INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 25, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Colonial House Outpatient 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document that each counselor met the experiential qualifications for the position.
Employee #3, who was hired as a counselor on August 12, 2021, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor for a person with a bachelor's degree.
This is a repeat citation from the inspection conducted on May 24, 2021.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #3's title has been corrected in our HR files to indicate Counselor Assistant until one year anniversary with CHI on August 12, 2022. Supervision requirements as a Counselor Assistant will continue to be provided by the Outpatient Clinical Supervisor until the Performance Evaluation is completed at the one year anniversary, at which time full promotion to Counselor will take place, as appropriate. The oversight of staff files and HR onboarding, along with training the Clinical Supervisors on DDAP regulations, will be provided by new Executive Director. Operations Manager and Clinical Supervisors have been individually addressed regarding DDAP regulations. A formal meeting with current Operations Manager and Clinical Supervisors to discuss new procedures for onboarding and supervision moving forward will take place before July 1, 2022. |
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 request to review the annual report made public by the governing body, the facility failed to provide the report during the on-site inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Previous CHI administration failed to complete the 2020-2021 annual report. Incoming administration completed the report on 05/02/2022 while DDAP auditor was onsite at another CHI facility. Link to the online website where the report could be viewed was emailed to the auditor on 05/02/2022. The 2021-2022 annual report will be completed by the current CHI administration and new Executive Director in July 2022 and updated on the company website. |
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 a review of client records, the facility failed to document a completed consent to release information in one out of seven records reviewed, as there was a form missing required information.
Client #7 was admitted on January 25, 2022 and was still active at the of the inspection. There was a consent to release form, signed and dated on March 22, 2022 to a medical provider, but the consent did not include the specific information disclosed.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
New Executive Director edited CHI consent to release confidential information forms on 05/09/2022 and disbursed this to the Clinical Supervisors. During the week of 05/09/2022, Clinical Supervisors discussed implementation of new releases with their clinical staff, along with a thorough review of Confidentiality regulations and components of the form which must be completed upon use, including the specific information to be disclosed. All clinical staff will complete Confidentiality Training if they have not already done so, as determined by Clinical Supervisors during weekly supervision meetings with staff. Clinical Supervisors will audit all current charts weekly to ensure appropriate completion of releases, and again at the time of discharge, with oversight by Executive Director. |
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 a completed consent to release information in one out of seven records reviewed, as there was a form missing required information.
Client #7 was admitted on January 25, 2022 and was still active at the of the inspection. There was a consent to release form, signed and dated on March 22, 2022 to a medical provider, but the consent did not include the purpose of disclosure.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
New Executive Director edited CHI consent to release confidential information forms on 05/09/2022 and disbursed this to the Clinical Supervisors. During the week of 05/09/2022, Clinical Supervisors discussed implementation of new releases with their clinical staff, along with a thorough review of Confidentiality regulations and components of the form which must be completed upon use, including the purpose for disclosure. All clinical staff will complete Confidentiality Training if they have not already done so, as determined by Clinical Supervisors during weekly supervision meetings with staff. Clinical Supervisors will audit all current charts weekly to ensure appropriate completion of releases, and again at the time of discharge, with oversight by Executive Director. |
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 a completed consent to release information in one out of seven records reviewed, as there was a form missing required information.
Client #1 was admitted on October 12, 2021 and was discharged on April 1, 2022. There was a consent to release form, signed and dated on October 5, 2021 to a funding source, but the consent did not include a dated signature of witness.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
New Executive Director edited CHI consent to release confidential information forms on 05/09/2022 and disbursed this to the Clinical Supervisors. During the week of 05/09/2022, Clinical Supervisors discussed implementation of new releases with their clinical staff, along with a thorough review of Confidentiality regulations and components of the form which must be completed upon use, including a dated signature of witness. All clinical staff will complete Confidentiality Training if they have not already done so, as determined by Clinical Supervisors during weekly supervision meetings with staff. Clinical Supervisors will audit all current charts weekly to ensure appropriate completion of releases, and again at the time of discharge, with oversight by Executive Director. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document a completed consent to release information in one out of seven records reviewed, as there was a form missing required information.
Client #1 was admitted on October 12, 2021 and was discharged on April 1, 2022. There was a consent to release form, signed and dated on October 5, 2021 to a funding source, but the consent did not include documentation that the client was offered a copy of the consent.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
New Executive Director edited CHI consent to release confidential information forms on 05/09/2022 and disbursed this to the Clinical Supervisors. During the week of 05/09/2022, Clinical Supervisors discussed implementation of new releases with their clinical staff, along with a thorough review of Confidentiality regulations and components of the form which must be completed upon use, including documentation that the client was offered a copy of the consent. All clinical staff will complete Confidentiality Training if they have not already done so, as determined by Clinical Supervisors during weekly supervision meetings with staff. Clinical Supervisors will audit all current charts weekly to ensure appropriate completion of releases, and again at the time of discharge, with oversight by Executive Director. |