INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, KARE Services, LLC dba Kolmac Outpatient Recovery, 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 the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document written individual training plans that are appropriate to the employee ' s skill level and developed annually with input from both the employee and the supervisor for each employee in one of five personnel reviewed.
Employee #5 was hired as the Office Manager on November 11, 2019.
This is a repeat citation from the September 8, 2021 and the July 24, 2020 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will ensure that all PA employees have a training plan created at the beginning of each year, which will be reviewed and updated as trainings are completed. Employees and supervisors will forward all training plans and records to HR to maintain.
Director of Quality Assurance has primary responsibility for this. |
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 and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics trainings within the regulatory time frame in one of one applicable personnel record reviewed.
Employee #3 was hired as a counselor on October 5, 2020. The HIV/AIDS and TB/STD trainings were due no later than October 5, 2021; however, both trainings were not completed at the time of inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As an update to our policies and procedures, Kolmac will inform new hires of the training requirement and will provide them resources and time needed to complete the trainings.
The CCO will audit these employee files each quarter to assure that all clinicians have the necessary training to satisfy DDAP regulations.
Director of Quality Assurance will have primary responsibility. |
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 and the Staffing Requirements Facility Summary Report, the facility failed to ensure that each counselor completed at least 25 hours of training annually in one of one applicable personnel record reviewed.
Employee # 3 was hired on February 10, 2020. The personnel record documented 18.5 hours of annual training for the facility ' s January 2021 through December 2021 training year.
This is a repeat citation from the September 8, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning in October 2022, Kolmac is implementing quarterly performance reviews of all FT employees, to include updates on completing targets for individual training plans. This quarterly review will ensure that each employee is working towards completing the necessary numbers of annual training for each year.
Chief Clinical Officer has primary responsibility for this implementation. |
709.26 (c) LICENSURE Personnel management.
§ 709.26. Personnel management.
(c) There shall be written job descriptions for project positions.
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Observations
Based on a review of the policy & procedure manual and personnel records, the facility failed to have written job descriptions for all project positions.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will collect signed job descriptions from all current staff to be maintained in their employee file. We will add a section to our new hire onboarding that will require each new hire to carefully review their job description and to sign off on it, acknowledging their understanding of their duties and responsibilities.
VP of HR and Director of Quality Assurance have primary responsibility. |
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 disclosed on consent to release information forms in two of seven client records reviewed.
Client #3 was admitted December 13, 2021 and was active at the time of inspection. The release of information form to the funding source was signed and dated by the client and witness on December 13, 2021, but the release form did not include the specific information to be released.
Client #6 was admitted February 1, 2022 and was discharged August 3, 2022. The release of information form to the funding source and a government agency was signed and dated by the client and witness on February 1, 2021, but the release form did not include the specific information to be released.
This is a repeat citation from the September 8, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Kolmac has reviewed and updated all releases of information in our new EMR, Credible. In all cases, the releases now include purpose of the release, specific information to be released, acknowledgment that the patient has access to a copy of the release, and that the release can be revoked verbally or in writing. The expiration date section was also updated.
Chief Clinical Officer implemented this and is responsible for this corrective action. The release of information that was in our EMR has been replaced with our updated ROI. Quarterly chart updates will take place to ensure compliance. |
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 client records, the facility failed to document the purpose of the disclosure on release of information forms in one of seven client records reviewed.
Client #3 was admitted December 13, 2021 and was active at the time of inspection. The release of information form to a funding source was signed and dated by the client on December 13, 2021, but the release form did not include the purpose of the disclosure.
This is a repeat citation from the September 8, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Kolmac has reviewed and updated all releases of information in our new EMR, Credible. In all cases, the releases now include purpose of the release, specific information to be released, acknowledgment that the patient has access to a copy of the release, and that the release can be revoked verbally or in writing. The expiration date section was also updated.
Chief Clinical Officer implemented this and is responsible for this corrective action. The release of information that was in our EMR has been replaced with our updated ROI. Quarterly chart updates will take place to ensure compliance |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of consent to release information forms were offered to the client in four of seven client records reviewed.
Client #1 was admitted October 13, 2021 and was active at the time of inspection. Release of information forms to the funding source and the emergency contact, were signed and dated by the client on October 13, 2021; however, there was no documentation that a copy of either form was offered to the client.
Client #4 was admitted January 7, 2022 and was discharged August 12, 2022. A release of information form to a medical provider was signed and dated by the client on January 7, 2022; however, there was no documentation that a copy of the form was offered to the client.
Client #6 was admitted February 1, 2022 and was discharged August 3, 2022. A release of information form to a government agency was signed and dated by the client on February 1, 2022; however, there was no documentation that a copy of the form was offered to the client.
Client # 7 was admitted July 14, 2021 and was discharged June 7, 2022. A release of information form to an emergency contact was signed and dated by the client on July 14, 2021; however, there was no documentation that a copy of the form was offered to the client.
This is a repeat citation from the September 8, 2021 annual licensing renewal inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Kolmac has reviewed and updated all releases of information in our new EMR, Credible. In all cases, the releases now include purpose of the release, specific information to be released, acknowledgment that the patient has access to a copy of the release, and that the release can be revoked verbally or in writing. The expiration date section was also updated.
Chief Clinical Officer implemented this and is responsible for this corrective action. The release of information that was in our EMR has been replaced with our updated ROI. Quarterly chart updates will take place to ensure compliance |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review, the facility failed to maintain a data collection system that allows for the efficient retrieval of data needed to measure the project's performance.
The facility was unable to produce client records in an efficient manner after the DDAP representative requested them. The facility took approximately two and a half hours to provide all the client records requested.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac has implemented the EMR, "Credible", as a reliable data collection system for all patient information. The delay in producing an active and discharge list during out audit was a result of user error and not the limitations of the system itself. The CEO and COO were notified of this delay and the impact it had on the ability of DDAP's auditing body to start and progress efficiently through the audit. To ensure this does not happen again in the future, Kolmac will ensure that those responsible for compliance items and leading audits are effectively trained on how to pull patient lists from Credible.
The Director of Quality Assurance will be responsible for making sure data is prepared on time for any future 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 plans were reviewed and updated at least every 60 days in five of seven records reviewed.
Client #1 was admitted October 13, 2021 and was active at the time of inspection. A treatment plan update was completed on March 31, 2022 and the next update was due no later than May 31, 2022. However, the treatment plan update was not completed until June 21, 2022.
Client #3 was admitted December 13, 2021 and was active at the time of inspection. A treatment plan update was completed on May 25, 2022 and the next update was due no later than July 25, 2022. However, the treatment plan update was not completed at the time of inspection.
Client #4 was admitted January 7, 2022 and was discharged August 12, 2022. The comprehensive treatment plan was completed on January 13, 2022 and an update was due no later than March 13, 2022. However, the treatment plan update was not completed until May 2, 2022.
Client #6 was admitted February 1, 2022 and was discharged August 3, 2022. The comprehensive treatment plan was completed on February 13, 2022 and an update was due no later than April 13, 2022. However, the treatment plan update was not completed at the time of inspection.
Client #7 was admitted July 14, 2021 and was discharged June 7, 2022. A treatment plan update was completed on October 28, 2021 and the next update was due no later than December 28, 2021. However, the treatment plan update was not completed at the time of inspection.
The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
As a result of this audit, Kolmac facilitated two weeks of "Back to Basics" training on creating treatment planning with patients, and updating treatment plan goals (on 8/31/2022 and 9/7/2022). The entire Kolmac clinical staff attended and were broken up into smaller groups to create treatment plans and address the frequency of update (every 60 days in OP). The teams were reminded that if the patient continued to miss these sessions, this should be noted in individual notes specific to the treatment plan updates.
Kolmac is also implementing a required supervision section to the treatment plans, regardless of the clinician's license, which will result in added quality assurance checks on treatment plans. The Chief Clinical Officer has primary responsibility for this task. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include case consultation notes, in every client record reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac has created a new form called "clinical staffing" which will now be applied to all patient cases. For IOP, all patients will have clinical staffing once/month, or unless there is a clinical need for additional staffing. For OP, all patients will have clinical staffing once every 60 days, or unless there is a clinical need for additional staffing. The Chief Clinical Officer is responsible for carrying out this new process.
Additionally, treatment team is held each week and notes on treatment team and cases discussed will be documented in a "treatment team" notes within our EMR. |
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 document a complete client record, which is to include follow-up information, in two of two applicable records reviewed.
Client # 6 was admitted February 1, 2022 and was discharged August 3, 2022.
Client # 7 was admitted July 14, 2021 and was discharged June 7, 2022.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Kolmac will provide a training to all clinical staff at our Pennsylvania office, facilitated by the CCO, to cover discharge planning. This will involve a review of our discharge summary and note the importance/requirement of included follow up appointment details for any follow up information. This will be completed by September 30, 2022.
Quarterly chart reviews will be implemented to ensure discharge planning is thorough, including follow up information. The Chief Clinical Officer is responsible for this. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection conducted at approximately 10:00 am, the facility failed to have the project ' s hours of operation displayed conspicuously to the general public.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Hours of operations and emergency contact information have been posted on our front windows where it is readily available to all patients and staff.
Quarterly site inspections will take place to ensure the hours of operations and emergency contact info are displayed conspicuously to the general public. The Director of Quality Assurance is responsible for this. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection conducted at approximately 10:00 am, the facility failed to have an emergency telephone number displayed conspicuously to the general public.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Hours of operations and emergency contact information have been posted on our front windows where it is readily available to all patients and staff.
Quarterly site inspections will take place to ensure the hours of operations and emergency contact info are displayed conspicuously to the general public. The Director of Quality Assurance is responsible for this. |
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 the Staffing Requirements Facility Summary Report and personnel records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for having individual training plans completed for each employee were submitted and approved by the Department for the July 24, 2020 and September 8, 2021 annual licensing inspections. Ensuring that each employee received an individual training plan was again found to be a deficiency in the August 15, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will require each new employee to create an individual training plan during onboarding, and HR will now maintain records for training plans each year for active employees.
Additionally, Kolmac will implement quarterly reviews of all employee records to confirm all training is being completed as per the timeline and goals set for the in employee training plan. The Director of Quality Assurance has primary responsibility for this. |