INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 31, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD New Start II, 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 ensure that each counselor met the appropriate educational and/or experiential qualifications for the position in one of two applicable personnel records reviewed.
Employee # 4 was hired as a counselor on January 18, 2023. The employee had a bachelor's degree; however, the major of the degree was unable to be verified by Department staff. The degree only stated bachelor of science and there were no transcripts or degree verification in the employee ' s record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, upon extending a job offer to prospective employees, they will be informed of the need to submit their credentials (highest level of education, and transcripts) their first day of employment. All documentation will be submitted to the residential manager and reviewed by the program director within 24hr of hire. Within the first 2 weeks it is expected that all required documents are submitted. Director will oversee the on-going monitoring of this process |
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
The first-floor client bathroom had an electrical socket, above the sink, that was burnt out/broken. Additionally, the bathroom's outside window screen had a large hole at the bottom.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Life Skills Professional staff will walk through the building daily to perform sanitary and safety checks to ensure that the bathrooms are clean and safe. A maintenance report form will be submitted to Residential Manager for any needed repairs discovered during the walk through. The Residential Manager will submit a Maintenance request to the Property Manager to request immediate repairs. Follow-up to ensure repairs are complete will be done during monthly property checks. By August 1st both the electrical socket and bathroom screen were repaired. Director and Residential Manager will monitor for ongoing compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client records reviewed.
The policy and procedure manual stated that the client's emergency contact be notified if client indicates they wish to leave treatment against medical advice, providing the client has not revoked consent to notify said emergency contact.
Client #4 was admitted on August 18, 2022 and left against medical advice on October 3, 2023. There was no documentation that facility staff contacted the client ' s emergency contact at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately all staff will be retrained in the AMA process by August 31th. Staff will contact the emergency contact immediately. The clinical manager will review the chart within 24hrs to ensure the emergency contact has been informed, if this step has not been completed the clinical manager will contact the emergency contact. No file will be closed until the clinical manager, and/or director gives approval for the chart to be closed. It will then be closed by the Residential Manager. The director will monitor ongoing for compliance |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project and the reason for termination, in one of one applicable client records reviewed.
Client # 6 was admitted on May 18, 2022 and was administratively discharged on September 27, 2022. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to administrative discharge, the clinical team will convene to determine if the client in question meets criteria for involuntary termination. Once a determination has been made, the team will meet with the resident and inform them of the intent and reasons for administrative discharge from the program. At that time, the resident will be given a written notice of termination of treatment. Both the termination letter and discharge note will be placed in the client chart. The Program Director will ensure policy on administrative discharge is implemented by reviewing documentation before client is physically discharged from treatment when applicable. The Program Director will retrain all clinical staff on the administrative discharge process by August 31, 2023. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment plans were reviewed and updated at least every 30 days in three of seven records reviewed.
Client #4 was admitted on August 18, 2022 and was discharged on October 3, 2023. A treatment plan update was completed on August 25, 2022 and the next update was due no later than September 25, 2022; however, the update was not completed at the time of the inspection.
Client #5 was admitted December 15, 2022 and was discharged February 23, 2023. The individual treatment plan was completed on December 15, 2022 and the first update was due no later than January 15, 2023; however, the update was completed on January 30, 2023.
Client# 7 was admitted September 14, 2022 and was discharged June 5, 2023. A treatment plan update was completed on January 6, 2023 and the next update was due no later than February 6, 2023; however, the update was completed on April 24, 2023
This is a repeat citation from the July 27, 2022 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective immediately, the Clinical Manager will run a weekly report in the electronic medical record to identify clients whose treatment plan due to expire within 7 days and coordinate with clinical staff to ensure the treatment plan is updated prior to expiring. A weekly clinical review will be sent to the Director who will conduct on-going monthly chart audits to monitor this process. The clinical team will be retrained in this process by August 31, 2023. |