INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 8-9, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Treatment and Healing 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
The drug and alcohol treatment project failed to provide documentation of a full-time clinical supervisor for every eight full-time counselors based on a review of the Staffing Requirements Facility Summary Reports for the four facilities within the project. The Staffing Requirements Facilities Summary Reports for the facilities were dated July 24, 2023 (Milton,) July 25, 2023 (E. Stroudsburg,) July 6, 2023 (Honesdale) and July 5, 2023 (Altoona) documented a total of 8.25 full-time counselors employed by the project. This number of
full-time counselors would require a minimum of one full-time clinical supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The position of clinical supervisor has been posted both internally and externally by the company. The clinical supervisor will be mobile and will conduct group supervision and 1-1 supervision with all clinical staff. They will also be responsible for the oversight and training of all counselor assistants. |
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 facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as an office manager on April 20, 2020 and is still in this position. This employee was due to have the communicable disease training no later than April 20, 2022. There was no documentation in the personnel file of the completion of the four-hour TB/STD training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The missing training has been placed on the employee's annual training plan, and she has been actively seeking the training. She is currently on all available waitlists for the needed training, both virtual or live, within a reasonable traveling distance. The Project Director will follow up with the staff, monthly, to monitor the progress of enrollment and attendance. All attempts to enroll will be documented. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to maintain the grounds in a safe manner. It was observed by DDAP staff that on the left side of the building there were two electrical boxes and one electrical outlet, that had been removed from the side of the building and were never reattached.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The property manager has been made aware of the issue and will be removing the electrical boxes, as they are not live. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
It was observed by DDAP staff that the door leading to the 1st floor exit at the back of the building was difficult to open as it met with substantial interference from the exit ramp leading from the facility.
Additionally, it was observed by DDAP staff that the exit leading from the basement at the back of the building was obstructed by sandbags.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The property manager has been made aware of the door sticking, and he will be adjusting it as needed to address the situation. Building staff have removed the sand bags, and they are no longer a tripping hazard. Project Director will follow up with property manager on 10/2/23 to make sure that the other issues have been addressed. Facility Director/Project Director will do a weekly physical plant check to ensure that all doors are in working order and that no exits are blocked. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from August 2022- July 2023, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the month of November 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
With the start of the new fiscal year, a new fire drill grid was begun. It will be utilized monthly to reflect drills being conducted. This will be audited monthly by the facility director. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of the facility's administrative actions, the governing body failed to make the annual report available to the public.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will contact the website developer to address the noted issues. The annual report link will be updated with a section to include the names of board members, directors, and any other invested share holders. This will be monitored monthly by the Project Director and updated as needed by the website developer. |
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, in one out of seven client records, 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: the name of the person, agency or organization to whom disclosure is made.
Client #1 was admitted on June 14, 2023, and was still active at the time of the inspection. A release of information form was signed and dated on June 14, 2023, but did not specify to whom information was being released.
There findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director will hold a staff training on the proper completion of consents on 9/28/23. This will include a step by step walk through on the completion of the consent. This will then be monitored with monthly chart audits conducted by the facility director. 2 charts/clinician will be pulled randomly each month for the check. These audits will begin following the training on 9/28/23. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent, in four out of seven client records, 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 the date, event, or condition upon which the consent will expire.
Client #3 was admitted on April 10, 2023, and was still an active client at the time of the inspection. A consent to release form dated April 10, 2023, for a medical provider did not include documentation of an expiration date or condition. Additionally, a consent to release form dated April 10, 2023, for a funding source did not include documentation of an expiration date or condition. Finally, a consent to release form dated June 21, 2023, for a medical provider did not include documentation of an expiration date or condition.
Client #4 was admitted on April 26, 2023, and was still an active client at the time of the inspection. Consent to release forms dated April 26, 2023, to a medical provider, insurance provider and a funding source did not include documentation of an expiration date or condition.
Client #5 was admitted on December 12, 2022, and was discharged on April 12, 2023. A consent to release form dated December 12, 2022 to a medical provider did not include documentation of an expiration date or condition.
Client #7 was admitted on September 13, 2022 and was discharged February 9, 2023. Consent to release forms dated September 13, 2022 to a medical provider, insurance provider and a funding source did not include documentation of an expiration date or condition.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will hold a staff training on the proper completion of consents on 9/28/23. This will include a step by step walk through on the completion of the consent. This will then be monitored with monthly chart audits conducted by the facility director. 2 charts/clinician will be pulled randomly each month for the check. These audits will begin following the training on 9/28/23. |
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:
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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 four out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days from the date of intake.
Client #1 was admitted on June 14, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than July 14, 2023. A comprehensive treatment plan was documented in the client record; however, it was not dated by the clinician or the client.
Client #5 was admitted on December 12, 2022 and was discharged on April 12, 2023. A comprehensive treatment plan was due no later than January 12, 2023; however, it was not completed until February 6, 2023.
Client #6 was admitted on September 2, 2022, and was discharged on February 7, 2023. A comprehensive treatment plan was due no later than October 2, 2022; however, there was no comprehensive treatment plan documented in the client record.
Client #7 was admitted on September 13, 2022 and discharged on February 9, 2023. A comprehensive treatment plan was due no later than October 13, 2022; A comprehensive treatment plan was documented in the client record; however, it was not dated by the client or the clinician.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director will provide in house training to all clinicians on timelines and how to manage/address them due to missed appointments and/or ASA discharges on 9/28/23.
Successful intervention will be measured by chart audits completed monthly by the facility director, which will be 2 charts, randomly selected, off of each caseload. These audits will begin following the training on 9/28/23.
If a treatment plan does not meet the said parameters, the Project Director will meet with the clinician 1-1 and offer further guidance.
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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 three out of five applicable client records reviewed.
Client #2 was admitted on April 13, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 11, 2023, and the next update was due no later than July 11, 2023; however, there was no treatment plan update documented in the record until July 20, 2023.
Client #3 was admitted on April 10, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 17, 2023, and the next update was due no later than June 17, 2023; however, there was no treatment plan update documented in the record until July 11, 2023.
Client #4 was admitted on April 26, 2023 and was still active at the time of the inspection. A comprehensive treatment plan update was completed on May 11, 2023 and the next update was due no later than July 11, 2023; however, there was no treatment plan update documented in the record until July 26, 2023.
This is a repeat citation from the October 6, 2021 and the August 11, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will provide in house training to all clinicians on timelines and how to manage/address them due to missed appointments and/or ASA discharges on 9/28/23.
Successful intervention will be measured by chart audits completed monthly by the facility director, which will be 2 charts, randomly selected, off of each caseload. These audits will begin following the training on 9/28/23.
If a treatment plan does not meet the said parameters, the Project Director will meet with the clinician 1-1 and offer further guidance.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy states that case consultations must be completed within thirty days of the intake session.
Client #4 was admitted on April 26, 2023, and was still active at the time of the inspection. The initial case consultation dated April 26, 2023, was signed only by the clinician. There was no secondary review or sign-off.
Client #5 was admitted on admitted on December 12, 2022, and was discharged on April 12, 2023 of the inspection. The initial case consultation dated December 12, 2022, was signed only by the clinician. There was no secondary review or sign-off.
Client #6 was admitted on September 2, 2022, and discharged on February 7, 2023. The initial case consultation dated September 2, 2022 was signed only by the clinician. There was no secondary review or sign-off.
Client #7 was admitted on September 13, 2022, and discharged on February 9, 2023. There was no case consultation documented in the client record until December 8, 2022.
This is a repeat citation from the October 6, 2021 and August 11, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director will provide in house training to all clinicians on timelines and how to manage/address them due to missed appointments on 10/19/23. They will also be trained on the importance of consults being presented and signed by all present for the consultation and not just the clinician or the supervisor.
Successful intervention will be measured by chart audits completed monthly by the facility director, which will be 2 charts, randomly selected, off of each caseload. These audits will begin following the training on 10/19/23,
If a case consult does not meet the said parameters, the Project Director will meet with the clinician 1-1 and offer further guidance.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on the review of client records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction was submitted to the Department for inspections occurring on October 6, 2021 and August 11, 2022, addressing the requirement to document follow-up information in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
When a client has successfully completed formal treatment and no longer has a need for treatment, follow up will occur at the thirty (30) day mark.
When a client has not successfully completed formal treatment (discharge statuses of disciplinary, administrative, therapeutic and against staff advice) follow up will occur within 7 days of discharge.
No follow up will be done on those clients who were discharged with the status of Incarceration or on those individuals who only received a drug and alcohol evaluation in which the individual was found to be inappropriate for treatment and/or no recommendation was made for further treatment.
This policy will be reviewed with the staff on 10/19/23. It will then be monitored by the facility director who will audit every closed chart within 30 days of d/c. Charts found to be noncompliant will be redirected back to the clinician and further training will be given. These audits will begin on 10/19/23. |