INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on January 19, 2023 through January 20, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Caron Treatment Centers 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(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 22 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that three applicable employees received the minimum of 6 hours of HIV/AIDS training and 4 hours of TB/STD training within the regulatory timeframe.
Employee #4 was hired as a counselor on July 6, 2021 and was due to have the communicable disease trainings no later than July 6, 2022. However, the facility provided no documentation of the completion of the HIV/AIDS or TB/STD trainings as of the date of the inspection.
Employee #8 was hired as a counselor on April 19, 2021 and was due to have the communicable disease trainings no later than April 19, 2022. However, the employee did not complete the TB/STD training until September 23, 2022.
Employee #12 was hired as a counselor on July 19, 2021 and was due to have the communicable disease trainings no later than July 19, 2022. However, the employee did not complete the HIV/AIDS training until November 11, 2022 and the TB/STD training until November 4, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 attended DDAP TB/STD training on 2/10/2023. Employee #4 is scheduled to attend DDAP HIV/AIDS on 2/24/2023.
The Director of Training will monitor the completion of the mandatory DDAP trainings for new hires on a quarterly basis to ensure staff receive the required trainings within their first year of employment. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of four personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director.
Employee # 1 was promoted to the position of Project Director on July 1, 2021 and has remained in that position. The facility's training year that was reviewed was from July 1, 2021 through June 30, 2022. Employee # 1's employee record only documented 1 hour of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 has completed 8 hours of training in the current training year which ends on June 30, 2023. Employee #1 is also scheduled to attend DDAP TB/STD for 4 hours in February which will bring his total training hours to 12 hours for the training year. The Director of Training will ensure the 12 hours of training are completed for the training year.
In addition, to monitor the completion of training hours the Director of Training will distribute a training hours report on a quarterly basis to the project director and facility director.
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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 document the completion of 25 clock hours of annual training required for counselors in three applicable records reviewed.
Employee # 5 has been employed as a counselor since July 27, 2020. The facility's training year that was reviewed was from July 1, 2021 through June 30, 2022. Employee # 5's personnel record only documented 20.75 hours of training for the period reviewed.
Employee # 9 has been employed as a counselor since May 21, 2019. The facility's training year that was reviewed was from July 1, 2021 through June 30, 2022. Employee # 9's personnel record only documented 22 hours of training for the period reviewed.
Employee # 13 has been employed as a counselor since June 18, 2018. The facility's training year that was reviewed was from July 1, 2021 through June 30, 2022. Employee # 13's personnel record only documented 5.75 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All three employee's have already completed their required training hours for the current training year. Employee #5 has completed 38.5 training hours, employee #9 has completed 31.5 training hours and employee #13 has completed 34.75 training hours.
To monitor the completion of training hours for clinicians the Director of Training will distribute a training hours report on a quarterly basis to all clinicians and their supervisors. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on January 20, 2023, the facility failed to ensure that heaters were permanently mounted as a space heater was found in the alumni office of the Villa building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The space heater was removed from the staff member's office on the day of the inspection. The staff member also received disciplinary action for violating Caron's policy on Prohibited items.
The Maintenance Supervisor conducts safety inspections on a monthly basis which includes inspections of staff offices for prohibited items. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel files, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one applicable record reviewed.
Employee #15 was hired as a counselor on August 1, 2022 and was due to be trained in the use of fire extinguishers upon hire; however, fire safety training was not documented as completed in the personnel record until November 21, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning on March 6, 2023 all new employees will be required to meet with a member of the HR/Training department on their first day to complete the fire safety and fire extinguisher training. the Director of Training will monitor the completion of this training on a weekly basis for all new hires to ensure the training is completed upon hire. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from November 2021 through October 2022 and the daily programming schedules presented by facility staff, the facility failed to conduct fire drills during sleeping hours at least every six months. The only fire drill conducted during sleeping hours in the following buildings: 100-400, 1000, and 1200 were in March 2022. Buildings 1400 and 3000 had no fire drills conducted during sleeping hours during the period reviewed.
This is a repeat citation from the February 10, 2021 and November 4, 2021 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill schedule has been revised so that sleeping hour drills are now scheduled to occur between the hours of 12am and 5am which will match the sleeping hours of the programming schedule.
The Director of Facilities will monitor the completion of fire drills on a monthly basis to ensure drills are completed as required.
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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, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients. The facility failed to follow their policy related to Against Staff Advice (ASA) discharges of calling the Emergency Contact within twelve hours in one of one applicable record reviewed.
Client #10 was admitted to the Rehabilitation level of care on April 23, 2022 and discharged Against Staff Advice (ASA) on May 8, 2022. There was no documentation in the client record that the emergency contact was called.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the requirement to notify the patient's emergency contact at the time the patient leaves the facility ASA.
Nonfiction of the emergency contact for ASA's will be added to the chart review form. The Quality Analyst will conduct quarterly chart reviews to monitor compliance. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of twenty-two personnel records, the facility failed to ensure that personnel records contained a reviewed and signed annual written staff performance evaluations in six of nineteen applicable records reviewed.
Employee # 2 has been the Facility Director since June 30, 2014 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by October 1, 2022 but was not signed by the employee until November 15, 2022.
Employee # 4 has been a counselor since July 6, 2021 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by October 1, 2022 but was not signed by the employee until October 24, 2022.
Employee # 5 has been a counselor since July 27, 2020 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by November 27, 2021 but was not signed by the employee until August 28, 2022.
Employee # 8 has been a counselor since April 19, 2021 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by July 16, 2022 but was not signed by the employee until January 13, 2023.
Employee # 16 has been a employed by the Project since June 22, 2010. They were promoted from Behavioral Health Tech to counselor on August 8, 2022. The annual written staff performance evaluation was due to be reviewed and signed by the employee by August 27, 2022 but was not signed by the employee until November 21, 2022.
Employee # 17 has been a counselor since January 6, 2020 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by March 31, 2022 but was not signed by the employee until December 25, 2022.
This is a repeat citation from the November 4, 2021 annual licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Supervisors who completed performance evaluations later were counseled by Human Resources.
All supervisors will be re-educated on the requirement to complete and sign performance evaluations on an annual basis per the timeframe outlined in Caron's policy.
The Corporate Director of Human Resources will monitor the completion of performance evaluations on a monthly basis to ensure evaluations are completed as required. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of fourteen records, the facility failed ensure that verbal orders were authenticated in writing by a physician or other medical professional within the regulatory timeframe in three records reviewed.
Client # 1 was admitted to the Detox activity on September 13, 2022 and discharged on September 16, 2022. Two verbal orders were given on September 13, 2022 but were not authenticated in writing by a physician.
Client # 4 was admitted to the Detox activity on October 24, 2022 and discharged on October 27, 2022. A verbal order was given on October 24, 2022 but was not authenticated in writing by a physician.
Client # 12 was admitted to the Rehab activity on December 20, 2022 and was active at the time of the inspection. A verbal order was given on December 30, 2022 but was not authenticated in writing by a physician.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Physicians will be re-educated on the requirement to authenticate verbal orders within 24 hours.
The Director of Medical Records monitors the authentication of verbal orders on a daily basis and will notify the physician and his/her supervisor of verbal orders that need to be authenticated on a daily basis. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of patient records, the facility failed to ensure that physician assistants or certified registered nurse practitioners (CRNP) that were performing functions delegated by the narcotic treatment physician had those duties properly countersigned in one record reviewed.
Patient #2 was admitted to the Detox activity on January 26, 2022 and was discharged on January 28, 2022. The record contained documentation of an order by the CRNP on January 27, 2022, which was not countersigned by the narcotic treatment physician within three days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director will re-educate physician's in the department meeting on the requirement to countersign orders entered by CRNP's within 72 hours.
Countersigning of orders will be monitored by the Quality Analyst through quarterly chart reviews. |
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 seven client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 15 days in two of six applicable records reviewed.
Client # 10 was admitted on April 19, 2022 and discharged on May 8, 2022. The individual treatment and rehabilitation plan was completed on April 20, 2022 and the treatment plan update was due to be completed by May 4, 2022; however, no treatment plan updates were completed prior to discharge.
Client # 11 was admitted on October 27, 2022 and discharged on November 23, 2022. The individual treatment and rehabilitation plan was completed on November 2, 2022 and the treatment plan update was due to be completed by November 17, 2022; however, the next treatment plan update was not completed until November 23, 2022.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Directors will re-educate the clinicians on the requirement to complete treatment plan updates every 15 days per Caron's policy during the weekly treatment team meeting.
Completion of treatment plan updates will be monitored via chart reviews on a quarterly basis by the Quality Analyst and results will be reported to the Clinical Directors. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on a review of six client records, the facility failed to follow their written client follow-up policy, to include attempted contact within one week of discharge, in two of six applicable records reviewed.
Client # 8 was admitted on September 16, 2022 and discharged on October 14, 2022. There was not documentation of an attempted follow up contact within one week of discharge in the record.
Client # 10 was admitted on April 19, 2022 and was discharged on May 8, 2022. There was not documentation of an attempted follow up contact within one week of discharge in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will develop a new process for completion of follow-up calls. The Executive Director will training the clinicians on the new process for completing follow-up by 3/10/23.
Follow-up calls will be added to closed record chart reviews and will be monitored by the Quality Analyst on a quarterly basis. |
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 fire drill logs and a discussion with facility staff, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for conducting fire drills during sleeping hours at least every six months was submitted and approved by the Department for the February 10, 2021 and November 4, 2021 annual licensing inspections. Conducting fire drills during sleeping hours at least every six months was again found to be a deficiency in the January 19, 2023 through January 20, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance/Risk Manager will ensure the plan of correction is implemented and followed. The Compliance/Risk Manager will monitor the implementation of the plan of correction on a quarterly basis to ensure the plan continues to be followed. |