INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 18, 2021 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records, the facility failed to complete individual training plan within a reasonable time. Licensing alert 03-05 states that initial training plans of newly hired employees shall be completed within 30 days of the date of hire.
Employee # 3 was hired as the Clinical Supervisor on March 1, 2021. The individual training plan was completed on May 12, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the first week of new hire orientation to the D&A program, direct supervisors will meet with new hires for completion and review of initial training plans, ensuring completion within the required timeframe.
Monthly, the Clinical Supervisor, Clinical Coordinator, and Regional Director will monitor this process for all new staff to ensure completion of all required onboarding documents, to include individual training plans. |
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 four of nineteen personnel records reviewed.
Employee # 5 was hired as a counselor on August 1, 2019. HIV/AIDS and TB/STD training should have been completed no later than August 1, 2020; however, there was no documentation of completed trainings at the time of the inspection.
Employee # 10 was hired as a counselor on September 17, 2019. TB/STD training should have been completed no later than September 17, 2020; however, there was no documentation of the completed training at the time of the inspection..
Employee # 12 was hired as a counselor on May 6, 2019. HIV/AIDS and TB/STD training should have been completed no later than May 6, 2020; however, there was no documentation of completed trainings at the time of the inspection.
Employee # 13 was hired as a counselor on May 13, 2019. TB/STD training should have been completed no later than May 13, 2020; however, there was no documentation of completed trainings at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Monthly, Clinical Coordinator will review program's internal training tracking spreadsheet to monitor staff's completion of DDAP and SCA required trainings, including HIV/AIDS and TB/STD, within allotted timeframes.
Progress toward obtaining required trainings will be reviewed during individual supervisions on a monthly basis with supervisors supporting staff members in identifying and registering for required trainings. Training certificates and feedback forms will be collected upon completion.
Specifically regarding HIV/AIDS and TB/STD trainings, Holcomb will explore developing in-house trainings (following DDAP guidelines and training requirement outlines) and/or contracting for in-house trainings by outside vendors to provide additional opportunities for staff to obtain the required trainings. |
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 during the facility's January 1, 2020 through December 2020 training year in eleven of fourteen applicable records reviewed.
Employee # 5 was hired as a counselor on August 1, 2019. The employee record documented 3.5 hours of annual training during the training year reviewed.
Employee # 7 was hired as a counselor on October 25, 2012. The employee record documented 0 hours of annual training during the training year reviewed.
Employee # 8 was hired as a counselor on February 6, 2012. The employee record documented 19.25 hours of annual training during the training year reviewed.
Employee # 9 was hired as a counselor on November 11, 2009. The employee record documented 0 hours of annual training during the training year reviewed.
Employee # 11 was hired as a counselor on August 3, 2017. The employee record documented 0 hours of annual training during the training year reviewed.
Employee # 12 was hired as a counselor on May 6, 2019. The employee record documented 0 hours of annual training during the training year reviewed.
Employee # 13 was hired as a counselor on May 13, 2019. The employee record documented 0 hours of annual training during the training year reviewed.
Employee # 14 was hired as a counselor on March 12, 2018. The employee record documented 0 hours of annual training during the training year reviewed.
Employee # 17 was hired as a counselor on October 2, 2019. The employee record documented 15.75 hours of annual training during the training year reviewed.
Employee # 18 was hired as a counselor on October 17, 2016. The employee record documented 3 hours of annual training during the training year reviewed.
Employee # 19 was hired as a counselor on May 21, 2015. The employee record documented 0 hours of annual training during the training year reviewed.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Monthly, Clinical Coordinator will review program's internal training tracking spreadsheet to monitor staff's progress toward annual completion of 25 hours of approved trainings.
Progress toward obtaining the required 25 hours of training will be reviewed during individual supervisions on a monthly basis with supervisor supporting staff in identifying and registering for trainings throughout the year.
Opportunities for internal trainings will include Holcomb Behavioral Health Systems' Annual conference, utilization of the agency's internal Learning Management System (LMS), and specific D&A program trainings to address staff/program needs--i.e. Motivational Interviewing.
Training certificates and feedback forms will be collected upon completion of all trainings. |
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 personnel records, the facility failed to provide fire extinguisher training upon staff employment in two of nineteen employee records reviewed.
Employee # 2 was hired as the Facility Director on September 7, 2020. There was no documentation that fire extinguisher training was provided to the employee as of the date of the inspection.
Employee # 3 was hired as a Clinical Supervisor on March 1, 2021. There was documentation that fire extinguisher training was provided to the employee on May 6, 2021; however, it was not provided upon employment.
This is a repeat citation from the April 24, 2020 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The agency's LMS offers fire safety and fire extinguisher trainings.
During the first week of new hire orientation to the D&A program, supervisors will direct new hires to the LMS to access and complete fire safety and extinguisher trainings. Training certificates and feedback forms will be collected upon completion.
Monthly, the Clinical Supervisor, Clinical Coordinator, and Regional Director will monitor this process for all new staff to ensure completion of all required trainings. |
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 personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in three of nineteen employee records reviewed.
Employee # 2 was hired as the Facility Director on September 7, 2020. There was no documentation that emergency preparedness training was provided to the employee as of the date of the inspection.
Employee # 3 was hired as a Clinical Supervisor on March 1, 2021. There was documentation that emergency preparedness training was provided to the employee on May 6, 2021; however, the training was not provided upon employment.
Employee # 4 was hired as a Clinical Supervisor on November 23, 2020. There was documentation that emergency preparedness training was provided to the employee on May 17, 2021; however, it was not provided upon employment.
This is a repeat citation from the April 24, 2020 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the first week of new hire orientation to the D&A program, supervisors will provide a training focused on emergency guidelines to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Monthly, Clinical Coordinator will review program's internal training tracking spreadsheet to monitor staff's completion of general emergency guideline training. The previous training tracker did not include emergency guidelines; however, it has now been added.
Monthly, the Clinical Supervisor, Clinical Coordinator, and Regional Director will monitor all new staff to ensure completion of all required trainings, including general emergency guidelines. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, the facility failed to secure hard copy client records within locked storage containers. The facility secured their hard copy client records in a locked room and not in locked containers within the room. However, the room was identified as a multi-purpose room and not solely a record storage room. This allowed for staff not designated to view client records access to the room.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At this time, the agency is utilizing an Electronic Health Record (EHR) with password protection. All staff are responsible for entering all pertinent client information into the EHR.
The Clinical Coordinator and Clinical Support Staff will ensure that all paper/hard charts contained in the current chart room be relocated to a double locked storage room within the facility. All appropriate charts will be archived by Clinical Support Staff.
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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 client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of two applicable client records reviewed.
Client # 3 was admitted on April 8, 2021 and discharged on May 5, 2021; however, there was no termination letter documented in the client record at the time of inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Weekly, Clinical Coordinator will monitor all client discharges. Upon review of completed discharge summaries, Clinical Coordinator will review client charts to ensure that discharge letters have been sent to clients notifying them of involuntary termination.
If notification has not been sent, Clinical Coordinator will contact staff within 24 hours to ensure that a discharge letter is completed and sent to the affected client.
Clinical Coordinator and/or Supervisor will follow up with staff during the next individual supervision. |