INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Greater Philadelphia Alliance Social Service Center 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 an administrative review, the facility failed to present the completed plan documenting the qualifications and training of staff to the Department Licensing Representative at the time of the project's site visit. At the time of the inspection, an incomplete Staffing Requirements Facility Summary Report, which is the plan documenting the staff qualifications and trainings, was presented to the Licensing Representative. During the entire licensing process, the Licensing Representative made multiple requests for corrections, accuracy, and re-submission. The requests included providing specific technical assistance instruction; however, the last copy of the plan submitted was still incomplete, which also questions the validity of the accuracy of the information in the plan. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program director will revise the training plan for all staff by November 1, 2024, and will update it after each new staff orientation. The program director will also periodically review the training plan to ensure that all information is accurate and up to date. |
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
Based on a review of personnel files, the facility failed to ensure all counselors met the appropriate educational qualifications for the position in one of four applicable personnel records reviewed. Employee #4 was hired as a counselor on August 11, 2023. The employee does possess a bachelor's degree; however, the Licensing Representative could not verify if the degree's major is a qualifying major. There was no indication of what the major was listed on the degree and there was no degree transcripts provided to the Licensing Representative during the entire licensing process.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 10/17/2024, the Program Director has updated the onboarding process to require both a degree and a transcript before an offer letter can be issued to potential staff.
To address the identified deficiency, we have implemented an update to the onboarding process. This enhancement enables the Clinical Supervisor to review candidates' transcripts prior to finalizing their start dates. By doing so, we aim to ensure that all necessary qualifications are verified, promoting a smoother transition into the role.
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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 ensure a written individual training plan was developed annually with input from both the employee and their supervisor in one of seven personnel records reviewed. Employee #1 was hired as the project director/facility director on January 17, 2023. There was no individual training plan for the current training year documented in the personnel record. The last individual training plan was completed on January 17, 2023.This is a repeat citation from the October 13, 2022 and the September 19, 2023 annual licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of October 17, 2024, the Program Director and the Chief Operating Officer have successfully finalized the written individual training plan for the Program Director.
Corrective action was completed on 10/03/2024. The COO and Program Director have completed their individual training plans. The COO will ensure the training plan is completed to prevent this deficiency from occurring again. |
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 within the regulatory timeframe in three of four applicable personnel records reviewed.Employee #3 was hired as a counselor on March 16, 2022 and was due to receive the HIV/AIDS training and the TB/STD training no later than March 16, 2023; however, there was no documentation of the completion of the HIV/AIDS training as of the date of the inspection.This is a repeat citation from the September 19, 2023 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff member #3 completed HIV/AIDS training on September 12, 2024. The certificate has been placed in the personnel chart.
This plan aims to prevent future deficiencies by ensuring that all staff are current with their training. The Program Director will oversee this process, and if training sessions are unavailable, staff members will keep track of upcoming training dates and inform the Director about the next available sessions. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, the facility failed to ensure that there were a sufficient number of staff persons, who were CPR certified and first aid trained, onsite during the facility's hours of operation. The facility's posted hours of operation are Monday, Wednesday, Thursday, and Friday from 9:00AM to 5:00PM and Tuesday from 9:00AM to 7:00PM. Documentation was provided indicating that only one employee, who works 6 hours per week at the facility, was the only employee with a CPR certification and first aid training from November 8, 2023 through August 28, 2024.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director, along with the evening therapist, is in the process of registering him for CPR and First Aid Training, which is scheduled for completion by October 31, 2024. The Program Director will ensure that copies of the certification are included in the personnel file.
Clinical Supervisors will ensure that at least one staff member in the morning and one staff member in the evening possess CPR and First Aid training to improve the likelihood of this occurring in the future.
Staff has been schedule for CPR and will have it completed by 10/31/2024 |
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 personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of training annually during the facility's June 1, 2023 through July 31, 2024 training year. Employee #3 was hired as a counselor on March 16, 2022. The personnel record documented 24 hours of annual training during the reviewed period.This is a repeat citation from the September 19, 2023 annual licensing renewal inspection.This finding was reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Program Supervisor has facilitated Staff #3's registration on 10/17/2024 for core training. It is essential that this training commence no later than January 5, 2025, in order to ensure compliance with DDAP regulations.
The Program Supervisor has developed a comprehensive training plan aimed at addressing and preventing any deficiencies in our operations moving forward. To facilitate this, all staff members have been given access to an online training platform specifically designed for their professional development. It is imperative that each staff member communicates their scheduled training dates and times to the Clinical Supervisor to ensure proper tracking and accountability. This approach aims to enhance skills and foster a culture of continuous improvement within the team. |
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 Requirement Facility Summary Report, the facility failed to ensure the Full Time Equivalent (FTE) counselor caseload for counseling in outpatient programs did not exceed 35 active clients.The counselor FTE is determined by dividing the total number of hours the counselor devotes to their clients by the facility's standard workweek hours. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the counselor FTE.Employee #2 was hired as a clinical supervisor on October 24, 2023. The counselor's ratio calculation was as follows: 10/37.50=.266 (FTE); 10/.266=37.59, which equals an FTE ratio of 37:1.Employee #3 was hired as a counselor on March 16, 2022. The counselor's ratio calculation was as follows: 11/37.50=.2933 (FTE); 11/.2933=37.50, which equals an FTE ratio of 37:1.Employee #4 was hired as a counselor on August 11, 2023. The counselor's ratio calculation was as follows: 12/37.50=.32 (FTE); 12/.32=37.50, which equals an FTE ratio of 37:1.Employee #5 was hired as a counselor on November 8, 223. The counselor's ratio calculation was as follows: 4/37.50=.1066 (FTE); 4/.1066=37.52, which equals an FTE ratio of 37:1.Employee #6 was hired as a counselor on June 28, 2024. The counselor's ratio calculation was as follows: 8/37.50=.2133 (FTE); 8/.2133=37.50, which equals an FTE ratio of 37:1.Employee #7 was hired as a counselor assistant on July 26, 2024. The counselor's ratio calculation was as follows: 11/37.50=.2933 (FTE); 11/.2933=37.50, which equals an FTE ratio of 37:1.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program is in the process of hiring new staff to provide additional services. This will help ensure that staff members do not exceed the client limits set by regulations. The Director will ensure that all staff caseloads comply with DDAP regulations. Additionally, the Program Director will review caseloads on a weekly basis.
This plan has been corrected as of 10/17/2024 |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of fire extinguishers upon staff employment in one of five applicable personnel records reviewed. Employee #7 was hired as a counselor on July 26, 2024. There was no documentation indicating the fire extinguisher training was provided to the employee as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director has integrated fire extinguisher training into the onboarding process to guarantee that all new staff members receive this essential training prior to their first day of employment. Furthermore, the Program Director will conduct a thorough review of all onboarding documentation to ensure that the necessary training and certificate is completed in accordance with DDAP regulations.
This plan has been corrected as of 10/17/2024 |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in five of six applicable personnel records reviewed. Employee #3 was hired as a counselor on March 16, 2022. There was no documentation indicating the emergency preparedness training was provided as of the date of the inspection.Employee #4 was hired as a counselor on August 11, 2023. There was no documentation indicating the emergency preparedness training was provided as of the date of the inspection.Employee #5 was hired as a counselor on November 8, 2023. There was no documentation indicating the emergency preparedness training was provided as of the date of the inspection.Employee #6 was hired as a counselor on June 28, 2024. There was no documentation indicating the emergency preparedness training was provided as of the date of the inspection.Employee #7 was hired as a counselor assistant on July 26, 2024. There was no documentation indicating the emergency preparedness training was provided as of the date of the inspection.This is a repeat citation from the October 13, 2022 and the September 19, 2023 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of October 3, 2024, all current staff have completed training on emergency preparedness. The Program Director has made this training a requirement for onboarding new employees. The Program Director will review all onboarding documentation to ensure that the emergency preparedness training has been completed, signed off, and that certificates have been provided. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's September 2023 through July 2024 fire drill log, the facility failed to set off a fire alarm or smoke detector during each fire drill conducted during the reviewed period.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective October 3, 2024, the CEO has established a Fire Drill Log designed to systematically record the specific date and time of each fire drill conducted within the facility. The Fire Captain will take charge of pulling the fire alarm during the drill and will meticulously document the precise time it is activated. To maintain adherence to DDAP regulations, the Program Director is tasked with reviewing this log on a monthly basis, ensuring that all drills are conducted regularly and that compliance standards are consistently met. This log will also help identify any potential areas for improvement in our fire safety procedures. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in two of three applicable client records reviewed.The policy and procedure manual stated the aftercare plans will be completed prior to discharge for individuals that complete treatment.Client #1 was admitted on February 1, 2024 and was discharged successfully on April 12, 2024. The aftercare plan was due prior to the discharge; however, the plan was completed on April 15, 2024, after the client was discharged.Client #3 was admitted on December 15, 2024 and was discharged successfully on May 31, 2024. The aftercare plan was due prior to discharge; however, the plan was completed on June 17, 2024, after the client was discharged.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director is collaborating with our Electronic Health Record (EHR) system to create a separate aftercare form, which will be completed 1 to 2 weeks before the discharge form. The Program Supervisor will oversee all discharge processes to ensure that aftercare plans are completed within the same 1 to 2-week timeframe before discharge. |
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 obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.Client #2 was admitted on April 2, 2024 and was discharged on July 31, 2024. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures. This is a repeat citation from the September 19, 2023 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of October 4, 2024, the Program Director is collaborating with the EHR team to develop a release for additional funding sources. The intake counselor will ensure that all necessary documentation is completed in compliance with DDAP regulations. Additionally, the Clinical Supervisor will conduct weekly reviews of charts to verify that documentation is complete. |
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 document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in one of seven client records reviewed.Client #6 was admitted on January 26, 2024 and was active at the time of the inspection. A release of information form to an outside individual was signed and dated by the client on January 26, 2024; however, the complete name of the person was not documented on the release form. Additionally, a release of information form to another outside individual was signed and dated by the client on February 26, 2024; however, the complete name of the person was not documented on the release form.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director has communicated to the Intake team that it is essential to complete all fields in the intake forms thoroughly. This directive is crucial for maintaining accurate records and ensuring that all necessary information is collected. To support this process, the Clinical Supervisor will conduct weekly chart audits to verify that the intake forms are filled out correctly and completely. Any discrepancies or incomplete information will be addressed promptly to uphold our standards of care. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be released on consent to release information forms in three of seven client records reviewed. Client #3 was admitted on December 15, 2023 and was discharged on May 31, 2024. There were release of information forms to a urinalysis laboratory and an emergency contact that were signed and dated by the client on December 15, 2023; however, the specific information to be disclosed was not included on both release forms. Client #4 was admitted on December 8, 2023 and was discharged on July 30, 2024. There was a release of information form to a urinalysis laboratory that was signed and dated by the client on December 8, 2023; however, the specific information to be disclosed was not included on the release form. Client #7 was admitted on December 28, 2023 and was active at the time of the inspection. There were release of information forms to a urinalysis laboratory and an emergency contact that were signed and dated by the client on December 28, 2023; however, the specific information to be disclosed was not included on both release forms. This is a repeat citation from the September 19, 2023 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/17/2024, The Program Director has collaborated with the EHR team to update the release of information forms, ensuring they clearly specify what information will be disclosed. The Clinical Supervisor will verify that the forms are fully completed during the weekly chart audits. The Program Director has reiterated this ongoing issue to all staff during the staff meetings. |
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 the purpose of the disclosure on consent to release information forms in six of seven client records reviewed. Client #1 was admitted on February 1, 2024 and was discharged on April 12, 2024. There were release of information forms to a urinalysis laboratory and an outside individual signed and dated by the client on February 1, 2024; however, the purpose of the disclosure was not included on both release forms. Client #2 was admitted on April 2, 2024 and was discharged on July 31, 2024. There were release of information forms to a urinalysis laboratory, a probation and parole office, and an emergency contact signed and dated by the client on April 2, 2024; however, the purpose of the disclosure was not included on any of the release forms. Client #4 was admitted on December 8, 2023 and was discharged on July 30, 2024. There was a release of information form to a probation and parole office signed and dated by the client on December 8, 2023; however, the purpose of the disclosure was not included on the release form. Client #5 was admitted on April 26, 2024 and was active at the time of the inspection. There were release of information forms to a urinalysis laboratory, a probation and parole office, a funding source, and an emergency contact that were signed and dated by the client on April 26, 2024; however, the purpose of the disclosure was not included on any of the release forms. Client #6 was admitted on January 26, 2024 and was active at the time of the inspection. There was a release of information form to an outside individual signed and dated by the client on January 26, 2024; however, the purpose of the disclosure was not included on the release form. Additionally, there was a release of information form to an outside individual signed and dated by the client on February 1, 2024; however, the purpose of the disclosure was not included on the release form. Also, there were release of information forms to a funding source and a urinalysis laboratory signed and dated by a witness/staff on January 26, 2024; however, the purpose of the disclosure was not included on both release forms.Client #7 was admitted on December 28, 2023 and was active at the time of the inspection. There were release of information forms to an emergency contact and a probation and parole office signed and dated by the client on December 28, 2023; however, the purpose of the disclosure was not included on both release forms.This is a repeat citation from the September 19, 2023 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of October 5, 2024, the Program Director has successfully worked with the Electronic Health Record (EHR) system to implement a requirement that clearly states the purpose of disclosure for all releases of information. This enhancement aims to improve transparency and compliance with regulatory standards. To ensure that this new procedure is being consistently applied, the Clinical Supervisor will perform weekly chart audits. These audits will review a sample of records to verify that the purpose of disclosure is documented appropriately and that all staff are adhering to the updated protocol. |
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 the dated signature of the client on release of information forms in one of seven client records reviewed. Client #6 was admitted on January 26, 2024 and was active at the time of the inspection. There were release of information forms to a funding source and a urinalysis laboratory signed and dated by a witness/staff on January 26, 2024; however, the dated signature of the client was not included on both release forms. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On October 17, 2024, the Program Director reiterated to the Clinical Supervisor the importance of conducting weekly chart audits. These audits are meant to verify that all releases of information have been properly signed. The goal is to identify any missing signatures and address any deficiencies promptly. This process will help maintain compliance and protect patient confidentiality. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a recordkeeping system that allows for the identification of client's admissions and discharges within a specific time period.Per a discussion with facility staff and a review of the client lists provided, the facility was unable to accurately identify the discharge dates of the clients who were discharged since the previous licensing inspection. Facility staff reported the "discharge" date listed on the client lists is when the record is closed out of their system by facility staff and not the client's discharge date from the program. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director convened a meeting with all staff members to emphasize the significance of accurately documenting discharge dates within our electronic health record (EHR). Effective immediately, all staff are required to close clients' charts on the actual date of discharge, thereby ensuring that the EHR report reflects the correct information.
Additionally, the Clinical Supervisor will verify adherence to this protocol during the weekly chart audits, thereby ensuring that the process is consistently implemented. This initiative aims to enhance the accuracy of our records and improve the overall quality of care delivered to our clients. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on review of the facility's unusual incident report logs, the facility failed to notify the Department within 3 business days following an unusual incident involving a death or serious injury to due trauma, suicide, medication error or unusual circumstances. On July 30, 2024, the facility was notified of the off-site death of an active client; however, the incident was not reported to the Department as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/15/2024, during the All-Staff meeting, the Program Director discussed strategies to reduce the likelihood of future deficiencies. Staff has been provided with the DDAP website to report all incidents.
The program encountered a severe oversight by failing to notify the necessary authorities regarding an unusual incident involving a client's death. This failure stemmed from a lack of clarity in understanding the incident report process. In response to this issue, the Program Director has emphasized to all staff the critical importance of promptly reporting any client deaths, regardless of whether these tragic events occur while the client is undergoing treatment at our facility or in their own home. This initiative aims to ensure that all incidents are properly documented and addressed, reinforcing our commitment to transparency and care. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document the short and long-term goals for treatment, as formulated by both staff and client, on the client's individual treatment and rehabilitation plan in seven of seven client records reviewed.In each client record reviewed, there were no long-term goals documented on the individual treatment and rehabilitation plans. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of October 3, 2024, the Program Director and the Electronic Health Record (EHR) system have integrated long-term goals into all treatment plans. This initiative aims to address the identified deficiency and ensure compliance with the regulations established by the Department of Drug and Alcohol Programs (DDAP). The Clinical Supervisor will oversee the implementation of all long-term treatment plan goals during weekly chart audits. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of six applicable client records reviewed.Client #5 was admitted on April 26, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 20, 2024 and the first update was due no later than July 20, 2024; however, the update was completed on August 5, 2024.Client #6 was admitted on January 26, 2024 and was active at the time of the inspection. A treatment plan update was completed on April 26, 2024, and the next update was due no later than June 26, 2024; however, the update was completed on July 2, 2024.Client #7 was admitted on December 28, 2023 and was active at the time of the inspection. A treatment plan update was completed on May 17, 2024, and the next update was due no later than July 17, 2024; however, the update was completed on August 6, 2024.This is a repeat citation from the September 19, 2023 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/15/2024, During the all-staff meeting, the Program Director conveyed to the staff the importance of completing treatment plans in a timely manner. Should timely completion prove unfeasible, it is essential to document the reasons for the delay. Furthermore, the Clinical Supervisor will perform weekly chart audits to ensure that this deficiency is addressed effectively. |
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 maintain a complete client record, which is to include the documentation of follow-up information, in two of three applicable client records reviewed.Client #1 was admitted February 1, 2024 and was discharged on April 12, 2024. There was no documentation of follow-up information in the record as of the date of the inspection.Client #2 was admitted April 2, 2024 and was discharged on July 31, 2024. There was no documentation of follow-up information in the record as of the date of the inspection.This is a repeat citation from the October 13, 2022 and the September 19, 2023 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 10/05/2024, the program has appointed one counselor to conduct all 30-day and 90-day follow-up calls. The Clinical Supervisor will oversee the timely completion of these follow-ups by conducting weekly chart audits. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license 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 completing treatment plan updates within the regulatory timeframe was submitted and approved by the Department for the October 22, 2022 and September 19, 2023 annual licensing inspections. Failing to complete treatment plan updates within the regulatory timeframe was again found to be a deficiency in the September 19, 2024 annual licensing inspection.A plan of correction for documenting follow-up information in the client record was submitted and approved by the Department for the October 22, 2022 and September 19, 2023 annual licensing inspections. Failing to document follow-up information was again found to be a deficiency in the September 19, 2024 annual licensing inspection.A plan of correction for providing emergency preparedness training to all staff was submitted and approved by the Department for the October 22, 2022 and September 19, 2023 annual licensing inspections. Failing to provide emergency preparedness training to all staff was again found to be a deficiency in the September 19, 2024, annual licensing inspection.These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Clinical Supervisor will monitor approved plans through alerts in EHR for all treatment plans which will not allow clinicians to move forward without completion.
Clinical Supervisor has been provided the task of completing all follow ups. If Clinical Supervisor is out or unable to complete, the Program Director will complete follow ups.
All staff have been provided emergency preparedness training and provided a certificate of completion for personnel chart. All new hires will be required to complete training within one week of hire.
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