INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 12, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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(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 review of the Staffing Requirement Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #3's record. Employee #3 was hired as a counselor on July 1, 1996 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2020, to June 30, 2021. Employee #3's record only documented 21 hours of annual training for the year reviewed. This is a repeat citation from April 21, 2021 annual licensing inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Employee #3 will have received 25 training hours as is required by the standard. Employee #3 had failed to complete the required trainings for training year July 1, 2020 through June 30, 2021. This employee will seek out & attend trainings throughout the year, which will address the areas set forth by the standard. Our facility will be in full compliance with this standard by 06/30/2022, which is the end of our current training year.
Clinical Supervisor is responsible for ensuring the corrective action(s) is implemented. In the future, the Project Director will conduct quarterly reviews of all training hours to ensure that this standard is being complied with.
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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 two out of three client records reviewed.Client # 2 was admitted to the facility on December 21, 2021 and still active at the time of the inspection. A treatment plan was developed on January 21, 2022 and the next update was due no later than March 21, 2022; however, there was no update in the record at the time of the inspection. Client #7 was admitted to the facility on August 18, 2021 and was discharged on February 3, 2022. A treatment plan was developed on September 9, 2021 and the next update was due no later than November 9, 2021; however, the treatment plan was not developed until December 2, 2021. This finding was reviewed with the facility staff during the licensing process.
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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 will be reviewed during our agency staff meeting on June 16, 2022. The Clinical Supervisor and Project Director met with the counselors of client records #2 and 7 to ensure the treatment plan updates will be completed every 60 days as per the agency policy. To ensure completion of treatment plan updates at least every 60 days the Clinical Director and Project Director will verify completion during monthly clinical supervision. The Clinical Supervisor will also review individual counselor's client records on a weekly basis and during weekly supervision to ensure compliance. |
709.93(a)(11) LICENSURE Client records
709.93. 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 the client records, the facility failed to provide a complete client record, which is to include follow up information in three out of three client records reviewed. Client #5 was admitted to the facility on May 6, 2021 and discharged on November 11, 2021. Client #6 was admitted on December 14, 2021 and discharged on January 27, 2022. Client #7 was admitted to the facility on August 18, 2021 and discharged on February 3, 2022. These findings were reviewed with facility staff during the licensing process.
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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 will be reviewed with all counselors at our staff meeting on June 16, 2022.The proper completion of client documentation of follow-up information. This standard and policy will also be reviewed with all counselors by the Clinical Supervisor during monthly staff supervision to assure compliance. In the future all counselors will bring open and closed charts to monthly supervision and the Clinical Supervisor will verify that the counselors have the completed documentation in the chart.
The Project Director and Clinical Supervisor will also discuss this standard during every mandatory monthly staff meeting and supervision
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