INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 8, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Clear Concepts Counseling 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
During a licensing inspection conducted on May 8, 2019, the facility failed to provide documentation of counselor qualifications for employee # 4.Employee # 4 was hired as a counselor on June 26, 2018 and was still in this position at the time of the inspection. At the time of hire, employee #4 did not have the required one-year experience as a counselor. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective immediately employee #4 will be classified as a counselor assistance and the clinical supervisor will conduct close supervision for 6 months in order to to satisfy the requirements to obtain a promotion to a full-time counselor position on December 8. 2019.
The Project Director and Clinical Supervisor will review the regulations and follow the correct standards in the future if the facility employs a counselor assistant.
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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
During an on-site licensing inspection conducted on May 8, 2019, the facility failed to document a completed consent to release information in 1 record, as there were forms that were missing required information.Client # 3 was admitted on November 1, 2018 and was still an active client at the time of the inspection. A consent to release form was signed and dated on November 7, 2018 that did not provide the name/organization to whom the information was to be released. The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard was reviewed during our agency staff meeting on May 23, 2019 and will be reviewed again during our agency staff meeting on June 20, 2019. The proper completion to obtain an informed and voluntary consent will be completed during client #3 next scheduled session. Our facility will obtain an informed and voluntary consent from all clients for the disclosure of information contained in the client record that adhered to 42 CFR Part 2 and 4 PA Code 255.5(b). A copy of all documentation mailed, faxed and/or emailed will be in the client record as well as the date, time and initials of the therapist (or staff personnel) will be documented. To ensure correct completion of an informed and voluntary consent where consent is applicable will be reviewed by the Clinical Supervisor during monthly supervision. The Clinical Supervisor will also review individual counselor's client records on a monthly basis and during monthly staff meetings to ensure compliance. |
709.28 (e) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(e) When consent is not required, the project personnel shall:
(2) Inform the client, as readily as possible, that the information was disclosed, for what purposes and to whom.
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Observations
During an on-site licensing inspection conducted on May 9, 2019, the facility failed to provide documentation of a consent for a letter that was sent on October 30, 2018.Client # 5 was admitted on January 29, 2013 and discharged on December 3, 2018. A letter was in the client record that did not disclose who the letter was sent to.The findings were discussed with the facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard was reviewed during our agency staff meeting on May 23, 2019 and will be reviewed again during our agency staff meeting on June 20, 2019. The proper completion of the required consent forms, including name of person/agency or organization, date, event, specific information disclosed and condition as well as the dated signature of a witness and the expiration date of the consent. Our facility will obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that adhered to 42 CFR Part 2. To ensure correct completion of consents forms the Clinical Director and Project Director will verify completion during monthly staff meeting/clinical supervision. The Clinical Supervisor will also review individual counselor's client records on a weekly basis and during monthly supervision to ensure compliance. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
During an on-site licensing inspection conducted on May 8, 2019, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights in client record # ' s 1, 2, 3, 4, 5, 6, 7. Client rights form was missing verbiage to include "Reasons for removing shall be documented in the record".These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard was reviewed during our agency staff meeting on May 23, 2019. Our facility will obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that adhered to 42 CFR Part 2. The proper completion of the required consent forms, including name of person/agency or organization, date, event, specific information disclosed and condition as well as the dated signature of a witness and the expiration date of the consent and a copy will be kept in the client record. To ensure correct completion of consents forms the Clinical Director and will verify completion during monthly staff/supervision.
The Project Director will be updating the Client Rights to include the reasons in which the Clinical Director would remove any documentation from the client record before a client reviews their own record.
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709.93(a) 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:
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Observations
During an on-site licensing inspection conducted on May 8, 2019, the facility failed to provide documentation of a complete client record in client record # 4.Client # 4 was admitted on January 16, 2019 and was still an active client at the time of the inspection. There was no documentation of a medical history, drug and alcohol history, and personal history in the client record.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard was reviewed with all counselors at our staff meeting on May23, 2019 and will be reviewed again during our agency staff meeting on June 20, 2019.The proper completion and timing of completion of client documentation of a medical history, drug and alcohol history, and personal history will begin immediately. This standard and policy will also be reviewed with all counselors by the Clinical Supervisor during monthly staff supervision to assure compliance. In the future all counselors will bring open and closed charts to monthly supervision and the Clinical Supervisor will verify that the counselors have the completed documentation in the chart.
The primary counselor for client #4 will complete the documentation of the client's medical history, drug and alcohol history, and personal history immediately.
The Project Director and Clinical Supervisor will also discuss this standard during every mandatory monthly staff meeting and supervision
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