INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 6, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, American Treatment Network 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(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel files, the facility failed to ensure that one applicable clinical supervisor had completed a core curriculum in clinical supervision which is a requirement for the position.
Employee # 3 was promoted to the position of clinical supervisor on November 7, 2023 and is current in that position. Employee # 3 has not functioned for 2 years as a supervisor in the provision of clinical services and did not complete a core curriculum as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will conduct Supervision once per month with all newly hired Clinical Supervisors to review Staff Development plans to ensure that The Clinical Supervisor has completed the applicable Clinical Supervision core curriculum or has registered for the training by the required time according to hire date.
Employee #3 who was promoted in the role as clinical supervisor on November 7, 2023, will complete the Clinical supervisor training by December 1, 2024.
The Quality Assurance Manager will monitor to ensure 100% of the clinical supervisor training has been completed by the required time frame by reviewing the Clinical Supervisor Training plan. Documentation will provide feedback on the completed training. |
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.
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Observations
Based on a review of eight personnel records, the facility failed to maintain documentation that counselor assistants received direct observation as part of their close supervision, in one applicable record.
Employee # 8 was hired by the facility as a counselor assistant on September 7, 2023 and is still current in that position. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision in each week reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will review all new hired clinical staff to ensure supervision is being conducted to meet the requirement of direct observation as part of their close supervision for all applicable counselor and counselor assistants.
The Clinical Supervisor will give direct supervision as part of their close supervision to all counselor assistants and document this in applicable supervision notes.
Employee # 8 now meets qualifications for a counselor and direct observation will not need to be completed for employee # 8.
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704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a discussion with facility staff and submitted documents, the facility failed to complete the overall plan, per policy, based on the findings of the annual evaluation and the organization's strategic planning and performance improvement goals. There was no documentation an overall plan was completed.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
The Facility Director will develop a comprehensive program for each personnel which will be included in the policies and procedures for all staff.
The Clinical Director will provide an assessment of all training needs for each staff member.
The Clinical Supervisor will identify and address all training needs and develop an overall training plan. Within the overall training plan documentation will be provided as well on the completed training development plan.
The clinical Supervisor will meet annually with staff to review and evaluate the year's overall training plan and add trainings the team needs to improve on based on the whole team's needs.
The Facility Director will monitor and make sure new trainings have been added on new substances or Changes that the team would benefit to gain knowledge in taking part in these additional trainings.
The Quality Assurance Manager will monitor to ensure all training plans meet the standards and policies have been included. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a discussion with facility staff and submitted documents, the facility failed to complete an annual evaluation of the overall training plan for the preceding training year.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
The Clinical Supervisor will implement an evaluation process will now incorporate an annual evaluation process that the overall staff will complete at the end of each training year.
The Clinical Director will review all evaluations to monitor the efficiency of the trainings offered and taken by clinical staff. Upon review The Clinical Director will look to find other training opportunities based on the evaluation of the overall staff.
The Quality Assurance Manager will review all Staff development plans to ensure that the required annual evaluation has been incorporated. |
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 that one of eight employees received a minimum of 6 hours of HIV/AIDS using a Department approved curriculum within the regulatory timeframe.
Employee # 6 has been in the position of counselor since September 6, 2023 and was due to have the communicable disease trainings no later than September 6, 2024. However, the personnel record contained no documentation of the completion of the HIV/AIDS training as of the date of the inspection.
This is a repeat citation from the October 6, 2023 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and Clinical Supervisor will monitor each staff's training plan to ensure all necessary communicable diseases are completed on time.
The Facility Director will document and add certificates of the completed training to the HR files once trainings are completed.
Employee # 6 will complete HIV/AIDS training by 12/1/2024 in order to meet this 6 hour of approved curriculum HIV/AIDs training. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of eight personnel records, the facility failed to demonstrate that a sufficient number of staff persons had CPR certification, as no full-time staff members were certified in CPR between November 30, 2023 and August 20, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Team took part in a CPR training Class on 8/20/24. This training will be active for two years. The Clinical Director and Clinical Supervisor will have a monitoring tool to track CPR training due dates. CPR will be placed on the staff training plan and annual review process.
The Quality Assurance manager will audit staff training plans to ensure CPR certifications are active and updated. |
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 a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2023 through December 31, 2023 training year in one of one applicable personnel record reviewed.
Employee # 4 has been in the position of counselor since March 28, 2022. The personnel record documented only 13 hours of annual training during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will meet will communicate in supervision the required 25 hours of training annually.
The Clinical Supervisor will review all staff training plans with each staff member to ensure that clinical team is meeting the required training hours.
The Facility Director will review all staff training plans to ensure trainings hours are being met and documented.
Employee # 4 has meet with Clinical Director and has signed up for the remaining trainings for the Calander year to meet the required training hours. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection on September 6, 2024, the facility failed to ensure interior exits were lit at all times.
The light in the vestibule connecting the main office suite to an emergency exit on the rear side of the building was not lit and the area was dark when the doors were closed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director put in work order to have light fixed in the hallway on 9/9/24. The work order was completed on 9/12/24. The fire safety concern has been resolved.
The Facility Director will conduct a walk-through on a weekly basis of light interior exits and stairs to ensure lights are functioning properly.
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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 eight client records, the facility failed to ensure that consent to release information forms included the purpose of disclosure in one record reviewed.
Client # 1 was admitted on April 26, 2024 and was discharged on July 2, 2024. Consent to release information forms to a family member and laboratory that were signed by the client on April 26, 2024, were missing the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and Clinical Supervisor will re-communicate and re-train staff to make sure the consent to release information form includes the purpose of disclosure for each client record.
The quality specialist will
will conduct a monthly audit on 20% of new admissions and 10% active clients to ensure the purpose of the disclosure is documented appropriately.
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709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document disclosure to the client of criteria for admission, treatment, or completion in four of seven applicable records reviewed.
Client # 2 was admitted on December 18, 2023 and was discharged on March 1, 2024.
Client # 3 was admitted on February 12, 2024 and was discharged on July 11, 2024.
Client # 6 was admitted on January 29, 2024 and was discharged May 1, 2024.
Client # 8 was admitted on November 27, 2023 and was active at the time of the inspection.
This is a repeat citation from the October 6, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has implemented a new intake and admission form to disclose to the client needed criteria for admission, treatment, and completion.
The Clinical Director and The Clinical Supervisor will ensure by reviewing that all staff is completing the newly implemented intake and admission form.
Client # 2 was discharged on March 1, 2024, and cannot update new form.
Client # 3 was discharged on July 11, 2024, cannot update admission form.
Client # 6 was discharged on May 1, 2024, no update admission form can be updated.
Client # 8 is currently active and completed a new intake form on 10/3/2024. |
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 ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of four applicable records reviewed.
Client # 7 was admitted on April 15, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 15, 2024 and a treatment plan update was due to be completed by June 15, 2024; however, the update was not completed until June 28, 2024.
Client # 8 was admitted on November 27, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 27, 2023 and a treatment plan update was due to be completed by January 27, 2024; however, the next treatment plan update was not completed until February 8, 2024. The following treatment plan update was due to be completed by April 8, 2024; however, the next update was not completed until April 23, 2024.
This is a repeat citation from the October 6, 2023, October 14, 2022 and December 1, 2021 annual licensure renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and Clinical Supervisor will work with staff during weekly supervisions to track treatment plan due dates to ensure treatment plans stay within compliance.
The Clinical Director and The Clinical Supervisor will communicate to the clinical team to update all treatment plans regardless of client attendance to eliminate any future past due treatment plans.
The quality specialist will audit a combination of 20% of new admissions and active client records for treatment plan updates at least every 60 days.
Client # 7 had a gap in treatment and made the treatment plan update late for the required update. Client # 7 treatment plan is updated and moving forward will be updated every 60 days to meet compliance.
Client # 8 had a gap in treatment and made the required 60-day treatment plan update late. Client # 8 treatment plan has been updated and will be updated moving forward every 60 days to meet treatment plan compliance.
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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 a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for updating treatment plans within the regulatory timeframe was submitted and approved by the Department for the October 6, 2023, October 14, 2022, and December 1, 2021, annual licensing inspections. Updating treatment plans was again found to be a deficiency in the September 6, 2023, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will be responsible to ensure plans of corrections are implemented as designed and approved.
The Clinical Director and The Clinical Supervisor, as well as the Compliance Director will assist in completing record audits on all client charts. |