INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Sobriety Solutions Pennsylvania 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on an administrative review, the facility failed to follow their staff development program policies and procedures.
At the time of the inspection, the facility did not complete the assessment of staff training needs, the overall training plan to address the staff training needs, and the annual evaluation of the overall training plan from the previous training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will enure individual training plans for all employees to include assessment of training needs, overall plan for addressing these needs, will collect feedback on completed trainings and complete and annual evaluation of the overall training plan per facility policies and procedures. Regulation 704.11(a) will be on the monthly leadership meeting agenda in effort to ensure compliance to this regulation and maintain records of staff development plan. |
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, 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 training within the regulatory timeframe in five of six applicable personnel records reviewed.
Employee # 1 was hired as the project director and facility director on November 11, 2019 and was due to have the TB/STD training no later than November 11, 2021. The 4-hour TB/STD training was not completed at the time of the inspection.
Employee # 3 was hired as a counselor on August 29, 2022 and was due to have the TB/STD training no later than August 29, 2023. The 4-hour TB/STD training was not completed at the time of the inspection.
Employee # 6 was hired as a counselor assistant on June 10, 2022 and was due to have the HIV/AIDS and TB/STD trainings no later than June 10, 2023. The 6-hour HIV/AIDS training was completed on December 18, 2023 and the 4-hour TB/STD training was not completed at the time of the inspection.
Employee # 7 was hired as a counselor assistant on August 25, 2022 and was due to have the HIV/AIDS and TB/STD trainings no later than August 25, 2023. Both the 6-hour HIV/AIDS training and the 4-hour TB/STD trainings were not completed at the time of the inspection.
Employee # 8 was hired as the director of admissions on October 22, 2018 and was due to have the TB/STD training no later than October 22, 2020. The 4-hour TB/STD training was not completed at the time of the inspection.
This is a repeat citation from the January 30, 2018, January 24, 2020, October 21, 2020, October 22, 2021, December 12, 2022, and June 27, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new staff will be trained with at least 4 hours of TB/STD and at least 6 hours of HIV/AIDS when hired. During weekly clinical meetings with Clinical Director and Chief Clinical officer, CD and CCO will identify any new staff members and have them complete these required trainings. Leadership Team will meet monthly and review new hires' training needs to ensure that all new staff have been trained. Employees 1, 3 and 8 will complete their TB/STD trainings. Employees 6 and 7 will complete the 6 hour HIV/AIDS and the 4 TB/STD training pursuant to regulation 704.11(c)(1). These trainings will be completed by or before 2/1/2024. Staff TB/STD trainings and HIV/AIDS training requirements will be on the monthly leadership meeting agenda in effort to ensure compliance for regulation 704.11(c)(1). |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor assistant completed at least 40 clock hours of training during their first year in two of two applicable personnel records reviewed.
Employee # 6 was hired as a counselor assistant on June 10, 2022. There were 0 hours of training documented during their first year in the position.
Employee # 7 was hired as a counselor assistant on August 25, 2022. There were 0 hours of training documented during their first year in the position.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director and HR will review files of counselor assistants employees 6 and 7. HR will identify deficiencies in trainings and will ensure training hours are complete. Leadership Team will meet monthly as an added agenda item to track trainings of all staff to ensure all staff have met the annual training requirements. Clinical Director and Chief Clinical Officer will meet weekly to ensure all trainings requirements are met. |
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 that copies of client consent to release information forms were offered to the client in fourteen of fourteen client records reviewed.
In every client record reviewed, the consent to release information form to the funding source was signed and dated by the client; however, there was no documentation that a copy of any of the forms were offered to the client.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Pursuant to regulation 709.28(d), an additional form has been created and implemented for the intake process. The form asks a client if they would like a copy of their releases and allows a client to specifically choose which release they would like a copy if any. Admissions director will review all new intakes to ensure that a client has chosen to receive copies of releases or if the client denies copied of releases. All current clients will be met with by Admissions Director to ensure current clients have been provided the option to accept or decline copies of releases which will be documented in the admissions section of the clinical chart. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure that individual counseling was provided at least twice weekly for clients in the partial hospitalization activity in three of seven applicable client records reviewed.
Client #1 was admitted into the partial hospitalization activity on October 19, 2023 and was active at the time of inspection. There were no documented individual counseling sessions being conducted two times a week during the weeks of October 31, 2023 through December 1, 2023.
Client #2 was admitted into the partial hospitalization activity on November 17, 2023 and was active at the time of inspection. There were no documented individual counseling sessions being conducted two times a week during the weeks of November 19, 2023 through December 9, 2023.
Client #3 was admitted into the partial hospitalization activity on November 20, 2023 and was active at the time of inspection. There were no documented individual counseling sessions being conducted two times a week during the weeks of December 8, 2023 through the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will conduct with weekly chart audits and will identify any issues with individual session documentation. Chief Clinical Officer and Clinical Director will with clinical staff for a policies and procedures training regarding treatment planning and timeframes to ensure compliance pursuant to 709.82(d)(1). Clinical staff will be trained regarding those clients in partial hospitalization requiring two individual sessions weekly and documentation of sessions including documentation of missed sessions. |
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 client records, the facility failed to ensure that treatment plans were reviewed and updated at least every 60 days in three of six applicable client records reviewed.
Client # 8 was admitted into the outpatient activity on July 5, 2023 and was active at the time of inspection. A treatment plan update was completed on September 13, 2023 and the next update was due no later than November 13, 2023; however, the update was not completed as of the date of the inspection.
Client # 9 was admitted into the outpatient activity on August 9, 2023 and was active at the time of inspection. The individual treatment plan was completed on October 8, 2023 and the first update was due no later than December 8, 2023; however, the update was not completed as of the date of the inspection.
Client # 10 was admitted into the outpatient activity on July 6, 2023 and was active at the time of inspection. A treatment plan update was completed on October 10, 2023 and the next update was due no later than December 10, 2023; however, the update was not completed as of the date of the inspection.
This is a repeat citation from the December 12, 2022 and June 27, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will conduct an in house training with clinical staff regarding regulation 709.92(b). Clinical staff will attend this training with emphasis on regulation requiring a treatment plan update be completed no longer than 60 days from treatment plan initiation. Chief Clinical Officer will review training and attendees. Clinical Director will review this regulation at weekly clinical staff meetings to ensure compliance. Clients 8 and 9 updates were completed on 1/4/2024. Client 10 discharged 12/20/23 as treatment plan was updated and closed. |
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 administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing 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 training within the regulatory timeframe was submitted and approved by the Department for the January 1, 2018, January 24, 2020, October 21, 2020, October 22, 2021, December 16, 2022, and June 27, 2023 licensing inspections. Failing 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 training within the regulatory timeframe was again found to be a deficiency in the December 19, 2023 licensing inspection.
A plan of correction for failing to document that treatment plans were reviewed and updated at least every 60 days was submitted and approved by the Department for the December 16, 2022 and June 27, 2023 licensing inspections licensing inspections. Failing to document that treatment plans were reviewed and updated at least every 60 days was again found to be a deficiency in the December 19, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Leadership team will meet with staff members who failed to complete the 6 hour HIV/AIDS and 4 hour TB/STD required trainings and will ensure that these have been satisfied. Clinical Director and Chief Clinical Officer will provide an in house training pursuant to regulation 709.92(b) in which staff members will sign off that they were in attendance of in house training. This training will be held weekly until all clinical staff attended and acknowledged this training. All new employees will be trained upon hire. Leadership team will include review of regulations 704.11(c)(1) and 709.92(b) in the monthly agenda to ensure that this deficiency has been corrected and not deficient in the future |