INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 18-19, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ARS of Lancaster, LP 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide direct observation by a trained counselor or clinical supervisor for the first 3 months of employment or for the next 9 months, under close supervision.Employee #11 was hired as a counselor assistant with a high school diploma on January 1, 2024 and was still employed at the time of the inspection. She had no documentation of direct or close supervision.This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Plan of Correction: Clinical Supervisors and Executive Director were educated on the regulations as it pertains to a counselor assistant with a high school diploma. The importance of documentation was gone over on 9.19.24. Moving forward if counselor assistants are hired Executive Director will review supervisions monthly until the first year is completed. |
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.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee in the required time frame, appropriate to that employee's skill level in four out of eleven employee records reviewed.Employee #5 was hired on January 22, 204 as a counselor and was still in the position as of the date of the inspection. The plan is dated September 6, 2024.Employee #6 was hired on April 29, 2024 as a counselor and was still in the position as of the date of the inspection. The plan is dated September 6, 2024.Employee #7 was hired on June 11, 2024 as a counselor and was still in the position as of the date of the inspection. The plan is dated September 6, 2024.Employee #8 was hired on July 24, 2024 as a counselor and was still in the position as of the date of the inspection. The plan is dated September 6, 2024.These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Plan of Correction: Executive Director to implement an individual training plan upon hire for every new hire. The direct supervisor to maintain the training plan for annual completeness. This will be best practice, however training plans were completed in the annual window. Trainings plans will be reviewed quarterly for compliance by Executive Director. Training Binder started. |
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.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies. Employee #1 was hired on August 27, 2024 as the Facility Director and was still in the position as of the date of the inspection. The training was not completed as of the date of the inspection.This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Plan of Correction: Executive Director had completed fire safety training on Relias 8.28.24. Natural Disaster training was completed on Relias 9.19.24. Executive Director started a binder for safety trainings. Executive is to add safety training for new hires in the first week. Executive Director to review every quarter. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
|
Observations
Based on a review of the patient records, the facility failed to ensure that a random urinalysis is completed at least monthly in two out of eleven records reviewed.Patient #3 was admitted on March 5, 2024 and was still active at the time of the inspection. No urinalysis was completed during the month of August, 2024.Patient #5 was admitted on March 28, 2024 and was still active at the time of the inspection. No urinalysis was completed during the months of April and August, 2024.These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Plan of Correction:The Executive Director meet with all staff at the all staff meeting held on 10/8/2024 and reviewed the Drug Screening policy and obtaining Monthly Urine Drug Screens (UDS) for existing patients. The dispensing staff will document when the UDS has been collected each month, if the UDS has been refused dispensing staff will document every attempt that is made to collect the UDS throughout the month. This will be tracked by the DON on a monthly basis. All staff were retrained that clients will be asked more than one time to provide a UDS throughout the month, even if a documented refusal is received multiple times in the month, this is to ensure that this deficiency does not reoccur. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Based on a review of patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in four out of six applicable records reviewed.Patient #3 was admitted on March 5, 2024 and was still active at the time of the inspection. In May, June, July, and August, 2024, the patient received only 60 minutes of individual psychotherapy sessions each month and no group psychotherapy.Patient #5 was admitted on March 28, 2024 and was still active at the time of the inspection. In May, 2024 the patient received 90 minutes of individual psychotherapy; in June, 2024 he received 60 minutes of individual psychotherapy; in July, 2024 he received 105 minutes of individual psychotherapy; and in August, 2024 he received 60 minutes of individual psychotherapy and no group psychotherapy during those months.Patient #6 was admitted on April 25, 2023 and was still active at the time of the inspection. In May, 2024 the patient did not receive any psychotherapy; in June, 2024 he received 45 minutes of individual psychotherapy; in July, 2024 he received 30 minutes of individual psychotherapy; and in August, 2024 he received 61 minutes of individual psychotherapy and no group psychotherapy during those months.Patient #7 was admitted on March 28, 2024 and was still active at the time of the inspection. He had no documentation of any individual or group psychotherapy since his admission.These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 13, 2023 licensing inspection.
|
Plan of Correction
Plan of Correction:The Clinical Supervisor will provide training to clinical staff regarding the 2.5 hours of required counseling per month. Primary counselors will review caseloads weekly to identify patients that have not completed their 2.5 hours of counseling/group requirements. Counselors will immediately schedule their patients who are not compliant with session requirements to become complaint. The clinical supervisor will review with counselor during weekly supervision, to ensure compliance. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Based on a review of patient records, the facility failed to provide patients with one hour of group or individual psychotherapy every two months after they have reached four years of treatment in out of three applicable record.Patient #2 was admitted on September 19, 2023 and was still active at the time of the inspection. In May, 2024 he received 30 minutes of individual psychotherapy, and he has not received any psychotherapy since that date.This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Plan of Correction:The Clinical Supervisor (CS) or the Executive Director (ED), in the absence of the CS, will retrain the clinical staff regarding clients need to have 2.50 hours of counseling in the first 0-2 years of treatment, 1 hour of counseling for patients in 2-4 years of treatment and 1 hour of counseling every other month for patients in treatment more than 4 years. The CS/ED will review each counselor's engagement on a monthly basis and discuss how improvements can be made. The CS/ED will train each counselor on how to monitor their own engagement through the course of the month by viewing their KIPU BI dashboard to see which patients are still in need of being seen. The CS/ED will also review this report and discuss areas of concern/improvement during bi-weekly supervision. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
|
Observations
Based on the review of patient records, the facility failed to document an annual clinical evaluation with all areas of regulation addressed and dated and signed by the medical director within the regulatory timeframe in two out of three applicable records reviewed.Patient #1 was admitted on April 2, 2022 and discharged on August 27, 2024. An annual clinical evaluation was completed on March 26, 2024; however, it was not signed by the medical director.Patient #6 was admitted on April 25, 2023 and was still active at the time of the inspection. An annual clinical evaluation was due by April 24, 2024; however, none was completed.This finding was reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 13, 2023 licensing inspection.
|
Plan of Correction
Plan of Correction:The Clinical Supervisor will complete training with clinical staff by 10/31/24, on annual evaluations. The clinical staff will be trained in creating a spread sheet to track the due dates for annual evaluations, to ensure timely completion. The Clinical Supervisor will review with counselors spread sheets during supervision. The clinical supervisor is responsible for implementation by 10/31/24. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in three out of five applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days following admission.Patient #3 was admitted on March 5, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 5, 2024; however, it was completed on April 29, 2024.Patient #7 was admitted on August 16, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than September 16, 2024; however, none was documented. Patient #8 was admitted on May 20, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than June 20, 2024; however, it was not completed until July 15, 2024. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Plan of Correction:The Clinical Supervisor (CS) or the Executive Director (ED), in the absence of the CS, on 10/1/2024 has retrained the clinical staff on Treatment Plan and Master Problem List Policy #8.10. The CS/ED will do a complete review of all existing client's charts and place a KIPU flag on those client charts to have Bio-Psychosocial Assessment completed by the 10/31/2024. Moving forward the Primary Counselors will be required to review their clients on a monthly basis to ensure that all client charts have a Treatment Plan completed every 60-90 days. This will be monitored during the quarterly peer audit review process, as well as weekly by the CS during the quality assurance review process. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in two out of four client records reviewed. Patient #8 was admitted on May 20, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 15, 2024 with no type or frequency identified.Patient #11 was admitted on May 3, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 4, 2024 with no type or frequency. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction: Clinical supervisors will complete a training on how to complete effective treatment planning. This training will include adding frequency and type of treatment recommended. Clinical supervisors will complete weekly reports to ensure treatment plans are completed. Counselor will be trained on how to identify when a treatment plan is coming due. |
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.
|
Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of eight records reviewed.Patient #3 was admitted on March 5, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 29, 2024 and an update was due no later than June 29, 2024; however, it was not completed until August 5, 2024. Patient #5 was admitted on March 28, 2024 and was still active at the time of the inspection. A treatment plan update was completed on May 17, 2024 and an update was due no later than July 17, 2024; however, it was not completed until July 24, 2024.Patient #6 was admitted on April 25, 2023 and was still active at the time of the inspection. A treatment plan update was completed on May 29, 2024 and the next update was due no later than July 29, 2024; however, it was not completed until August 23, 2024.Patient #8 was admitted on May 20, 2024 and was still active at the time of the inspection. A treatment plan update was completed on July 15, 2024 and an update was due no later than September 15, 2024; however, none was not completed. These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the September 13, 2023 licensing inspection.
|
Plan of Correction
Plan of Correction: The clinical supervisor will complete a treatment plan training on 10/31/24. The training will be information on the requirement of treatment plan update reviews timeframes, and signatures. Primary counselor will identify "next review dates" on the problem list and will ensure treatment plans are reviewed and updated by the next review date. The Clinical Supervisor will track the next review dates weekly. |
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.
|
Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in two out of three applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed 7 days following discharge.Patient #1 was admitted on April 8, 2022 and was discharged on August 27, 2024. A follow up was due no later than September 3, 2024; however, it none was completed.Patient #4 was admitted on September 25, 2023 and was discharged on December 14, 2023. A follow up was due no later than December 21, 2023; however, none was completed.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction: Clinical Supervisor will complete a group supervision with all counselors to review discharge policy and re-implement follow up calls. The supervisors will complete a weekly report to ensure compliance in this area. |