INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 29, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Trehab 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 a review of personnel records, the facility failed to ensure each employee had a written individual training plan, with input from both the employee and supervisor, in two of two personnel records reviewed.
Employee #1 was hired as the project/facility director on April 1, 1995. There was no individual training plan documented in the record at the time of the inspection.
Employee #2 was hired as the clinical supervisor on December 1, 2022. The individual training plan was signed by employee on July 8, 2022; however, there was no documentation verifying it was completed with input from the supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with regulation 704.11 (b) (1) Licensure: 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, the following plan of correction will be implemented: Clinical Supervisor and QM Coordinator will inform Facility Director and D&A department staff that annual training plans are due by July 7, 2023. Clinical Supervisor will schedule half-hour appointments with each D&A department staff as well as the Facility Director to review each individual training plan for the fiscal year 2023-2024 prior to the July 7, 2023 deadline. Upon approval of the individual training plans, individual staff and Clinical Supervisor will sign the training plan, then Clinical Supervisor will immediately scan and email it to Fiscal Assistant to be filed in individual personnel files. Individual Staff will be provided the signed copy of the individual training plan to be included in their FY 23-24 training binder. |
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 the facility's Staffing Requirement Facility Report and personnel records, 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 training within the regulatory timeframe in one of seven personnel records reviewed.
Employee #6 was hired as a client care coordinator on July 9, 2018. There was no documentation of the HIV/AIDS training, in the personnel record, at the time of the inspection.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with regulation 704.11 Staff development program (general training requirements. (1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STF and other health related topics using a department approved curriculum, the following plan of correction will be implemented: Clinical Supervisor, QM Coordinator, and Client Care Coordinator will compile a form of all trainings mandated through DDAP and review what D&A department staff need to complete any required trainings. If a staff is out of compliance, they will complete the training by June 30, 2023. If any identified trainings are not available prior to June 30, 2023, this deadline will be extended to September 30, 2023. This will be assessed on an individual basis. |
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
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project directors and facility directors during the facility's July 1, 2021 through June 30, 2022 training year in one of one applicable personnel record reviewed.
Employee #1 was hired as the project/facility director on April 1, 1995. There was only 9.5 documented hours of training during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with regulation 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, the following plan of correction will be implemented:
Clinical Supervisor and Quality Management Coordinator will review the status of Facility Director's training plan/training hours during scheduled monthly Quality Management meetings. Clinical Supervisor and Quality Management Coordinator will inform Facility Director of upcoming trainings during these meetings as well as provide him with email correspondence outside of meetings to facilitate completion of 12 hours of training annually. A section has been added to the QM Meeting Agenda titled: "Training Plan / Training Hours Review" with subtitles (categories) of, "Counseling Staff Training Status," "Support Staff Training Status," and "Facility Director Training Status." This consistent agenda item will prompt monthly review, allow for scheduling appropriate training and facilitate completion of hours.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee, in one of one applicable personnel record reviewed.
Employee #1 was hired as the project/facility director on April 1, 1995. There was no annual written staff performance evaluation completed as of the date of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with regulation § 709.26. Personnel management. (b) The personnel records must include, but are not limited to: (3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee, the following plan of correction will be implemented:
Clinical Supervisor will submit a written request (email and/or memo) to Facility Director and Facility Director's administrative assistant within the first two (2) weeks of July for the completion of Facility Director's annual review by Trehab's Board of Directors during that month's scheduled board meeting (board meetings are conducted the third Wednesday of each month). This written request will prompt the review to become an official meeting agenda item. Clinical Supervisor will follow up with Facility Director and Facility Director's administrative assistant to obtain a copy of the completed annual review form completed and signed by Trehab's Board of Directors President.
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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 document the name of the person, agency, or organization to whom the disclosure was to be made to on informed and voluntary consent forms in four of seven client records reviewed.
Client #1 was admitted on September 6, 2022 and was active at the time of inspection. Release of information forms to a housing assistance agency, an emergency contact, and a medical director were signed and dated by the client on September 2, 2022; however, none of the consent forms included the specific name of the person, agency, or organization to whom the disclosures were to be made.
Client #2 was admitted on October 19, 2022 and was active at the time of inspection. A release of information form to a certified recovery specialist was signed and dated by the client on October 12, 2022; however, the consent form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
Client #3 was admitted on January 6, 2023 and was active at the time of inspection. Release of information forms to a housing assistance agency and a medical director were signed and dated by the client on December 30, 2022; however, neither consent form included the specific name of the person, agency, or organization to whom the disclosures were to be made.
Client #5 was admitted on February 23, 2022 and was discharged on June 8, 2022. A release of information form to a certified recovery specialist was signed and dated by the client on February 17, 2022; however, the consent form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In order to comply with regulation 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 limited to: (1) Name of the person, agency, or organization to whom the disclosure is made, the following plan of correction will be made: During a clinical staff meeting scheduled for April 19, 2023, Clinical Supervisor will review this regulation and citation with all clinical staff. Clinical staff will be directed by Clinical Supervisor to specify who the disclosure is being made to, such as specific CRS names or agency, specific housing program, and specific medical director. QM coordinator will review all new charts to ensure these specifications are being addressed. If a disclosure is found to be non-specific in nature (ie, disclosure written out for CRS and not specifying what CRS), clinical staff will address this oversight with client and a new disclosure with specificity will be created and signed by client and clinical staff. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a release of information form in one of seven client records reviewed.
Client #6 was admitted on June 6, 2022 and was discharged on September 12, 2022. A release of information form to a legal representative was signed by client, but the signature was not dated.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In order to comply with regulation 709.28 Confidentiality. ( c ) The project shall obtain an informed and voluntary consent from the clients for the disclosure of information contained in the client record. The consent must be in writing and include, but not limited to: (4) Dated signature of client or guardian as provided for under 42 CFR 2.14 (a) and (b) and 2.15 (related to minor patients; and incompetent and deceased patients), the following plan of correction will be made:
During a clinical staff meeting scheduled for April 19, 2023, Clinical Supervisor will review this regulation and citation with all clinical staff. Clinical staff will be directed by Clinical Supervisor to ensure all releases of information are dated by the client at the same time that the client provides their signature. QM coordinator will review all new charts to ensure these specifications are being addressed. If a release of information is found to not have been dated by the client, QM coordinator will alter Clinical Supervisor to this oversight, and Clinical Supervisor will address this with the client's primary counselor. From there, the primary counselor will review the release of information with the client during their next scheduled session, document the review with the client, and create a new release of information to sign/date appropriately. |
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 that treatment plans were reviewed and updated at least every 60 days in three of six applicable client records reviewed.
Client #1 was admitted on September 6, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on September 14, 2022 and the first update was due no later than November 14, 2022. However, the update was not completed until December 7, 2022.
Client #2 was admitted on October 19, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on November 2, 2022 and the first update was due no later than January 2, 2023. However, the update was not completed at the time of inspection as it was started by the clinician on January 13, 2023, but the plan was not signed by the counselor.
Client #5 was admitted on February 23, 2022 and was discharged on June 8, 2022. A treatment plan update was completed on March 16, 2022 and the next update was due no later than May 16, 2022. However, the update was not completed until May 25, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In order to comply with regulation 709.92 (b) Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at lease every 60 days, the following plan of correction will be implemented: During a clinical staff meeting scheduled for April 19, 2023, Clinical Supervisor will review this regulation and citation with all clinical staff. Clinical staff will be directed by Clinical Supervisor to complete treatment plan updates every 45-50 days to ensure this regulation is being met. Client care coordinator will create a document for clinical staff to organize client paperwork deadlines such as treatment plan updates, and this new document will be available to clinical staff at the April 19, 2023 clinical staff meeting. |