INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 26-27, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, PA Treatment and Healing 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
A review of personnel records was conducted on August 28, 2019 at the PA Treatment and Healing Scranton facility. During the review, it was discovered that employee #1 did not have an annual individual training plan.
Employee #1 was hired as the project director on June 3, 2019 and was still in the position as of the date of the on-site inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to have an annual individual training plan in employee #1 personnel record. The employee and the HR department representative will complete an annual individual training plan and have it in the employee file as required. The program director will continue to monitor this for compliance. The agency will be in compliance with this standard as of 9/26/2019 |
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 and personnel records on August 28, 2019 at the PA Treatment and Healing Scranton facility, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #3's employee record.
Employee #3 was hired as a counselor on July 10, 2000 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2018 through June 30, 2019. Employee #3's employee record only documented 22 hours of annual training for the training year reviewed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the review of the staffing requirements facility summary report and personnel records the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #3 record. Employee #3 only had 22 documented training hours for the training year reviewed. The program director and facility director will review and address this deficiency with employee #3 and retrain on the required yearly training hours with said counselor. The counselor will also submit any additional training hours that were completed during that time period to bring it into compliance. The Facility director will monitor training hours quarterly to ensure that the employee will meet training requirements for the year annually as required. The facility will be in compliance with this standard as of 10/1/19. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on August 26, 2019 at approximately 2:30pm, the facility's bathroom hot water temperature was measured at 141.7 degrees.
This is a repeat citation from an annual inspection conducted on September 12, 2018. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure that the hot water did not exceed 120 degrees in the bathroom as the temperature measured at 141.7 degrees on August 26, 2019.
The Program Director has again contacted the landlord regarding the issue with the water temperature and readjusting the water heater to ensure that it does not exceed the required 120 degree temperature. The Program Director and Facility Director will do monthly water temperature checks to ensure compliance with this standard. The agency will be in compliance with this standard as of 9/26/2019. |
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 a review of seven client records and the policy and procedures manual on August 26-27, 2019, the facility failed to ensure that the client had been made aware of their client rights in client record #'s 1, 2, 3, 4, 5, 6 and 7. In addition, the facility's client rights policy failed to include all parts of the client rights regulation. In both the client record documentation and the policy and procedures manual, the project failed to include that a client may not be discriminated against based on color, marital status and handicap.
This is a repeat citation from the September 12, 2018 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document that they may not discriminate against color, marital status, or handicap in their client rights policy in seven of the client charts that were reviewed.
The Program Director will update client rights in the policy and procedure manual and document in the client rights that we may not discriminate against color, marital status, or handicap.
This updated policy will be reviewed with all counselors and the corrected version will be filed in the agency policy and procedure manual. Counselors will have each client sign the revised client rights policy and document this in each client chart.
The agency will be in compliance with this standard on 11/15/19
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of four applicable client records on August 26-27, 2019, the facility failed to maintain a photograph of client #4 in his/her client record.
Client #4 was admitted on April 28, 2019 and discharged on August 23, 2019.
This is a repeat citation from the September 12, 2018 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to maintain an onsite photograph of client #4 in his/her record.
The Facility Director will review the requirement of maintaining an on sight photograph of each client in their client record during supervision with each counselor.
The counselor will obtain a valid picture identification of each client upon admission and if no identification card is available the counselor will obtain a photograph with a camera that will be kept on site at the time of admission to be kept in the client record.
The facility director/program director will ensure compliance with this standard through supervision and quality reviews of client charts.
The agency will be in compliance with this standard as of 10/1/19 |
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 seven client records on August 26-27, 2019, the facility failed to follow their policy and procedures manual timeline for developing the master treatment plan with the client in client records #1, 2 and 3. The "Coordination of Outpatient Drug & Alcohol Treatment Services" section of the policy and procedures manual states "it is the clinical staff person's responsibility to develop the Preliminary Treatment Plan with the client during the Intake Session and the Master Treatment Plan with fifteen (15) days of the date of the Intake Session."
Client #1 was admitted on February 4, 2019 and was still active at the time of the inspection. Intake was completed on February 4, 2019 and the master treatment plan was completed on March 4, 2019.
Client #2 was admitted on December 20, 2018 and was still active at the time of the inspection. Intake was completed on December 20, 2018 and the master treatment plan was completed on April 17, 2019.
Client #3 was admitted on November 1, 2018 and was discharged on March 22, 2019. Intake was completed on November 1, 2018 and the master treatment plan was completed on December 13, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on a review of seven client records the facility failed to follow their policy and procedures manual timeline for developing the master treatment plan within 15 days of the intake session.
The facility director will retrain each counselor regarding the policy and procedure manual timeline for developing the master treatment plan and provide documentation in each counselors training file to verify that this has been completed.
The facility director and Program director will ensure compliance with this regulation through ongoing supervision and quality review of client files.
The agency will be in compliance with this as of 10/1/2019 |