INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 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, ADAPPT Counseling Treatment Services 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 the review of personnel records, the project failed to document a written initial individual training plan for each employee, appropriate to that employee's skill level with input from both the employee and the supervisor in one out of four records reviewed.
Employee #4 was hired on March 4, 2024, and was to have an initial individual training plan documented by April 4, 2024; however, there was no training plan documented in the personnel record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project and Facility Director shall add to all annual training plans, the development of an initial individual training plan for all new employees, that will be appropriate to the new hire's skill level with input from the new hire and the supervisor. A record of the plan shall be maintained in the new hire's employment file. Project Director shall review the new hire's plan within the first 30 days of employment to ensure compliance. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the review of the fire drill log from February 2024 through November 2024, the facility failed to maintain written fire drill records that indicated whether the fire alarm or smoke detector was operative.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project and Facility Director shall develop a method to test fire alarms monthly and record findings on the fire drill record. Alarm testing and records will begin by 1/24/25 and be completed by the Facility Director. The Project Director shall review Fire Drill records monthly to ensure compliance. Fire alarm testing and recording shall begin no later than 1/24/25. |
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 the review of the fire drill log from February 2024 through November 2024, the facility failed to set off a fire alarm or smoke detector during each fire drill.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project and Facility Director shall set off either the fire alarms or smoke detector during each fire drill and record use of fire alarm or smoke detector in the fire drill record. The Project Director shall review Fire Drill records monthly to ensure compliance. Fire alarm or other method during each drill shall begin no later than 1/24/25. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the project ' s policies and procedures, the project failed to document a completed psychosocial evaluation within 30-days in five of seven client records reviewed.
Client #3 was admitted on October 1, 2024, and was a current client at the time of the licensing inspection. The psychosocial evaluation was not documented in the client ' s record.
Client #4 was admitted on March 20, 2024, and was discharged on September 20, 2024. The psychosocial evaluation was not documented in the client ' s record.
Client #5 was admitted on April 25, 2024, and was discharged on October 29, 2024. The psychosocial evaluation was not documented in the client ' s record.
Client #6 was admitted on May 9, 2024, and was discharged on November 8, 2024. The psychosocial evaluation was not documented in the client ' s record.
Client #7 was admitted on June 11, 2024, and was discharged on December 12, 2024. The psychosocial evaluation was not documented in the client ' s record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director shall retrain all personnel of the requirement to complete the psychosocial evaluation within 30-days of service and retain in client records. The Facility Director shall review case files monthly to ensure psychosocial evaluation is completed as required. The Facility Director shall review all active files for completed psychosocial evaluation is present. New training and review shall be completed by 1/24/2025. |
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 and the project ' s policies and procedures, the project failed to document a preliminary treatment plan during intake in six of seven client records reviewed.
Client #1 was admitted on August 19, 2024 and was a current client at the time of the licensing inspection. A preliminary treatment plan was not documented in the client record.
Client #2 was admitted on July 15, 2024 and was a current client at the time of the licensing inspection. A preliminary treatment plan was not documented in the client record.
Client #4 was admitted on March 20, 2024, and was discharged on September 20, 2024. A preliminary treatment plan was not documented in the client record.
Client #5 was admitted on April 25, 2024, and was discharged on October 29, 2024. A preliminary treatment plan was not documented in the client record.
Client #6 was admitted on May 9, 2024, and was discharged on November 8, 2024. A preliminary treatment plan was not documented in the client record.
Client #7 was admitted on June 11, 2024, and was discharged on December 12, 2024. A preliminary treatment plan was not documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director shall retrain all personnel of the requirement to complete the preliminary treatment plan during intake and retain in client records. The Facility Director shall review case files monthly to ensure preliminary treatment plan is completed as required. The Facility Director shall review all active files for a completed preliminary treatment plan and that it was completed at intake. New training and review shall be completed by 1/24/2025. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in four of seven client records reviewed.
Client #2 was admitted on July 15, 2024 and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on August 24, 2024, indicated that the client was to receive two group counseling session per week; however, there was only one group counseling session documented in the client record for the weeks of August 11, 2024 through August 17, 2024, August 18, 2024 through August 24, 2024, October 6, 2024 through October 12, 2024, November 17, 2024 through November 23, 2024 and November 24, 2024 through November 30, 2024.
Client #4 was admitted on March 20, 2024, and was discharged on September 20, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on April 20, 2024, indicated that the client was to receive one individual counseling session and two group counseling session per week; however, there were no individual counseling session documented in the client record for the weeks of April 28, 2024 through May 4, 2024, June 2, 2024 through June 8, 2024, July 21, 2024 through July 27, 2024, July 28, 2024 though August 3, 2024, August 25, 2024 through August 31, 2024 and September 1, 2024 through September 7, 2024. Additionally, there were no group sessions documented the weeks of July 21, 2024 through July 27, 2024 and July 28, 2024 through August 3, 2024.
Client #6 was admitted on May 9, 2024, and was discharged on November 8, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on May 16, 2024, indicated that the client was to receive one individual counseling session and two group counseling session per week; however, there were no individual counseling session documented in the client record for the weeks of June 2, 2024 through June 8, 2024, June 9, 2024 through June 15, 2024, June 30, 2024 through July 6, 2024, August 11, 2024 through August 17, 2024, August 25, 2024 through August 31, 2024, September 29, 2024 though October 5, 2024 and October 20, 2024 through October 26, 2024. Additionally, there were no group sessions documented for the weeks of September 29, 2024 through October 5, 2024 and October 27, 2024 through November 2, 2024.
Client #7 was admitted on June 11, 2024, and was discharged on July 11, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on May 16, 2024, indicated that the client was to receive one individual counseling session and two group counseling session per week; however, there were no individual counseling session documented in the client record for the weeks of June 23, 2024 through June 29, 2024, June 30, 2024 through July 6, 2024, November 17, 2024 through November 23, 2024 and November 24, 2024 through November 30, 2024. Additionally, there were no group sessions documented for the weeks of June 30, 2024 through July 6, 2024, August 18, 2024 through August 24, 2024, August 25, 2024 through August 31, 2024, September 22, 2024 through September 28, 2024, November 10, 2024 through November 16, 2024 and November 17, 2024 through November 23, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Facility Director shall review all individual treatment plans to ensure clients are receiving counseling services as indicated in the record of services. Facility Director shall retrain staff on individual treatment plans and services. Facility Director shall review treatment plans and records of services on bi-weekly basis. This shall occur by 1/24/25 |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the review of outpatient client records, the project failed to document a complete client record on an individual that included progress notes documenting information related to each dated individual counseling session in three of seven client records reviewed.
Client #4 was admitted on March 20, 2024, and was discharged on September 20, 2024. Progress notes documented in the record did not provide details of each individual session. The progress notes were duplicated identically for the following dates: March 21, 2024, April 2, 2024, April 9, 2024, April 23, 2024, May 7, 2024, May 14, 2024, May 21, 2024, June 25, 2024, July 2, 2024, August 8, 2024. August 15, 2024 and September 12, 2024.
Client #6 was admitted on May 9, 2024, and was discharged on November 8, 2024. Progress notes documented in the record did not provide details of each individual session. The progress notes were duplicated identically for the following dates: May 23, 2024, June 20, 2024, June 27, 2024, July 11, 2024, July 18, 2024, September 5, 2024, September 12, 2024, September 19, 2024 and September 26, 2024.
Client #7 was admitted on June 11, 2024, and was discharged on July 11, 2024. Progress notes documented in the record did not provide details of each individual session. The progress notes were duplicated identically for the following dates: September 3, 2024, September 10, 2024, September 24, 2024, October 1, 2024, October 8, 2024 and October 15, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director shall retrain all personnel on unique individual progress notes related to counseling sessions. The Facility Director shall review case files monthly to ensure progress notes are completed for all counseling sessions and that the documentation is unique to the treatment event. Training on documenting individual counseling sessions training shall be completed by 1/24/2025. Files reviews by Facility Director shall begin one week after the training. |