INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 24, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of two applicable personnel records, the facility failed to provide a mechanism to provide feedback on a completed training in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated that staff are to complete the conference report section on the Conference Request Form within five working days after their training. Staff #2 was hired on November 2, 2019, has been in the role of facility director since November 1, 2021, and was still in this position at the time of inspection. The facility was unable to provide feedback collected from trainings Staff #2 had participated in.Staff #7 was hired on June 14, 2021 and was still in this position at the time of inspection. The facility was unable to provide feedback collected from trainings Staff #7 had participated in.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Training feedback will become part of the overall training plan for the year. This section will be added where staff will provide feedback on completed training. Facility Director will monitor completion of training feedback annually. |
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 review of The Staffing Requirements Facility Summary Report, the FTE counselor caseload for two staff members in the outpatient program exceeded 35 active clients.
Staff #3 was hired as a counselor on September 27, 2022 and was still in this position at the time of the inspection. Staff #3 was reported to have 20 hours per week devoted to their 18 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 20/40 = .5(FTE); 18/.5 = 36, which equals to a client/counselor ratio of 36:1.
Staff #7 was hired as a counselor on June 24, 2021 and was still in this position at the time of the inspection. Staff #7 was reported to have 28 hours per week devoted to their 26 clients on their caseload.The FTE counselor's caseload calculation is as follows: 28/40=.7(FTE); 26/.7=37.14, which equals to a client/counselor ration of 37:1.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facilities hours of operation 40. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will monitor counselor caseloads on a weekly basis insuring FTE do not exceed 35 clients. The whiteboard in the clerical department will be utilized to update clinician's caseload on a weekly basis. Facility Director will assign cases to counselors according to clinician's caseload to remain in compliance with 704.12(a)(6) Licensure. |
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 provide documentation of all staff being instructed on the use of the fire extinguisher upon employment.
Staff #3 was hired as a counselor on September 27, 2022 and was still in this position at the time of the inspection. There was no documentation of fire extinguisher training.
Staff #5 was hired as a counselor on September 8, 2022 and was still in this position at the time of the inspection. There was no documentation of fire extinguisher training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the orientation process, new staff will complete the fire extinguisher training and it will be documented in the Learning management system database. Facility Director will coordinate training with HR department upon hire. |
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 a review of personnel records, the facility failed to provide documentation of all staff being trained to perform assigned tasks during emergencies upon employment.
Staff #3 was hired as a counselor on September 27, 2022 and was still in this position at the time of the inspection. There was no documentation of emergency training.
Staff #5 was hired as a counselor on September 8, 2022 and was still in this position at the time of the inspection. There was no documentation of emergency training.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
During the orientation process, new staff will complete the fire extinguisher training and it will be documented in the Learning management system database. Facility Director will coordinate training with HR department upon hire. |
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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client record #1.
Client #1 was admitted on May 16, 2022 and was still active at the time of the inspection. A review of client records indicated that a written disclosure summarizing the client's admission into treatment was sent to an outside agency. The client record did not contain an informed and voluntary consent from the client for disclosure of the information.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Policy statement: Community Counseling Center will follow 42 CFR, Part 2 (Federal regulation) with regard to retention and release of information about current, past, or future clients.
The findings were reviewed with the facility staff during the licensing process, however Facility Director reviewed chart and found proper consent in client's chart.
Facility Director will review all findings before the end of the DDAP audit and review with auditor upon exit.
Facility Director will review confidentiality policy with clinicians during D&A treatment team once a month. Any documentation that needs to be released to an external provider will go through the Clinical Administrator who will check client's chart for consents before releasing information.
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709.92(a) 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:
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Observations
Based on three of seven client records reviewed, the facility failed to provide an initial comprehensive treatment and rehabilitation plan in accordance with the facility policy and procedure manual. The project policy and procedure manual indicated an initial comprehensive treatment and rehabilitation plan be completed within thirty days of intake.Client #2 was admitted on October 7, 2022 and was still active at the time of the inspection. An initial comprehensive treatment plan was due no later than November 7, 2022, however this was not completed until December 20, 2022.Client #3 was admitted on May 12, 2022 and was still active at the time of the inspection. An initial comprehensive treatment plan was due no later than June 12, 2022, however this was not completed until June 21, 2022.Client #5 was admitted on September 12, 2022 and discharged on December 14, 2022. An initial comprehensive treatment plan was due no later than October 12, 2022, however this was not completed until November 3, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Treatment and Rehabilitation Services
Initial Comprehensive treatment plan
Community Counseling policy states that each client who continues to receive clinical services beyond the initial evaluation will have an electronic Comprehensive Treatment plan developed within 30 days of intake.
IT Staff will create a data base report alerting clinicians that their client's initial comprehensive treatment plans are due 10 days before treatment plan is due in 30 days. The report will be sent out to the primary clinician of the client and Facility Director. The Facility Director will monitor the data base on a weekly basis. During the Drug & Alcohol weekly meeting and individual supervision, treatment plan report will be reviewed with D&A staff to insure clinicians are following the initial Comprehensive treatment plan policy.
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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 five of seven applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records #1, #2, #3, #6, and #7.Client #1 was admitted on May 16, 2022 and was still active at the time of the inspection. A treatment plan was developed on June 10, 2022. A treatment and rehabilitation plan update was due no later than August 10, 2022, however this was not completed until August 18, 2022. Client #2 was admitted on October 7, 2022 and was still active at the time of the inspection. A treatment plan was developed on October 25, 2022. A treatment and rehabilitation plan update was due no later December 25, 2022, however this was not completed until December 30, 2022.Client #3 was admitted on May 12, 2022 and was still active at the time of the inspection. A treatment plan was developed on October 12, 2022. A treatment and rehabilitation plan update was due no later December 12, 2022, however this was not completed until December 29, 2022.Client #6 was admitted on July 18, 2022 and discharged on December 8, 2012. A treatment plan was developed on August 11, 2022. A treatment and rehabilitation plan update was due no later October 11, 2022, however this was not completed until October 17, 2022.
Client #7 was admitted on May 25, 2022 and discharged on September 7, 2022. A treatment plan was developed on June 7, 2022. A treatment and rehabilitation plan update was due no later August 7, 2022, however this was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment and Rehabilitation Services
Community Counseling policy states that Electronic Treatment plans shall be reviewed and updated at least every 60 days.
IT Staff will create a data base report alerting clinicians that their client's treatment plans are due 14 days (46 day) before treatment plan is due. The report will be sent out to the primary clinician of the client and Facility Director. The Facility Director will monitor the data base on a weekly basis. During the Drug & Alcohol weekly meeting and individual supervision, treatment plan report will be reviewed with D&A staff to insure clinicians are following the treatment plan review policy.
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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 four of six applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a case consultation to occur every ninety days. Client #1 was admitted on May 16, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than August 16, 2022, however this was not completed until September 7, 2022. A case consultation was due to occur no later than December 7, 2022, however this was not completed until January 11, 2023.Client #2 was admitted on October 7, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than January 7, 2023, however this was not completed at the time of the inspection.Client #6 was admitted on July 18, 2022 and discharged on December 8, 2022. A case consultation was due to occur no later than October 18, 2022, however this was not completed until December 7, 2022.Client #7 was admitted on May 25, 2022 and was discharged on September 7, 2022. A case consultation was due to occur no later than August 25, 2022, however this was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinicians will receive an alert 60 days by email after client has been in treatment that a case consult needs to be completed. D&A staff will discuss and complete a case consult at that time well before the policy that states that a case consult will be completed every 90 days.
Facility Director will be alerted at the 60-day date that a case consult needs to be completed and will review in supervision or D&A weekly treatment team the case consult that needs to be completed.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on one of one applicable client records reviewed, the facility failed to complete an aftercare plan in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated an aftercare plan will be completed with the client for all planned discharges. Client #6 was admitted on July 18, 2022 and successfully completed the program on December 8, 2022. An aftercare plan was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Aftercare plan
Community Counseling policy states that discharges will have a completed electronic Aftercare Plan with input from the client and the counselor.
The Facility Director during the Drug & Alcohol weekly meeting will conduct a refresher on the aftercare policy. Also, before a client is successfully completed primary clinician will discuss the client's aftercare plan completing treatment in the D&A weekly treatment meeting.
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