INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 9 & 13, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Chartiers Community Mental Health and Retardation Center, Inc. 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to provide a complete and accurate documentation of the qualifications and training of staff at the project ' s site visit.
The SRFSR form was requested as part of the presubmission process; however, it was not submitted as requested. The SRFSR form was provided to the licensing specialist upon arrival at the onsite inspection; however, the form was found to be incomplete and inaccurate. Facility staff was provided with multiple opportunities to revise the form during the licensing process and multiple revisions were made. After the inspection was completed, it was reported that the information documented on the SRFSR was still incorrect. The SRFSR was signed by the project / facility director as being complete and accurate on January 9, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward, the Staffing Form will be submitted as requested and will be accurate and complete. The Program/Facility Director will be responsible for verifying for accuracy and for submitting as requested by the appropriate deadline. |
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to document that the project facility director met both the educational and experiential requirements for the position in one of one staff records.
Staff #1 was hired at the facility on November 8, 2021 and was put in the project / facility director position on March 3, 2022. Staff #1 meets the experience requirement for the position; however, the documented bachelor ' s degree in Music does not meet the educational requirement for the position.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/15/2023, we submitted the necessary paperwork to have the project/facility manager changed to an individual who meets the qualifications listed in 704.5(c). This has been processed by the Licensure Division and the change has been made.
When a new Director is hired in the future, the identified person will fully meet the qualifications listed in 704.5(c). Person responsible ? Chief Clinical Officer.
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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 staff training records, the facility failed to document TB/STD and HIV/AIDS training within the required timeframes in two of four staff records.
Staff #4 was hired as a counselor on October 1, 2018. TB/STD and HIV/AIDS training was due to be completed by October 1, 2019. There was no documentation of TB/STD training in staff record #4.
Staff #8 was hired as a support staff on January 8, 2018. TB/STD and HIV/AIDS training was due to be completed by January 8, 2020. There was no documentation of TB/STD or HIV/AIDS training in staff record #8.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff 8 has corrected the training issues: HIV/AIDS training completed on 11/18/2021 and TB/STD on 2/25/2022. These certificates are on file in the personnel record as well as on the DDAP training site.
Staff 4 has submitted his resignation as of 2/10/2023. No additional training is required.
For current and future clinicians, the Project/Facility Director will add any needed DDAP trainings to each staff schedule within 90 days of hire. In cases where there are delays due to waitlists, the Project/Facility Director will document communication with training providers and present this information upon request.
Effective immediately, the Project/Facility Director will ensure that all training certificates and supportive documentation will be forwarded to Human Resources for placement in the Personnel file.
All staff will complete the required mandatory training within the timeframes required by regulation for their position.
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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 staffing training records, the facility failed to document at least 25 hours of training for the 2021 / 2022 training year in two of two counselor records.
Staff #3 was hired as a counselor on November 2, 2020. Staff #3 had documentation of 0 training hours for the July 1, 2021 - June 30, 2022 training year.
Staff #4 was hired as a counselor on October 1, 2018. Staff #4 had documentation of 13 hours of training for the July 1, 2021 - June 30, 2022 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All trainings that are required will be added to the staff training plan and assigned either within 90 days of hire, or within 30 days of the new fiscal year.
Effective immediately the Project/Facility Director will develop and implement a monthly tickler file to ensure registration and completion of required trainings.
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to maintain outpatient caseloads at or below 35/1 in four of four counselor caseloads.
Employee #3 was hired as a counselor on November 2, 2020 and was still in this position at the time of the inspection. Employee #3 was reported to have 10 hours per week devoted to their 26 D/A clients on their caseload.
The FTE counselor's caseload calculation is as follows: 10/37.5 = .26(FTE); 26/.26= 100, which equals to a client/counselor ratio of 100:1.
Employee #4 was hired as a counselor on October 1, 2018 was still in this position at the time of the inspection. Employee #4 was reported to have 4 hours per week devoted to their 4 D/A clients on their caseload.
The FTE counselor's caseload calculation is as follows: 4/37.5 = .10 (FTE); 4/.10= 40, which equals to a client/counselor ratio of 40:1.
Employee #5 was hired as a counselor on September 12, 2022 was still in this position at the time of the inspection. Employee #5 was reported to have 20 hours per week devoted to their 20 D/A clients on their caseload.
The FTE counselor's caseload calculation is as follows: 20/37.5 = .53 (FTE); 20/.53 = 37.73, which equals to a client/counselor ratio of 37:1.
Employee #6 was hired as a counselor on September 26, 2022 was still in this position at the time of the inspection. Employee #6 was reported to have 7.5 hours per week devoted to their 13 D/A clients on their caseload.
The FTE counselor's caseload calculation is as follows: 7.5/37.5 = .2 (FTE); 13/.2 = 65, which equals to a client/counselor ratio of 65:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Errors on the Staffing Requirements Facility Summary Report were related to the amount of time that each clinician had dedicated to the program and these errors have already been corrected by Program/Facility Director. All three (3) counselors were allotted to the program for 37.5 hours per week each, which was sufficient time for the assigned caseloads. This data will be updated on an ongoing basis by the Program/Facility Director |
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 employee performance reviews that were reviewed and signed by the employee in two of two personnel records.
Staff #3 was hired as a counselor on November 2, 2020. An annual employee performance review was documented on November 2, 2022; however, it did not include an employee signature.
Staff #4 was hired as a counselor on October 1, 2018. There were no annual employee performance reviews documented since 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff 3's performance review was presented and signed on 11/3/22 but was not forwarded for filing; it has now been filed.
Staff 4's performance review was completed and signed on 9/14/22 during supervision but was not forwarded for filing; it has now been filed.
Subsequent yearly evaluation meetings will be scheduled no less than 2 weeks before they are due and ADDED to the staff's schedule and into the schedule of the Project/Facility Director. The evaluation will be signed and dated on or before the due date. For the current clinicians, this will be completed by 2/15/23.
The Project/Facility Director is responsible for completion.
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709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in five of six client records.
The facility billed for treatment services during the intake process without written consent from the client in the following records:
Client # 1 was admitted May 18, 2022 and is currently active.
Client # 2 was admitted September 20, 2022 and is currently active.
Client # 3 was admitted April 1, 2022 and is currently active.
Client # 4 was admitted April 26, 2022 and discharged on October 3, 2022
Client # 7 was admitted March 9, 2022 and discharged on September 12, 2022.
The findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the February 7, 2022 annual licensing inspection.
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Plan of Correction
Effective immediately and on an ongoing basis, Needs Assessments are completed in person and staff have new clients sign this form at the time of admission. The Intake Clinician is responsible for obtaining the signature on informed and voluntary consent.
For clients 1, 2, 3, informed and voluntary consent forms with signatures for the disclosure of information will be obtained.
The Project/Facility Director is responsible for ensuring that the Intake is not billed unless this form is completed and signed.
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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 client records, the facility failed to document an informed and voluntary consent from the client that included the dated signature of the client in six of six client records.
Consents were documented during the intake process in the following client records.
Client # 1 was admitted May 18, 2022 and is currently active. The consent for the funding source did not include the dated signature of the client.
Client # 2 was admitted September 20, 2022 and is currently active. The consent for the funding source did not include the dated signature of the client.
Client # 3 was admitted April 1, 2022 and is currently active. The consent for the funding source did not include the dated signature of the client.
Client # 4 was admitted April 26, 2022 and discharged on October 3, 2022. The consent for the funding source did not include the dated signature of the client.
Client # 5 was admitted May 5, 2022 and discharged on October 18, 2022. The consent for the funding source did not include the dated signature of the client.
Client # 7 was admitted March 9, 2022 and discharged on September 12, 2022. The consent for the funding source did not include the dated signature of the client.
The findings were reviewed with staff during the licensing process.
This is a repeat deficiency from the February 7, 2022 annual licensing inspection.
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Plan of Correction
Effective immediately and on an ongoing basis, Needs Assessments are completed in person in person and staff have new clients sign this form at the time of admission. The Intake Clinician is responsible for obtaining the signature on informed and voluntary consent.
For clients 1, 2, 3, informed and voluntary consent forms with signatures for the disclosure of information will be obtained.
The Project/Facility Director is responsible for ensuring that intake is not billed unless this form is completed and signed.
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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 client records, the facility failed to document the type and frequency of treatment services on the treatment plan in five of six client records.
The treatment plans documented in client records #1, 3, 4, 5 and 6 did not include documentation of the type and frequency of treatment services.
Client #1 was admitted on May 18, 2022 and is currently an active client. Treatment plans dated August 17, 2022 and June 2, 2022 did not include documentation of the type and frequency of treatment services.
Client #3 was admitted on April 1, 2022 and is currently an active client. Treatment plans dated December 14, 2022 and October 20, 2022 did not include documentation of the type and frequency of treatment services.
Client #4 was admitted on July 18, 2022 and discharged on October 3, 2022. Treatment plans dated July 18, 2022 and May 16, 2022 did not include documentation of the type and frequency of treatment services.
Client #5 was admitted on May 5, 2022 and discharged on October 18, 2022. Treatment plans dated October 18, 2022 and May 10, 2022 did not include documentation of the type and frequency of treatment services.
Client #6 was admitted on February 1, 2022 and discharged on November 1, 2022. Treatment plans dated October 18, 2022 and February 8, 2022 did not include documentation of the type and frequency of treatment services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff will be retrained on the procedure for documenting type and frequency of treatment services. The Project/Facility Director will provide training no later than 03/01/2023.
Clinical staff will review all open charts to ensure that type and frequency of treatment services is documented accurately in the treatment plan. Updated Treatment Plans with type and frequency of treatment services will be completed no later than 03/15/2023.
The Project/Facility Director will review and if the information is done incorrectly, will reject plan to be corrected and resubmitted.
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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 at least every 60 days in four of six client records.
Client #1 was admitted on May 18, 2022 and is currently an active client. The most recent treatment plan updates documented were completed on June 2 and August 17, 2022. Treatment plan updates were due to be completed by October 17 and December 17, 2022. There was no documentation of treatment plan updates for October and December 2022.
Client #4 was admitted on April 26, 2022 and discharged on October 3, 2022. The most recent treatment plan updates documented were completed on May 16 and July 18, 2022. A treatment plan update was due to be completed by September 18, 2022. There was no documentation of a treatment plan update for September 2022.
Client #5 was admitted on May 5, 2022 and discharged on October 18, 2022. A treatment plan update was documented May 10, 2022. Treatment plan updates were due to be completed by July 10 and September 10, 2022. A treatment plan update was completed on October 18, 2022.
Client #6 was admitted on February 1, 2022 and discharged on November 1, 2022. A treatment plan update was documented February 8, 2022. Treatment plan updates were due to be completed by April 8, June 8, August 8 and October 8, 2022. A treatment plan update was completed on October 18, 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the February 7, 2022 annual licensing inspection.
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Plan of Correction
Clinical staff will review treatment plans no later than 60 days after completion of plan.
If the client is unavailable, staff will complete review and acknowledge that a full review will be completed when client is next seen.
If the client goes more than 45 days after that review without contact, the Project/Facility Director will send pre-term letter to client stating that contact must be made to continue active treatment.
If there is no contact, the case will be closed no later than 15 days after pre-term letter is sent.
The Project/Facility Director will monitor these cases in supervision and is responsible for the above.
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709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to document that counseling services were provided to the client on a regular and scheduled basis in four of seven client records.
Client #4 was admitted on April 26, 2022 and discharged on October 3, 2022. The client's late date of treatment was July 18, 2022. No treatment sessions were documented between July 18 - October 3, 2022.
Client #5 was admitted on May 5, 2022 and discharged on October 18, 2022. The client's late date of treatment was June 8, 2022. No treatment sessions were documented between June 8 - October 18, 2022.
Client #6 was admitted on February 1, 2022 and discharged on November 1, 2022. The client's late date of treatment was March 22, 2022. No treatment sessions were documented between March 22 - November 1, 2022.
Client #7 was admitted on March 9, 2022 and discharged on September 12, 2022. This client attended teh intake session on March 9, 2022 and did not return to treatment. No treatment sessions were documented between March 9 - September 12, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
If client does not show for a scheduled appointment, the clinician will reschedule within 10 days and communicate that information to client.
If a Treatment Plan is due for review, staff will complete a Review of Progress and acknowledge that a full review will be completed when client is next seen.
If client goes more than 45 days after that review without contact, the Project/Facility Director will send pre-term letter to client stating that contact must be made to continue active treatment.
If there is no contact, the case will be closed no later than 15 days after pre-term letter is sent.
The Project/Facility Director will monitor these cases in supervision and is responsible for the above.
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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 case consultations quarterly, as per facility policy, in six of seven client records.
Client #1 was admitted on May 18, 2022 and is currently active. There were no case consultations documented in client record #1.
Client #2 was admitted on September 20, 2022 and is currently active. There were no case consultations documented in client record #2.
Client #4 was admitted on April 26, 2022 and discharged on October 3, 2022. There were no case consultations documented in client record #4.
Client #5 was admitted on May 5, 2022 and discharged on October 18, 2022. There were no case consultations documented in client record #5.
Client #6 was admitted on February 1, 2022 and discharged on November 1, 2022. There were no case consultations documented in client record #6.
Client #7 was admitted on March 9, 2022 and discharged on September 12, 2022. There were no case consultations documented in client record #7.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the February 7, 2022 annual licensing inspection.
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Plan of Correction
The Project/Facility Director will monitor that each consumer's progress is reviewed during psychiatric staffing meetings. This will occur at least quarterly, from the date of admission, at a case conference consisting of representatives from the various service components, when appropriate. At a minimum, consultation shall include the psychiatrist and the Project/Facility Director. For consumers in treatment longer than one year, case consultations shall occur and be documented at least once annually but shall be more frequent, if necessary, based on the consumer response to treatment. Documentation shall be maintained in the electronic record.
The Project/Facility Director will monitor the completion of Case Consultations and is responsible for the above.
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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.
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Observations
Based on a review of client records, the facility failed to document follow up contact, within one week as per facility policy, in four of four client records.
Client #4 was admitted on April 26, 2022 and discharged on October 3, 2022. There was no follow up contact documented in client record #4.
Client #5 was admitted on May 5, 2022 and discharged on October 18, 2022. There was no follow up contact documented in client record #5.
Client #6 was admitted on February 1, 2022 and discharged on November 1, 2022. There was no follow up contact documented in client record #6.
Client #7 was admitted on March 9, 2022 and discharged on September 12, 2022. There was no follow up contact documented in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project/Facility Director will oversee follow-up contact.
Follow up contact shall occur in the following manner:
For consumers discharged and referred to an outside resource, staff shall attempt to determine from the resource, the disposition of the referral within one (1) week of the day that the referral was to have been completed. Written consent of the consumer is required for this activity.
For consumers not referred after discharge, within one (1) week from discharge, telephone contact to discuss follow up needs and verification of status shall be made to the client. All activities shall be documented in the electronic record.
The Project/Facility Director is responsible for completion.
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