INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 10, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, Inc. 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors and lead counselors who have not functioned for 2 years as a supervisor in the provision of clinical services completed a Department-approved core curriculum in clinical supervision in one of two applicable personnel records reviewed.
Employee #10 was hired as a clinical supervisor on March 28, 2022. There was no documentation on their resume indicating having at least 2 years of clinical supervision experience. There was no documentation, in the record, that a Department-approved core curriculum was completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: Employee #10 failed to complete clinical supervisor training. Employee #10 is now registered for the DDAP supervisor training and will be completed by 6/9/23.
Clinical Coordinator will utilize a training tracker that includes all supervisors, all clinical support staff, and all clinical staff to monitor completion of trainings within required timeframes. The Clinical Manager will monitor monthly to ensure compliance with annual trainings and will follow up with the Clinical Coordinator and individual staff to ensure compliance with training requirements and timeliness. |
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 personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in six of nineteen applicable personnel records reviewed.
Employee # 2 was hired as Facility Director on September 7, 2020. The HIV/AIDS training should have been completed no later than September 7, 2022; however, the training was not completed until December 16, 2022.
Employee #15 was hired as clinical support on November 13, 2017. The HIV/AIDS and TB/STD trainings should have been completed no later than November 13, 2019; however, the TB/STD training was not completed until February 24, 2020 and the HIV/AIDS training was not completed at time of inspection.
Employee #16 was hired as administrative case manager on December 17, 2020. The HIV/AIDS and TB/STD trainings should have been completed no later than December 17, 2022; however, neither training was completed at time of inspection.
Employee #17 was hired as clinical support on January 7, 2019. The HIV/AIDS and TB/STD trainings should have been completed no later than January 7, 2021; however, neither training was completed at time of inspection.
Employee #18 was hired as clinical support on January 17, 2019. The HIV/AIDS and TB/STD training should have been completed no later than January 17, 2021; however, neither training was completed at time of inspection.
Employee #19 was hired as clinical support on September 30, 2019. The HIV/AIDS and TB/STD training should have been completed no later than September 30, 2021; however, neither training was completed at time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: Employee #2, #16, #17, #18, and #19 failed to complete the HIV/AIDS training within the required timeframe from their hire date. Employee #2 completed the HIV/AIDS training on 12/16/2022 and employee #16 completed the training on 5/17/2023. Clinical Manager and Clinical Coordinator registered employee #17, #18, and #19 to complete the HIV/AIDS training through the TrainPA portal by 6/9/23.
Employee #15, #16, #17, #18, and #19 failed to complete the TB/STD/HEP training within the required timeframe from their hire date. Employee #15 completed the TB/STD/HEP training on 2/24/2020 and employees #16, #17, #18, #19 are registered to complete the training on 6/9/2023.
The Clinical Coordinator will provide staff with information regarding external training opportunities, to include trainings offered through Chester County Drug and Alcohol and DDAP. The Clinical Coordinator will also be responsible for collecting trainings certificates and feedback forms upon completion of trainings, and provide copies to Human Resources.
Clinical Manager will review training trackers with clinical support staff during team meeting to ensure that staff members have identified and are registered for the earliest, open trainings for completion within mandated timeframes. The Clinical Coordinator will review trainings expectations of available upcoming trainings during weekly team meetings.
Clinical Coordinator will utilize a training tracker that includes the Facility Director, all supervisors, all clinical support staff, and all clinical staff to monitor completion of trainings within required timeframes. The Clinical Manager will monitor monthly to ensure compliance with annual trainings and will follow up with the Clinical Coordinator and individual staff to ensure compliance with training requirements and timeliness. |
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 personnel records, the facility failed to ensure that all counselors completed 25 clock hours of annual training during the facility's January 2022 through December 2022 training year in one of eight applicable personnel records reviewed.
Employee #6 was hired as a counselor on August 12, 2019. The record included documentation that only 12.5 hours of training received during the reviewed training year.
This is a repeat citation from the May 18, 2021 and May 23, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:Employee #6 failed to complete the required 25 clock hours of annual training throughout January 2022 to December 2022. Clinical Coordinator will create and review a corrective action plan with employee #6 to include measurable benchmarks for number of trainings completed per month. Clinical Coordinator and employee #6 reviewed current registrations for trainings and future trainings that employee #6 will complete to obtain the 25 clock hours of annual trianings.
Clinical Coordinator and Clinical Supervisor will monitor employee #6's progress in following the corrective action plan.
The Clinical Coordinator will provide staff with information regarding internal and external training opportunities, to include trainings offered through Chester County Drug and Alcohol and DDAP. The Clinical Coordinator will also be responsible for collecting trainings certificates and feedback forms upon completion of trainings, and provide copies to Human Resources.
Additionally, as a way to increase training opportunities, the agency hired a Clinical Trainer for the organization. All staff will have access to bi-weekly trainings ranging from 1-6 hours of training.
Clinical Coordinator will utilize a training tracker that includes the Facility Director, all supervisors, all clinical support staff, and all clinical staff to monitor completion of trainings within required timeframes. The Clinical Manager will monitor monthly to ensure compliance with annual trainings and will follow up with the Clinical Coordinator and individual staff to ensure compliance with training requirements and timeliness. |
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 the specific information to be disclosed on consent to release information forms in one of seven client records reviewed.
Client #3 was admitted on December 14, 2022 and was active at the time of inspection. A release of information form to a government agency was signed and dated by the client on March 14, 2023; however, the form did not include the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:The consent to release information was completed by clinician who failed to adequately indicate information to be released for Client #3. When discovered, clinicians were provided trainings to review the consent process that included what information must be included on completed consents. A consent training document was created to review what information must be included in releases of information for various situations and stakeholders. This training document has been made available and has been distributed to all clinical and support staff. Clinical Coordinator reviewed with clinicians the role of ACM and when communication and support should be received by the ACM for releases of information.
As of June 5th, 2023, the consent to release information has been corrected and updated with client to include all required information.
Clinical Coordinator implemented a tracking system to ensure all consents are completed properly and updated prior to date of expiration. Clinical Coordinator and Clinical Supervisor will monitor weekly to ensure consents are in compliance with confidentiality laws and regulations. In addition, Clinical Manager will audit a minimum of five charts monthly to ensure consents are completed as expected and include the specific information to be disclosed for each consent completed. Results of the audits will be reported at the Quality Management Committee meeting each month. This meeting includes COO/Project Director, Clinical Director, Director of Operations, Facility Director, Human Resources, and Director of Clinical Support Services. If issues are identified, staff will be held accountable via corrective action and/or retraining. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on review of the facility's unusual incident report logs, the facility failed to notify the Department within 3 business days of a death or serious injury due to trauma, suicide, medication error or unusual circumstances.
On March 6, 2023, the facility was notified of the off-site death of a client; however, there was no documentation that the incident was reported to the Department within 3 business days.
This is a repeat citation from the May 23, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:The facility was notified of the off-site death of a client that was not yet engaged in services at that time, as the client had not completed or attended any appointments with the facility. It was determined that due to the client not yet being engaged in the facility's services at that time, a report was not to be made to the Department. The client was engaged in services through another agency facility and an incident report was completed accordingly for that facility. It was discovered that the other facility's incident report appeared on the unusual incident report log mistakenly.
Staff responsible for generating the unusual incident report log has been notified of the error and will take steps to ensure the incident report log is completed accurately. Clinical Manager and Clinical Coordinator will review the unusual incident report in depth to ensure each identified report is appropriately listed.
In the event that an unusual incident does occur, the Clinical Coordinator will file a report to the Department within 3 business days after learning of a death or serious injury due to trauma, suicide, medication error or unusual circumstance. The Clinical Coordinator will submit the report to the Facility Director/Regional Director and Regional Director will ensure the report was filed with the Department. All incidents are then submitted to the Incident Manager; the Incident Manager will track if any unusual incident was submitted to the Department. Further, the Project Director and Quality Management Committee will monitor monthly to ensure compliance with this requirement. |
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 a maintain a complete client record on an individual, which is to include case consultation notes, in three of three applicable client records reviewed.
Client #1 was admitted on January 5, 2023 and was active at the time of inspection. There was no documentation of case consult in the client record.
Client #2 was admitted on January 5, 2023 and was active at the time of inspection. A case consultation note was entered in the client record on May 3, 2023; however, the note was blank and not completed at the time of inspection.
Client #3 was admitted on December 14, 2022 and was active at the time of inspection. A case consult note was completed and signed by the clinician on May 8, 2023; however, the note did not document the case being discussed with any other staff members.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: Case consultation notes were not completed within a timely manner for clients #1, #2, and #3. Clinical Supervisor failed to ensure Client #1 had a completed case consultation note on file. Clinical Supervisor failed to ensure case consultation note for Client #2 was completed in timely manner after it had been generated in the file. Clinician mistakenly signed the case consultation note on file for Client #3, resulting in the supervisor failing to have documented in the case consult note all participants of the meeting and signing the note themselves.
Clinical Coordinator implemented a tracking system to ensure all case consultation notes are completed properly and updated in a timely manner. Clinical Coordinator and Clinical Supervisor will monitor weekly to ensure compliance. In addition, Clinical Manager will audit a minimum of five charts monthly to ensure case consultation notes are completed as expected and will follow up with Clinical Coordinator with any concerns or upcoming notes coming due. Results of the audits will be reported at the Quality Management Committee meeting each month. This meeting includes COO/Project Director, Clinical Director, Director of Operations, Facility Director, Human Resources, and Director of Clinical Support Services. If issues are identified, staff will be held accountable via corrective action and/or retraining. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of personnel records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for failing to document 25 hours of annual training for each counselor were submitted and approved by the Department for the May 23, 2022 and May 18, 2021 annual licensing inspections. Failing to document 25 hours of annual training for each counselor was again found to be a deficiency in the May 10, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: Clinical Coordinator, Clinical Manager, and Facility Director failed to ensure actions were taken to adequately address repeat citations from the previous year's inspection. Clinical Coordinator has implemented a formal warning for the repeat citation with staff. Clinical Coordinator and Clinical Supervisor will review in team meetings and individual supervisions citations and steps to be taken to address regulation requirements. Clinical Coordinator, Clinical Supervisor, and Clinical Manger will continue to monitor progress made towards corrective action plan deadlines to ensure compliance with regulations. The agency executive team is committed to improvement and will review repeat citation and corrective action plan on a regular basis during Quality Management Committee meetings. The meetings include COO/Project Director, Clinical Director, Director of Operations, Human Resources, Chief Compliance Officer, Director of Clinical Support Services and Facility Director. If a problem with compliance is identified, staff will be held accountable and/or pulled from schedule. The agency's approach to monitoring these specific citations at an executive level will ensure these areas are kept as a priority. |