INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, MCP/Caring Together 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(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 personnel records, the facility failed to provide documentation that written individual training plans were developed for each employee, with input from both the employee and the supervisor, in three of five applicable personnel records reviewed.
Employee # 2 was hired as a clinical supervisor on September 1, 2024. The individual training plan was signed by the employee on June 24, 2024, but there was no documentation indicating there was any input from the supervisor.
Employee # 3 was hired as a counselor on December 20, 2019. The individual training plan was signed by the employee on June 24, 2024, but there was no documentation indicating there was any input from the supervisor.
Employee # 4 was hired as a counselor on May 8, 2023. The individual training plan was signed by the employee on June 24, 2024, but there was no documentation indicating there was any input from the supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Individual Training Plans will be revised by the Program Director to include an area for the Supervisor to provide input and sign noting that the plan was reviewed.
The Clinical Supervisor reviews the completed forms for the Clinicians and the Program Director will review the forms for the support team and Clinical Supervisor. The forms will be filed in the staff member's file after review. The Clinical Supervisor and the Program Director will review the individual staff member's file annually at the end of May.
The Individual Treatment Plans are completed annually in May. The new forms will be revised by May 10th. |
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 personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of one applicable personnel records reviewed.
Employee # 4 was hired as a counselor on May 8, 2023 and was due to complete the HIV/AIDS training and the TB/STD training no later than May 8, 2024. There was no documentation indicating the both the HIV/AIDS and TB/STD trainings were completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff completed the trainings in a timely manner. However, due to not completing the mandatory evaluation in a timely manner, certificates of completion were not issued. Staff have a transcript to note completion. Going forward, supervisor will ensure that the evaluation is completed immediately after the training. |
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 personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure the Full Time Equivalent (FTE) counselor caseload in outpatient programs did not exceed 35 active clients in one of five applicable personnel records reviewed.
The counselor FTE is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee # 4 was hired as a counselor on May 8, 2023 and was still employed. The employee's counselor caseload calculation was as follows: 40/40 = 1(FTE); 37/1 = 37, which equals to a client/counselor FTE ratio of 37:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review the Program Census prior to the assignment of new clients to ensure that the caseloads do not exceed 35. In the absence of the Clinical Supervisor, the Program Director will review the Program Census to ensure that caseloads do not exceed 25 clients.
During supervision sessions with the counselors, the Clinical Supervisor will review caseloads to ensure compliance.
Currently all caseloads meet the counselor to client ratio. Participants that were discharged that had not engaged. per their treatment schedule. |
711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days was submitted and approved by the Department for the March 29, 2023, October 10, 2023, March 11, 2024, and November 22, 2024 licensing inspections. Failing to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days was again found to be a deficiency in the March 10, 2025 licensing inspection.
A plan of correction for failing to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record was submitted and approved by the Department for the March 11, 2024 and November 22, 2024 licensing inspections. Failing to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record was again found to be a deficiency in the March 10, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will continue to provide ongoing training. Trainings will address the importance of completing treatment plans every 60 days. The training will also include the need to have timely written consents completed and filed in the clients' records.
The Clinical Supervisor will work with each counselor to develop a spreadsheet noting the due dates for treatment plan updates. The spreadsheet will also include expiration dates of written consents. The spreadsheets will be monitored during Clinical Supervision sessions by the Clinical Supervisor.
The Clinical Supervisor will provide a monthly report of progress for each counselor to the Program Director.
The Clinical Supervisor and Program Director will review POCs during the monthly meeting. The Clinical Supervisor will present spreadsheets with updates of progress/lack of progress. During the meeting we will review random files for each counselor.
The policies for each POC will be reviewed at the meeting in May 2025. If warranted policies, may be edited and submitted to the Medical Director for approval.
The Clinical Supervisor will also review the policies and POCs with the counselors.
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) 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 ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in four of nine applicable client records reviewed.
Client # 7 was admitted on September 23, 2024 and was discharged on February 4, 2025. A treatment plan update was completed on November 12, 2024 and the next update was due no later than January 12, 2025; however, the update was not completed prior to discharge.
Client # 12 was admitted on May 9, 2024 and was discharged on February 24, 2025. A treatment plan update was completed on October 17, 2024 and the next update was due no later than December 17, 2024; however, the update was not completed at the time of discharge.
Client # 14 was admitted on January 28, 2022 and was still active at the time of the inspection. A treatment plan update was completed on January 22, 2024 and the next update was due no later than March 22, 2024; however, the update was not completed at the time of the inspection.
Client # 15 was admitted on September 25, 2024 and was still active at the time of the inspection. A treatment plan update was completed on December 23, 2024 and the next update was due no later than February 23, 2025; however, the update was not completed at the time of the inspection.
This is a repeat citation from the March 29, 2023, October 10, 2023, March 11, 2024, and November 22, 2024 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will continue to provide ongoing Treatment Plan Training to include the importance of competing the plans within 60 days.
The Clinical Supervisor will continue to have counselors note the due dates of treatment plans on a spreadsheet or their work calendar. The Clinical Supervisor will also note the due dates and review with counselors during supervision.
The Clinical Supervisor will host a semi-monthly or monthly Treatment Plan meeting with the counselors to aid in monitoring timely and satisfactory completion of treatment plans.
The Clinical Supervisor will provide the Program Director with updates during monthly meetings.
Files that were deficient during the March 2025 review will all be updated by May 12, 2025. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in two of seventeen client records reviewed.
Client # 14 was admitted on January 28, 2022 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on November 28, 2022 and expired on November 28, 2023. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after November 28, 2023.
Client # 17 was admitted on April 21, 2021 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on April 23, 2023 and expired on April 23, 2024. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after April 23, 2024.
This is a repeat citation from the March 11, 2024 and November 22, 2024 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will continue to provide training for the appropriate completion of consents, including timeliness of the consent.
The Clinical Supervisor will assist each counselor in developing a spreadsheet to monitor the need to update the consents. The spreadsheet will include expiration dates of written consents. The spreadsheets will be monitored during Clinical Supervision sessions by the Clinical Supervisor. The Clinical Supervisor will provide monthly progress to the Program Director.
For clients that remain active all consents will be corrected by 4/30/2025.
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