INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 21, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Christian Counseling Associates of Western Pennsylvania LLC, 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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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the policy and procedure, the facility failed to develop a comprehensive staff development program indicating who is responsible and the time frames for completion for a mechanism to collect feedback on completed training.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will create training feedback mechanism and the Facility Director will be repsonsible for ensuring feedback is collected. Facility will be in compliance by 4/1/25. The training feedback will be due one week after the training. QA Team will conduct monthly reviews to monitor for compliance |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents and an interview with the facility director, the project failed to document an annual financial audit for the fiscal year ending December 31, 2023.
The facility requested an exception for the financial audit, which was approved on February 14, 2025, and in lieu of an audit they are to submit business tax returns.
The facility failed to submit an audit or business tax returns for years ending 2022 and 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will meet with the Project Director by 4/1/25 to create a plan regarding the submission of future business tax returns. Facility Director will be responsible to ensure that business tax returns are submitted to DDAP if required for our next audit. Facility Director will submit another financial audit exception request to DDAP, if required, for our next audit. Facility will be in compliance by 4/1/25. |
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 an informed and voluntary consent from the client which includes name of the person, agency, or organization to whom disclosure is made in two of seven records.
Client #4 was admitted on September 9, 2024, and was still active at the time of the inspection. Client record contained a release of information dated September 30, 2024, that did not contain the name of the person, agency, or organization to whom disclosure is made.
Client #5 was admitted on October 28, 2024, and was still active at the time of the inspection. Client record contained a release of information dated November 5, 2024, that did not contain the name of the person, agency, or organization to whom disclosure is made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director has already met with the Counselors to create a new plan to ensure timely and proper completion of informed and voluntary consent forms. Facility Director will audit new client charts weekly with the help of the Quality Assurance team to ensure timely and proper completion of informed and voluntary consent forms. Facility will be in compliance by 4/1/25. Counselors will inform Facility Director of when Counselors admit a new client to help Facility Director maintain timely audits. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document a purpose of disclosure on the release of information form in one of seven records.
Client #4 was admitted on September 9, 2024, and was still active at the time of the inspection. A release of information was signed and dated by the client on September 30, 2024, but did not indicate a purpose of disclosure.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will audit new client charts weekly with the help of the Quality Assurance team to ensure timely and proper completion of release of information forms. Facility will be in compliance by 4/1/25 and all current clients will be compliant by 4/1/25. Counselors will inform Facility Director of when Counselors admit a new client to help Facility Director maintain timely audits. Facility Director will meet with Counselors by 4/1/25 to review the importance of the purpose of disclosure in release of information forms.
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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 a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire in one of seven records.
Client #4 was admitted on September 9, 2024, and was still active at the time of the inspection. A release of information was signed and dated by the client on September 30, 2024, but did not document when the consent will expire.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will meet with Counselors during our bi-weekly DACCA Group Supervision and ensure they know how to indicate when consents will expire. QA team will audit charts monthly to check if this part of the consent form is done properly. Facility will be in compliance by 4/1/25. |
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 the disclosure of the criteria for admission to clients, during the intake process, in seven of seven records.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will meet with our IT staff and have them add criteria for admission to the Agreement for Counseling form that is administered on Intake to all client charts. Facility will be in compliance by 4/1/25. QA Team will audit charts monthly to check for compliance in this area. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan in five of seven applicable records.
The facility ' s policy and procedure manual states the preliminary treatment plan must be completed by the third session.
Client #1 was admitted on November 21, 2024, and discharged on February 12, 2025. There was no documentation of a preliminary treatment plan in the client record.
Client #4 was admitted on September 9, 2024, and was still active at the time of the inspection. There was no documentation of a preliminary treatment plan in the client record.
Client #5 was admitted on October 28, 2024, and was still active at the time of the inspection. There was no documentation of a preliminary treatment plan in the client record.
Client #6 was admitted on September 26, 2024, and was still active at the time of the inspection. There was no documentation of a preliminary treatment plan in the client record.
Client #7 was admitted on October 17, 2024, and was still active at the time of the inspection. There was no documentation of a preliminary treatment plan in the client record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will ensure the preliminary treatment plan is present in the charts by using the QA Team to audit charts, review charts in Group and Individual Supervision. Counselors have the potential to be put on a Performance Improvement Plan if not following protocol. Facility will be in compliance by 4/1/25. |
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 in three of seven applicable records.
The facility ' s policy and procedure manual states the comprehensive treatment plan must be completed between within 30 days following admission.
Client #1 was admitted on November 21, 2024, and discharged on February 12, 2025. A comprehensive treatment plan was due no later than December 21, 2024; however, it was not completed until January 15, 2025.
Client #2 was admitted on November 19, 2024, and discharged on January 15, 2025. A comprehensive treatment plan was due no later than December 19, 2024; however, it was not completed until December 24, 2024.
Client #6 was admitted on September 26, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than October 26, 2024; however, it was not completed until November 12, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will meet with Counselors by 4/1/25 to review our policy on timeliness of comprehensive treatment plans. Facility Director will meet with QA Team by 4/1/25 to review this policy, too. QA Team and Facility Director will be responsible for policy enforcement. QA Team will monitor for adherence to policy. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in seven of seven records.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will meet with IT staff and ask them to add a Supoort Services section, which can be tailored to fit each unique client, to treatment plan shell. If shell cannot be altered, then Facility Director will direct Counselors to add social services themselves directly into each treatment plan. QA Team will monitor for compliance with monthly chart audits and facility will be in full compliance by 4/1/25. |
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 every 60 days in five of five applicable records.
Client #3 was admitted on June 28, 2024, and discharged on November 14, 2024. A treatment plan update was completed on September 6, 2024, and the next update was due no later than November 6, 2024; however, it was completed on November 14, 2024.
Client #4 was admitted on September 9, 2024, and was still active at the time of the inspection. A treatment plan was completed on October 16, 2024, and an update was due no later than December 16, 2024; however, it was completed on January 8, 2025.
Client #5 was admitted on October 28, 2024, and was still active at the time of the inspection. A treatment plan was completed on November 19, 2024, and an update was due no later than January 19, 2025; however, it was completed on January 21, 2025.
Client #6 was admitted on June 11, 2021, and was still active at the time of the inspection. A treatment plan was completed on November 12, 2024, and an update was due no later than January 12, 2025; however, it was not completed until January 22, 2025.
Client #7 was admitted on October 17, 2024, and was still active at the time of the inspection. A treatment plan update was completed on November 20, 2024, and the next update was due no later than January 20, 2025; however, it was completed on January 29, 2025.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the April 23, 2024 licensing inspection.
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Plan of Correction
Facility Director will meet with Counselors by 4/1/25 to review treatment plan update timeliness policy. Current clients will be in compliance by 4/1/25. QA Team will audit charts for compliance. |