INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on November 2, 2021 through November 4, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Caron Treatment Centers - Detox Unit 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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704.9(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 twenty-four personnel records, the facility failed to maintain documentation that the bachelor level counselor assistant only counseled clients under close supervision, to include at least one hour a week of direct observation, for at least the first six months of employment in one of one applicable record.
Employee # 19 was hired as a counselor assistant on November 7, 2020 and was promoted to counselor on July 26, 2021. The supervision notes provided at the time of inspection did not indicate that direct observation was a part of the supervision.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors and Clinical Directors will be re-educated on the requirements for clinical supervision for counselor assistants including the requirement for direct observation. The Compliance Specialist will provide the re-education to the supervisors and directors.
The Compliance Specialist will monitor the completion of clinical supervision for counselor assistants for 3 months to ensure compliance with DDAP regulations. The Corporate Director of Compliance & Quality will ensure all corrective actions are 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.
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Observations
Based on a review of twenty-four personnel records, the facility failed to ensure that each employee had a training plan completed in three records reviewed.
Employee # 15 was hired as a counselor on July 19, 2021 and was still in that position at the time of the inspection. A training plan was due by August 19, 2021 but was not completed until October 15, 2021.
Employee # 23 was hired as a counselor assistant on September 10, 2021 and was still in that position at the time of the inspection. The record contained no documentation of an individual training plan.
Employee # 24 was hired as a counselor assistant on September 8, 2021 and was still in that position at the time of the inspection. The record contained no documentation of an individual training plan.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training plans will be developed for employees #23 and #24 by December 14, 2021. The training department will forward a copy of the completed training plans to the Compliance Department once completed.
A new process for completion of initial training plans for new employees has been developed and will be implemented with all new hires as of December 14th.
The Director of Training will monitor the completion of training plans for new employees on a monthly basis for the next 3 months to ensure compliance. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on November 2, 2021, the facility failed ensure that either individual paper towels or a mechanical dryer was in each of the patient bedrooms in Buildings 100, 200, 400, 700, 1000, 1200, 1400, 3000, 3100, and 3300, as well as the Women' s Executive Program and Men' s Executive Program.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New paper towel dispensers have been ordered and will be installed in all bathrooms in buildings 100, 200, 400, 700, 1000, 1200, 1400, 3000, 3100 and 3300 by 12/30/21.
The Director of Facilities will conduct a physical plant inspection in January 2022 to ensure paper towel dispensers have been installed in all bathrooms.
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection on November 2, 2021, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag.
A fire extinguisher located in the Villa Men ' s Program and one in the Executive Men ' s Program did not have the date of the inspection punched on the inspection tag.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The two fire extinguishers that were missing the annual inspection date punch were inspected and the date punched on 11/19/21 by the contracted fire protection vendor.
For future annual fire extinguisher inspections an employee from the facilities department will accompany the fire protection vendor to ensure all fire extinguishers are inspected, dated and punched as required.
The Director of Facilities will monitor the completion of annual fire extinguisher inspections to ensure all fire extinguishers are inspected, dated and punched as required. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of twenty-four personnel files, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one record reviewed.
Employee #12 was hired as a counselor on August 23, 2021 and was due to be trained in the use of fire extinguishers by August 30, 2021; however, fire safety training was not documented until October 19, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new onboarding and training process has been developed for new employees including fire extinguisher training. This new process will be implemented by 1/4/22. The Director of Employment/Recruiting will monitor the completion of fire extinguisher training for new employees for 3 months to ensure compliance. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from March 2021 through October 2021, the facility failed to conduct fire drills during sleeping hours at least every six months in four of ten residential program units.
The only fire drill during sleeping hours in Building #400 was on September 21, 2021.
Building #1000 had no fire drills during sleeping hours for the unit, which were 11:00 P.M. to 06:15 A.M.
The only fire drill during sleeping hours in Building #1200 was on March 25, 2021.
The only fire drill during sleeping hours in Building #3000 was on March 25, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new process and schedule for completion of fire drills has been developed and implemented as of December 1, 2021. The VP of Facilities will monitor the completion of fire drills on a monthly basis to ensure all drills are completed as required. The Compliance Specialist will monitor the completion of fire drills on a quarterly basis to ensure drills are completed as required. |
709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
Based on a review of twenty-four personnel records, the facility failed to ensure that each personnel record included written verification of qualifying professional credentials in two records.
Employee # 23 was hired as a counselor assistant on September 10, 2021 and was still in that position at the time of the inspection. There was no written verification of qualifying professional credentials in the personnel record.
Employee # 24 was hired as a counselor assistant on September 8, 2021 and was still in that position at the time of the inspection. There was no written verification of qualifying professional credentials in the personnel record.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The two counselor assistants that were missing verification of professional credentials were interns. A new process for verification of professional credentials has been developed and implemented for all interns as of December 1, 2021. The Director of Training will monitor the completion of verification of credentials for new interns on a monthly basis for the next 3 months to ensure compliance. |
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 twenty-four personnel records, the facility failed to ensure that personnel records contained a reviewed and signed annual written staff performance evaluation in two records.
Employee # 14 has been a Clinical Supervisor since July 5, 2014 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by September 2021 but was not signed by the employee until October 20, 2021.
Employee #17 has been a counselor since July 4, 2016 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by September 2020 but was not signed by the employee until February 10, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All supervisors and directors will be re-educated on the requirement to complete annual performance evaluations for their employees within 30 days of the employee's annual hire date anniversary. The Director of Employment/Recruitment will monitor the completion of performance evaluations on a monthly basis to ensure compliance. |