INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 27, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Treatment Trends Inc. Confront 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of eleven personnel records, the facility failed to hire counselors that met the experience requirements for the position in two personnel records reviewed.Employee #6 was hired as a counselor on October 22, 2021, did not meet the experience requirements. Employee #10 was hired as a counselor on December 30, 2020, did not meet the experience requirements. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All future candidates for clinical positions will have their education verified via official transcript by Treatment Trends' human resource representative and field experience listed on the resume will be verified by the program director and/or clinical director. Any individual not meeting the qualifications for counselor will be considered for a CA position and subject to CA guidelines.
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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.
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Observations
Based on a review of seven client records, the facility failed to ensure that comprehensive treatment plans included the frequency of treatment and rehabilitation services in four client records reviewed. Client #3 was admitted on November 19, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was completed on December 3, 2021, that failed to include the frequency of treatment and rehabilitation services.Client #5 was admitted on November 3, 2021 and was discharged on January 12, 2022. A comprehensive treatment plan was completed on November 17, 2021, that failed to include the frequency of treatment and rehabilitation services.Client #6 was admitted on November 23, 2021 and was discharged on January 25, 2022. A comprehensive treatment plan was completed on November 30, 2021, that failed to include the frequency of treatment and rehabilitation services.Client #7 was admitted on October 27, 2021 and was discharged on January 24, 2022. A comprehensive treatment plan was completed on November 11, 2021, that failed to include the frequency of treatment and rehabilitation services.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
As of 2/1/22, Confront staff have been addressed in staff meetings, and via email, about the type and frequency of treatment needing to be documented in treatment plans. Staff will mark in the "Additional Comments" section of the Treatment Plan form in Azzly, (the Electronic Medical Record-EMR), the frequency of individual and group sessions. Within 30 days of (DATE POC is submitted), any client who was active on the day of the Licensing Audit (1/27/22) will have addendums added to their current and past treatment plans to reflect the frequency and type of treatment. This will be completed by the individual counselor or the individual counselor's supervisor.
Client #3, #5 #6 and #7 have had addendums added to their treatment plans as of 2/17/22 to reflect their frequency and type of treatment.
Any Treatment Plans submitted via our EMR, Azzly, that do not contain the frequency and type of treatment will be rejected by the assigned supervisor for correction, effective on 2/1/22.
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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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in two of three applicable client records reviewed.Client #1 was admitted on October 25, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was completed on October 28, 2021, and the next update was due no later than December 28, 2021; however, there was no update documented in the record at the time of the inspection.Client #7 was admitted on October 27, 2021 and was discharged on January 24, 2022. A comprehensive treatment plan was completed on November 11, 2021, and the next update was due no later than January 11, 2022; however, there was no update documented in the record at the time of the inspection. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
As of 2/1/22, Confront staff have been addressed in staff meeting, and via email, about treatment plan updates needing to be completed even if the client is not present at the time the update is due. The staff were instructed to do this and have the client sign once the client is back in the office. The Clinical Supervisor created a spreadsheet on 2/18/22 that tracks when Master Treatment Plans and Treatment Plan Updates are due. The Clinical Supervisor will implement this spreadsheet by 2/25/22, for all clinical staff to bring into supervisions as well as staff meetings.
Client #7 Treatment Plan Update was not completed and client was discharged.
Client #1 Treatment Plan update was completed on 2/1/22.
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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 the facility ' s policy and procedure manual and seven client records, the facility failed to complete and document at least one case consultation in one of three applicable client records reviewed. Client #4 was admitted on November 23, 2021 and discharged on January 25, 2022. The client record did not contain documentation of a case consultation.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
As of 2/1/22 Confront staff have been addressed in staff meeting, and via email, about Case Consultations needing to be conducted prior to a discharge. The Clinical Supervisor created a spreadsheet on 2/18/22 that tracks when Case Consults are due. The Clinical Supervisor will implement her spreadsheet by 2/25/22, for all clinical staff to bring into supervisions as well as staff meetings. |