INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 6, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clear Concepts Counseling 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
Eleven personnel records were reviewed on June 6, 2017. The facility failed to provide documentation of required HIV/AIDS and TB/STD training for employee record # 9. Employee # 9 was hired by the facility on 11/24/15 as a counselor. The employee was required to complete HIV/AIDS and TB/STD training by no later than 11/24/16. The facility failed to provide documentation of this training.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our project will be in full compliance with this standard by 06/30/2018, which is the end of our current training year. By that date employee #9 will have received the required 6 hours of HIV/AIDS and 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training that are DDAP approved. This employee will seek out and attend trainings throughout the year which will address the areas set forth by the standard. In the future, the Project Director and Clinical Supervisor will conduct quarterly reviews as well as bi-monthly clinical supervision of all training requirements to ensure that this standard is being complied with. |
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
One personnel record was reviewed for the Facility Director position on June 6, 2017. The facility failed to document at least 12 hours of annual training for employee record # 2. Employee # 2 was hired by the project on 2/20/09, and then assumed the project director position on 1/1/14. The facility's last complete training year of July 1, 2015 - June 30, 2016 was reviewed. Documentation in the employee's record indicated that the employee completed 4.5 hours of annual training for the training year reviewed. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard by 06/30/2018, which is the end of our current training year. By that date the Facility Director will have received 12 training hours as is required by the standard. Employee #2 had failed to complete the required trainings. This employee will seek out & attend trainings throughout the year, which will address the areas set forth by the standard. The Clinical Supervisor and Project Director are responsible for ensuring the corrective action(s) is implemented. In the future, the Clinical Supervisor and Project Director will conduct quarterly reviews of all training hours as well as monthly clinical supervision to ensure that this standard is being complied with. |
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
Eight personnel records were reviewed for the Counselor position on June 6, 2017. The facility failed to document at least 25 hours of annual training for employee record # 6. Employee # 6 was hired by the facility on 9/6/06 as a counselor. The facility's last complete training year of July 1, 2015 - June 30, 2016 was reviewed. Documention in the employee's record indicated that the employee completed 16.5 hours of annual training for the training year reviewed.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard by 06/30/2018, which is the end of our current training year. By that date each employee will have received 25 training hours as is required by the standard. Employee #6 had failed to complete the required trainings. This employee will seek out & attend trainings throughout the year, which will address the areas set forth by the standard. The Clinical Supervisor and Project Director are responsible for ensuring the corrective action(s) is implemented. In the future, the Clinical Supervisor and Project Director will conduct quarterly reviews of all training hours as well as monthly clinical supervision to ensure that this standard is being complied with. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
A physical plant inspection was conducted on June 6, 2017. A space heater that was not permanently mounted or installed was observed in a counselor's office located on the first floor of the facility. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project was in full compliance with this standard immediately. The space heater was removed and the Project Director is looking into the mounted space heater. In the future the Project Director will conduct a walk thru of the office to make sure that no individual space heaters that are not mounted or installed are being utilized. This standard was reviewed during our agency monthly staff meeting on June 21, 2017. |
709.28 (c) 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.
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Observations
Seven client records were reviewed on June 6, 2017. The facility failed to specify the date, event, or condition upon which the consent would expire for client record # 1. In addition, the facility failed to obtain an informed and voluntary consent where consent was applicable for client records # 1 and 7. Client # 1 was admitted into treatment on 8/17/16 and was still active in treatment. A consent to release to the client's treatment funding source, signed and dated on 8/17/16, did not specify the date, event, or condition upon which the consent would expire. In addition, documentation in the client's record indicated that the facility forwarded the client's treatment court evaluation to a treatment court on 1/13/17. A consent to release information to the treatment court was not documented in the client's record. Client # 7 was admitted into treatment on 10/12/16 and was discharged on 3/6/17. A consent to release information to the client's treatment funding source was not documented in the client's record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard was reviewed during our agency staff meeting on June 21, 2017. The proper completion and documentation of the consent to release information to the treatment funding source will be obtained during client #1 next scheduled session. Our facility will obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The proper completion of the required consent forms, including date, event, and condition as well as the expiration date of the consent.
To ensure correct completion of consents forms the Clinical Director and Project Director will verify completion during weekly supervision. The Clinical Supervisor will also review individual counselor's client records on a weekly basis and during weekly supervision to insure compliance.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Seven client records were reviewed on June 6, 2017. The facility failed to document a psychosocial evaluation for client records # 1, 2, 5, and 7. In addition, the facility failed to ensure that a psychosocial evaluation was completed during the intake process for client record # 4. Client # 1 was admitted into treatment on 8/17/16 and was still active in treatment. A psychosocial evaluation was not documented in the client's record. Client # 2 was admitted into treatment on 7/27/16 and was still active in treatment. A psychosocial evaluation was not documented in the client's record. Client # 4 was admitted into treatment on 12/29/16 and was discharged on 4/28/17. The psychosocial evaluation documented in the client's record was completed on 3/31/17. Client # 5 was admitted into treatment on 3/21/16 and was discharged on 11/18/16. A psychosocial evaluation was not documented in the client's record. Client # 7 was admitted into treatment on 10/12/16 and was discharged on 3/6/17. A psychosocial evaluation was not documented in the client's record. This finding was was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard were reviewed with all counselors during staff meeting on June 21, 2017. The biopsychosocial evaluation (consolidated assessment) by our standards is to be completed by the end of the 5th session. However, during our onsite licensing renewal inspection it was brought to the attention that the consolidated assessment must be completed during the intake process. The Project Director has updated the agency policy and procedure to include the consolidated assessment must be completed during the intake process which is by the end of the clients first session. The Clinical Supervisor and Project Director will also review updated policy and procedures with all counselors in individual supervision weekly as an added measure to insure compliance. The Clinical Supervisor will also review individual counselor's client records on a weekly basis and during weekly supervision to insure compliance. |
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
Seven client records were reviewed on June 6, 2017. The facility failed to document an individual treatment and rehabilitation plan for client records # 5 and 7. The facility also failed to document the type and/or frequency of treatment services on the individual treatment and rehabilitation plan for client records # 2, 3, and 6. Lastly, the facility failed to ensure that an individual treatment and rehabilitation plan was completed in a timely manner for client records # 1 and 4. Client # 1 was admitted into treatment on 8/17/16 and was still active in treatment. The individual treatment and rehabilitation plan documented in the client's record was completed on 3/16/17. Client # 2 was admitted into treatment on 7/27/16 and was still active in treatment. The individual treatment and rehabilitation plan documented in the client's record, completed on 8/27/16, did not specify the type of treatment services. Client # 3 was admitted into treatment on 9/13/16 and was still active in treatment. The individual treatment rehabilitation plan documented in the client's record, completed on 10/13/16, did not specify the type frequency of treatment services. Client # 4 was admitted into treatment on 12/29/16 and was discharged on 4/28/17. The individual treatment and rehabilitation plan documented in the client's record was completed on 3/17/17. Client # 5 was admitted into treatment on 3/21/16 and was discharged on 11/18/16. An individual treatment and rehabilitation plan was not documented in the client's record. Client # 6 was admitted into treatment on 8/23/16 and was discharged on 11/14/16. The individual treatment and rehabilitation plan documented in the client's record, completed on 9/23/16, did not specify the type and frequency of treatment services. Client # 7 was admitted into treatment on 10/12/16 and was discharged on 3/6/17. An individual treatment and rehabilitation plan was not documented in the client's record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard were reviewed during our agency staff meeting on June 21, 2017. The comprehensive (master) treatment plan will be completed at the end of the client's first session. The comprehensive treatment plan will be developed with the clients input, signed and dated by the client. The primary therapist will document the specific type and/or frequency of treatment services on all individual client treatment plans. To ensure the comprehensive (master) treatment plan is completed by the end of the client's first session the Clinical Director and Project Director will verify completion during weekly clinical supervision. The Clinical Supervisor will also review individual counselor's client records on a weekly basis. |
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
Seven client records requiring the documentation of treatment plan updates were reviewed on June 6, 2017. The facility failed to document a treatment plan update at least every 60 days for client records # 1, 2, and 3. Client # 1 was admitted into treatment on 8/17/16 and was still active in treatment. A comprehensive treatment plan was completed for the client on 3/16/17. A subsequent treatment plan update documented in the client's record indicated that it was for the period of 5/16/17 - 7/16/17. The facility failed to document the date in which the treatment plan update was completed. Client # 2 was admitted into treatment on 7/27/16 and was still active in treatment. A treatment plan update was completed for the client on 2/27/17. A subsequent treatment plan update was due to be completed for the client by 4/27/17, and one was not documented in the client's record. Client # 3 was admitted into treatment on 9/13/16 and was still active in treatment. A treatment plan update was completed for the client on 2/13/17. A subsequent treatment plan update was due to be completed for the client by 4/13/17, and one was not documented in the client's record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard were reviewed during our agency staff meeting on June 21, 2017. The Clinical Supervisor and Project Director met with the counselors of client records #1, 2 and 3 to insure the treatment plan updates were completed and up to date on June 21, 2017. The individual treatment plan update will be completed at least every 60 days. To ensure completion of treatment plan updates at least every 60 days the Clinical Director and Project Director will verify completion during bi-monthly clinical supervision. The Clinical Supervisor will also review individual counselor's client records on a weekly basis and during weekly supervision to insure compliance. |