May 24, 2024.
Client #4 was admitted on admitted on September 10, 2024 and was still active at the time of the inspection. A case consultation was due no later than November 10, 2024; however, it none was completed.
Client #5 was admitted on February 8, 2024 and was discharged on June 20, 2024. A case consultation was due no later than April 9, 2024; however, it was not completed until April 15, 2024.
Client #7 was admitted on April 22, 2024 and was discharged on September 11, 2024. A case consultation was completed on June 19, 2024 and the next one was due no later than August 19, 2024; however, it was not completed until September 6, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will re-educate staff on the case consultation process, including timeframes and the requirement that every patient record needs to contain documentation of a Case Consultation during Clinical Supervision by 12/13/24. The Clinical Supervisor will also track due dates for case consultation for each patient and will send weekly reminders to the clinical team of these due dates. The Clinical Supervisor will do chart audits monthly to ensure that case consultations are completed on time. The Quality Analyst will do quarterly chart reviews and will report progress to leadership. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in one out of two applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed 10 days following discharge.
Client #7 was admitted on April 22, 2024 and was discharged on September 11, 2024. A follow up was due no later than September 21, 2024; however, it was not completed until October 1, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will re-educate staff on follow up information documentation, including required timeframes by 12/13/14. The Quality Analyst will do quarterly chart reviews for the completion of follow up information documentation within required timeframes and will report progress to leadership. |