INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 6, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, R&D Center LLC 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of five personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee # 5 has been in the position of counselor assistant since August 26, 2024. Employee # 5 had a high school diploma at the time of promotion and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Employee # 5 did not receive documented direct observation from August 26, 2024 - November 26, 2024.
Direct observation is defined by regulation as follows: "In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities." In accordance with 28 Pa. Code 704.9(a), a counselor assistant must be supervised by a fulltime clinical supervisor or a full-time counselor. The fully qualified clinical supervisor or counselor is then responsible for weekly supervision notes relating to the counselor assistant. Clear documentation in the weekly notes and in the pertinent client charts must also demonstrate that direct observation is occurring.
Close supervision is defined by regulation as follows: "Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week."
Documented supervision did not identify that direct observation was occurring during the dates noted above.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will monitor all incoming interns on prior education received. Interns that do not have approved DDAP Bachelor's Degrees will receive weekly additional supervision and all sessions with clients will be observed for the first 3 months. We have have updated the supervision form to include acknowledgement of direct observation.
Employee #5 received 3 months of direct supervision but it was not fully documented. Clnical Director will ensure supervision is documented appropriately
Clinical Director will be responsible for ensuring continued compliance of 28 PA. Code 404.9(a) |
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 two of five applicable employees received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 3 has been a counselor ember since November 6, 2023 and was due to have the communicable disease trainings no later than November 6, 2024. However, the personnel record only contained documentation of the completion of 3 hours of TB/STD training as of the date of the inspection.
Employee # 4 has been a counselor since November 27, 2023 and was due to have the communicable disease trainings no later than November 27, 2024. However, the personnel record did not contain documentation of the completion of the HIV/AIDS or TB/STD trainings as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3 and Employee #4 have scheduled trainings for HIV/AIDS (6 hours) and TB/STI (4 hours).
Clinical Director will ensure that these trainings are complete. Clinical Director will also ensure continued compliance for all employees. All staff shall have HIV/AIDS (6 hours) and TB/STI (4 hours) within the first year of employment. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of five personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in two records reviewed.
Employee # 4 has been in the position of counselor since November 27, 2023 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete as of the date of the inspection.
Employee # 5 has been in the position of counselor assistant since August 26, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new hires, including on-site, contracted labor, trainings will include fire safety training and will be documented accordingly. Employee #4 and #5 have been trained on the use fire estinguishers.
Executive Director is responsible for continued compliance. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of five personnel records, the facility failed to ensure that two applicable staff members were trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 4 has been in the position of counselor since November 27, 2023 and is current in that position. Employee # 4 began working shifts on November 27, 2023; however, the record did not contain documentation that the employee was trained to perform assigned tasks during emergencies as of the date of the inspection.
Employee # 5 has been in the position of counselor assistant since August 26, 2024 and is current in that position. Employee # 5 began working shifts on August 26, 2024; however, the record did not contain documentation that the employee was trained to perform assigned tasks during emergencies as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new hires, including on-site, contracted labor, trainings will include fire safety training and will be documented accordingly. Employee #4 and #5 will complete fire safety training and emergency preparedness training in Relias.
Exective Director is responsible for continued compliance. |
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
Based on a review of eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client # 4 was admitted on April 8, 2024 and was discharged on July 24, 2024. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
This is a repeat citation from the December 20, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"Consent for Funding Source" has been added to the list of mandatory forms to admit clients into our EMR.
Admissions Director will be responsible for continued 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 eight client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project, in one of one applicable record reviewed.
Client # 2 was admitted on April 25, 2024 and was involuntarily discharged on July 8, 2024. The record contained no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff have been trained on the policy of notifying clients in writing when being involuntarily discharged.
Clinical Director is responsible for ensuring compliance of this policy. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document disclosure to the client of criteria for admission, treatment, or completion in eight of eight applicable records reviewed.
Client # 1 was admitted on March 22, 2024 and was discharged on October 31, 2024.
Client # 2 was admitted on April 25, 2024 and was discharged on July 8, 2024.
Client # 3 was admitted on February 29, 2024 and was discharged on November 12, 2024.
Client # 4 was admitted on April 8, 2024 and was discharged on July 24, 2024.
Client # 5 was admitted on April 1, 2024 and was discharged on October 24, 2024.
Client # 6 was admitted on July 30, 2024 and was active at the time of the inspection.
Client # 7 was admitted on September 23, 2024 and was active at the time of the inspection.
Client # 8 was admitted on July 29, 2024 and was active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The new client handbook has been updated to include criteria for admission and discharge. This includes what is necessarry for successful completion of treatment and criteria for involuntary discharge.
Admissions Director is responsible for compliance of this policy. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a preliminary treatment plan within 72 hours of intake, per policy, in four of eight records reviewed.
Client # 1 was admitted on March 22, 2024 and was discharged on October 31, 2024. The record did not contain a preliminary treatment plan.
Client # 3 was admitted on February 29, 2024 and was discharged on November 12, 2024. The record did not contain a preliminary treatment plan.
Client # 6 was admitted on July 30, 2024 and was active at the time of the inspection. The record did not contain a preliminary treatment plan.
Client # 7 was admitted on September 23, 2024 and was active at the time of the inspection. The record did not contain a preliminary treatment plan.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
We have updated our EMR system to prohibit admission until an initial treatment plan is completed during the intake process.
Clinical Director will montior intakes to ensure that initial treatment plans are completed within 72 hours of admission. |
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 document treatment plan updates within the regulatory timeframe in three of seven applicable records reviewed.
Client # 1 was admitted on March 22, 2024 and was discharged on October 31, 2024. The individual treatment and rehabilitation plan was completed on April 18, 2024, and the treatment plan update was due no later than June 17, 2024; however, no treatment plan updates were completed prior to discharge.
Client # 3 was admitted on February 29, 2024 and was discharged on November 12, 2024. The individual treatment and rehabilitation plan was completed on March 15, 2024, and the treatment plan update was due no later than May 14, 2024; however, no treatment plan updates were completed prior to discharge.
Client # 6 was admitted on July 30, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 15, 2024, and the treatment plan update was due no later than October 14, 2024; however, no treatment plan updates were completed prior to the date of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will be trained on the policy of updating treatment plans within 60 days.
Clinical Director is responsible for chart audits and ensuring compliance of this ploicy. |