INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 15-16, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, George Junior Republic in Pennsylvania 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of administrative information, the facility failed to develop a comprehensive staff development program including the assessment of staff training needs and overall plan for addressing these needs. Additionally, the current staff development policy and procedure is missing the timeframes for completion.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Prior to the start of a new project training year (September 1 - annually),
All employees of the drug and alcohol program will complete a training needs assessment for the upcoming training year. These will be tracked and provided to the Facility Director upon completion. These training needs assessments are due no later than July 31 annually.
2. In conjunction with employee training needs assessment and based on individual employee job description, the Project Director and Facility Director will review each employee's individual plan with the staff development director by August 31 annually.
3. These updates will be added to the project Staff Development Policy and Procedure Manual by February 20, 2025.
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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 personnel records, the facility failed to ensure four support staff received the minimum of at least 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within two years of employment in four of four records.
Staff #6 was hired as support staff on September 6, 2022 and still employed at time of inspection. Staff #6 was due to have the communicable disease trainings no later than September 6, 2024. There was documentation provided of the completion of some TB/STD trainings but staff did not have 4 hours completed by the date of the inspection.
Staff #7 was hired as support staff on October 5, 2020 and still employed at time of inspection. Staff #7 was due to have the communicable disease trainings no later than October 5, 2022. There was documentation provided of the completion of some HIV/AIDS trainings but staff did not have 6 hours completed. Additionally, there was no documentation provided of the completion of the TB/STD training as of the date of the inspection.
Staff #8 was hired as support staff on October 5, 2020 and still employed at time of inspection. Staff #8 was due to have the communicable disease trainings no later than October 5, 2022. There was no documentation provided of the completion of the HIV/AIDS or TB/STD training as of the date of the inspection.
The findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 annual licensure inspection.
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Plan of Correction
1. Project Director and Facility Director will ensure that Staff #6, Staff #7 and Staff #8 have completed the required training hours in both HIV/AIDS and TB/STD by March 30, 2025.
2. New employees hired to the Drug and Alcohol Project after 1/15/2025 will have the mandatory HIV/AIDS and TB/STD training placed on their job description along with expected dates of completion. Facility Director will meet with all new project staff within 90 days of hire to review compliance with mandatory training requirements.
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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 client records, the facility failed to obtain a consent to release information form prior to releasing information in one of seven records.
Client #5 admitted on July 12, 2024 and discharged on December 6, 2024. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 annual licensure inspection.
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Plan of Correction
1. Facility Director will review confidentiality as it pertains to funding source billing with all project staff by February 21, 2025.
2. A review of completed orientation packets, which include ROI's, will be completed by Facility Director within 7 days of each client's admission to the project.
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709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client which includes name of the person, agency, or organization to whom disclosure is made in seven of seven records.
Client #1 admitted on October 10, 2024 and still a current client. Client record contained two releases of information dated October 11, 2024 that did not contain the name of the person, agency, or organization to whom disclosure is made.
Client #2 admitted on November 8, 2024 and still a current client. Client record contained two releases of information dated November 8, 2024 that did not contain the name of the person, agency, or organization to whom disclosure is made.
Client #3 admitted on November 12, 2024 and still a current client. Client record contained two releases of information dated November 12, 2024 that did not contain the name of the person, agency, or organization to whom disclosure is made.
Client #4 admitted on July 24, 2024 and discharged on November 14, 2024. Client record contained a release of information dated July 24, 2024 that did not contain the name of the person, agency, or organization to whom disclosure is made.
Client #5 admitted on July 12, 2024 and discharged on December 6, 2024. Client record contained a release of information dated July 12, 2024 that did not contain the name of the person, agency, or organization to whom disclosure is made.
Client #6 admitted on August 21, 2024 and discharged on December 13, 2024. Client record contained a release of information dated August 22, 2024 that did not contain the name of the person, agency, or organization to whom disclosure is made.
Client #7 admitted on June 21, 2024 and discharged on September 20, 2024. Client record contained two releases of information dated June 21, 2024 that did not contain the name of the person, agency, or organization to whom disclosure is made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Facility Director will review confidentiality as it pertains to releases of information with all project staff by February 21, 2025.
2. A review of completed orientation packets. which includes Releases of Information, will be completed by Facility Director within 7 days of each client's admission to the project. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of administrative information and client records, the facility failed to utilize a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the projects performance in relationship to its stated goals and objectives.
The facility is currently utilizing hybrid paper records, StreamLine electronic health records, and a sharefolder. The Information is different based on which recordkeeping system was in review. Some dated signatures do not match or line up for the same sessions, treatment plans, etc. from one recordkeeping system to the other. The facility was unable to provide access to the shared folder, so had to work with facility staff to gather all required information to complete inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On January 31, 2025, Project Director and Facility Director met with staff of the project, along with our Compliance Officer, with the goal of having all documentation placed in the facility electronic health record moving forward. We have begun this transition with an expected full completion date of May 1, 2025. |
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 and staff interviews, 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 one applicable client record.
Client #7 admitted on June 21, 2024 and discharged on September 20, 2024. There was a letter sent to an agency explaining the termination on September 20, 2024 but no letter sent to the client.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director and Facility Director met with the Case Manager on 1/20/25 and again on 1/31/2025 and reviewed the Involuntary Termination policy. The Case Manager was informed that, even if a client is on the run or current address unknown, a letter of involuntary termination will be sent to the last known address and a copy of such placed in the client file. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days. The facility had an unusual incident occur on December 8, 2024 which involved a physical assault. The facility has not submitted a written unusual incident report to the Department at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The requirement of reporting an unusual Incident to the DDAP web site was reviewed with all project staff on 1/31/2025. It was explained that a fight of any nature is considered an assault by DDAP standards. The Facility Director and/or the Project Director will report all events based on the DDAP list of required reporting events within 3 days of their occurrence. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days. The facility had an unusual incident occur on July 14, 2024 which involved an ambulance on site. The facility has not submitted a written unusual incident report to the Department at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The requirement of reporting an unusual Incident to the DDAP web site was reviewed with all project staff on 1/31/2025. The Facility Director and/or the Project Director will report all events based on the DDAP list of required reporting events within 3 days of their occurrence. |
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 client records, the facility failed to document treatment plan updates every 30 days in three of seven records.
Client #4 admitted on July 24, 2024 and discharged on November 14, 2024. A treatment plan update was completed on August 16, 2024 and the next update was due no later than September 15, 2024; however, the next update was completed on September 26, 2024.
Client #5 admitted on July 12, 2024 and discharged on December 6, 2024. A treatment plan was completed on July 15, 2024 and the update was due no later than August 14, 2024; however, it was completed on August 16, 2024. Another treatment plan update was due by September 15, 2024; however, it was completed on September 18, 2024.
Client #7 admitted on June 21, 2024 and discharged on September 20, 2024. A treatment plan update was completed on August 16, 2024 and the next update was due no later than September 15, 2024; however, no updates were completed prior to the clients discharge.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 annual licensure inspection.
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Plan of Correction
The Project Director and Facility Director met with the Therapist and Case Manager on 1/20/25 and 1/31/25. The Treatment Plan Update policy was reviewed. Therapist will inform Facility Director of each client's treatment plan update at it's completion to insure it falls within the 30 day deadline. Facility Director will provide therapist with a list by the 27th of each month for the next month's due dates to assist with the supervision of this plan. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure the clients received counseling services according to their individual treatment plan in seven of seven records. Each treatment plan indicated individual therapy should occur once a week.
Client #1 admitted on October 10, 2024 and still a current client. There was no documentation the client received individual therapy the following week: December 22.
Client #2 admitted on November 8, 2024 and still a current client. There was no documentation the client received individual therapy the following week: December 8.
Client #3 admitted on November 12, 2024 and still a current client. There was no documentation the client received individual therapy the following weeks: December 8 and December 22.
Client #4 admitted on July 24, 2024 and discharged on November 14, 2024. There was no documentation the client received individual therapy the following week: August 25.
Client #5 admitted on July 12, 2024 and discharged on December 6, 2024. There was no documentation the client received individual therapy the following weeks: August 25, September 8, and November 3.
Client #6 admitted on August 21, 2024 and discharged on December 13, 2024. There was no documentation the client received individual therapy the following week: August 25.
Client #7 admitted on June 21, 2024 and discharged on September 20, 2024. There was no documentation the client received individual therapy the following week: August 25.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 annual licensure inspection.
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Plan of Correction
Facility Director and Project Director met with Therapist on 1/20 ad 1/31/25. A review of the policy for weekly individual sessions was completed with the Therapist. Therapist was informed that every week should have a documentation note-either the counseling session itself or a note indicating why a session did not occur. Client records will be reviewed monthly-random selection of a minimum of 2-to review that sessions are noted weekly or indicate why not held. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to ensure the client record included an accurate depiction of services received in three out of seven records reviewed.
Individual progress notes are written in DAP format. Notes for the following dates were word for word for each client in the Data, Assessment, and Plan sections of the progress notes: October 17, 24, 25, 29, November 1, 12, 18, 22, 25, and December 2.
Client #4 admitted on July 24, 2024 and discharged on November 14, 2024.
Client #5 admitted on July 12, 2024 and discharged on December 6, 2024.
Client #6 admitted on August 21, 2024 and discharged on December 13, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director and Project Director met with Therapist on 1/20/25 and again on 1/31/25. Therapist was informed that each client note should be individualized. Additionally, if a session is unable to be held due to illness, vacation, or other circumstance-then a note should also be recorded in that record to reflect such. Facility Director will complete random monthly record audits to verify individualization of notes and notation for any week a session not held. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to ensure the client record included an accurate record of services provided in four of seven records.
Client #4 admitted on July 24, 2024 and discharged on November 14, 2024. The record of services provided to the client was missing for the following dates: October 25-28 and November 1-14, 2024.
Client #5 admitted on July 12, 2024 and discharged on December 6, 2024. There was individual progress notes in the clients record that were not indicated on the record of service for the following dates: August 5, October 21, October 30, November 12, November 22, November 25, and December 2.
Client #6 admitted on August 21, 2024 and discharged on December 13, 2024. There was individual progress notes in the clients record that were not indicated on the record of service for the following dates: October 3 and October 17. Additionally, the record of services provided to the client was missing for the following dates: November 1-30, 2024.
Client #7 admitted on June 21, 2024 and discharged on September 20, 2024. The record of services provided to the client was missing for the following dates: August 15- 31, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Project Director met with Therapist, Case Manager, and Counselor Parent on 1/31/25 to review Record of Services policy. Each client record is to contain a record of services provided. Facility director will conduct monthly random client record audit to verify that a record of service is included and completed in the file. Results will be provided to Project Director on a monthly basis. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to ensure the client record included progress notes in six of seven records.
According to the facilities policy and procedure manual, progress notes should be completed by the counselor within 24 hours of a sessions completion.
Client #1 admitted on October 10, 2024 and still a current client. Record of service indicated an individual session on December 4, 2024 which did not have a corresponding progress note. Additionally, the following progress notes were found in the client record but completed late according to agency policy and procedure: December 16 progress note was signed on December 24; December 31 progress note was signed on January 6; January 7 progress note was signed on January 10.
Client #2 admitted on November 8, 2024 and still a current client. The clients record of service indicated an individual session on December 20, 2024 which did not have a corresponding progress note.
Client #3 admitted on November 12, 2024 and still a current client. The following progress notes were found in the client record but completed late according to agency policy and procedure: November 26 progress note was signed on December 6; December 7 progress note was signed on December 9; December 16 progress note was signed on December 24; December 31 progress note was signed on January 6.
Client #4 admitted on July 24, 2024 and discharged on November 14, 2024. Record of service indicated individual sessions on September 16, September 26, and October 18 which did not have corresponding progress notes.
Client #6 admitted on August 21, 2024 and discharged on December 13, 2024. The clients record of service indicated an individual session on October 3 which did not have a corresponding progress note.
Client #7 admitted on June 21, 2024 and discharged on September 20, 2024. The clients record of service indicated an individual session on August 12 which did not have a corresponding progress note.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Project Director met with Therapist on 1/20/25 and again on 1/31/2025 and reviewed policy regarding client records and progress notes. The facility policy will be amended to reflect 48 hours for completion and entry into EHR system. Encounter forms are signed and dated by client at end of each session. Each individual session will have a corresponding progress note. Facility Director will complete random monthly audit of files to verify this plan of correction. |