INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Auberle 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on applicable staff records reviewed, the facility failed to provide documentation of an annual written individual staff performance evaluations reviewed and signed by the employee in three of three records.
Staff #1 was hired as a project and facility director on April 18, 2023 and was still employed at the time of the inspection. There was no documentation of an annual performance evaluation signed and dated by the supervisor and staff.
Staff #2 was hired as a lead counselor on December 11, 2023 and was still employed at the time of the inspection. There was no documentation of an annual performance evaluation signed and dated by the supervisor and staff.
Staff #3 was hired as a counselor on December 13, 2023 and was still employed at the time of the inspection. There was no documentation of an annual performance evaluation signed and dated by the supervisor and staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will write a policy holding staff and leadership accountable for ensuring performance evaluations are completed on an annual basis. This will be completed by 4/4/2025. The Facility Director will ensure all performance evaluations are being completed by the Clinical Supervisor and the Program Manager during weekly supervision. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on applicable client records reviewed, the facility failed to ensure there was documentation of written acknowledgment by the client that the client had been made aware of their rights in five of seven records.
Client #2 was admitted on May 16, 2024 and was discharged on October 17, 2024.
Client #3 was admitted on July 15, 2024 and was discharged on November 20, 2024.
Client #4 was admitted on May 17, 2024 and was discharged on November 4, 2024.
Client #5 was admitted on November 2, 2024 and was still active at the time of the inspection.
Client #7 was admitted on December 18, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will write a policy detailing the intake process. This will include ensuring the clients have received a copy of the client handbook that details their rights. This policy will be written by 4/4/2025. All staff will have the policy reviewed with them, sign off, and taught how and where to document in the client's electronic record. This will be completed by the Clinical Supervisor and the Program Manager. They will both report to the Facility Director. This training will be completed by 4/30/2025. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the administrative documentation, the facility failed to provide documentation the inspections of storage areas were completed per program policy.
The facility ' s policies and procedures state inspections are to be completed quarterly.
The facility was unable to provide documentation of the inspections completed from January 2024 to December 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 18, 2024 annual licensing inspection.
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Plan of Correction
The Facility Director will write a policy detailing the inspections of the storage areas. This policy will be written by 4/4/2025. The FHC Nurse will then have this policy reviewed and signed off on it. This will happen by 4/30/2025. The Facility Director will then follow up during supervision with FHC Nurse on a bi-weekly basis. |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on applicable client records reviewed, the facility failed to ensure that there was documentation of intake procedures that included the disclosure of criteria for admission, treatment, completion, and discharge in five of seven records.
Client #2 was admitted on May 16, 2024 and was discharged on October 17, 2024.
Client #3 was admitted on July 15, 2024 and was discharged on November 20, 2024.
Client #4 was admitted on May 17, 2024 and was discharged on November 4, 2024.
Client #5 was admitted on November 2, 2024 and was still active at the time of the inspection.
Client #7 was admitted on December 18, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 18, 2024 annual licensing inspection.
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Plan of Correction
The Facility Director will write a policy detailing the intake process. This will include ensuring the clients have received a copy of the client handbook that details the criteria for admission, treatment, completion, and discharge. This policy will be written by 4/4/2025. All staff will have the policy reviewed with them, sign off, and taught how and where to document in the client's electronic record. This will be completed by the Clinical Supervisor and the Program Manager. They will both report to the Facility Director. This training will be completed by 4/30/2025. |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on applicable client records reviewed, the facility failed to ensure that there was documentation of client orientation to the project, which included a familiarization with project policies in five of seven records.
Client #2 was admitted on May 16, 2024 and was discharged on October 17, 2024.
Client #3 was admitted on July 15, 2024 and was discharged on November 20, 2024.
Client #4 was admitted on May 17, 2024 and was discharged on November 4, 2024.
Client #5 was admitted on November 2, 2024 and was still active at the time of the inspection.
Client #7 was admitted on December 18, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will write a policy detailing the intake process. This will include ensuring the clients have been oriented to the program. This policy will be written by 4/4/2025. All staff will have the policy reviewed with them, sign off, and taught how and where to document in the client's electronic record this orientation was complete. This will be completed by the Clinical Supervisor and the Program Manager. They will both report to the Facility Director. This training will be completed by 4/30/2025. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 applicable client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client within their policy ' s timeframe in six of six records.
The facility ' s policies and procedures state that an individualized treatment and rehabilitation plan will be completed within 72 hours of admission.
Client #1 was admitted on June 25, 2024 and was discharged on December 20, 2024. The individualized treatment and rehabilitation plan was due by June 28, 2024, however this was completed on July 5, 2024.
Client #2 was admitted on May 16, 2024 and was discharged on October 17, 2024. The individualized treatment and rehabilitation plan was due by May 19, 2024, however this was completed on May 20, 2024.
Client #3 was admitted on July 15, 2024 and was discharged on November 20, 2024. The individualized treatment and rehabilitation plan was due by July 18, 2024, however this was completed on July 19, 2024.
Client #4 was admitted on May 17, 2024 and was discharged on November 4, 2024. The individualized treatment and rehabilitation plan was due by May 20, 2024, however this was completed on May 22, 2024.
Client #5 was admitted on November 2, 2024 and was still active at the time of the inspection. The individualized treatment and rehabilitation plan was due by November 5, 2024, however this was completed on November 26, 2024.
Client #7 was admitted on December 18, 2024 and was still active at the time of the inspection. The individualized treatment and rehabilitation plan was due by December 21, 2024, however this was completed on December 22, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will write a policy detailing the clinical documentation process for clinical staff (currently defined as Clinical supervisor, Facility Director, and Drug and Alcohol Counselors). This will include when and how to often to complete treatment plans, ASAM, and other clinical documents in a client's electronic record. This policy will be written by 4/4/2025. All clinical staff will have the policy reviewed with them, sign off, and taught how and where to document in the client's electronic record. This training to the staff will be completed by the Clinical Supervisor. They will report to the Facility Director. This training will be completed by 4/30/2025. Clinical Supervisor and Facility Director will monitor charts on a weekly basis. Any issues will be discussed with the clinician during weekly supervision. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days in five of five applicable records.
Client #1 was admitted on June 25, 2024 and was discharged on December 20, 2024. A treatment and rehabilitation plan was developed on July 5, 2024. A treatment and rehabilitation plan update was due no later than August 5, 2024, however this was not completed prior to discharge.
Client #2 was admitted on May 16, 2024 and was discharged on October 17, 2024. A treatment and rehabilitation plan was developed on May 20, 2024. A treatment and rehabilitation plan update was due no later than June 20, 2024, but was not completed until July 5, 2024.
A treatment plan update was completed on July 5, 2025 and the next update was due no later than August 5, 2024; however this was not completed prior to discharge.
Client #3 was admitted on July 15, 2024 and was discharged on November 20, 2024. A treatment and rehabilitation plan was developed on July 18, 2024. A treatment and rehabilitation plan update was due no later than August 18, 2024, however this was not completed prior to discharge.
Client #4 was admitted on May 17, 2024 and was discharged on November 4, 2024. A treatment plan update was completed on August 22, 2024. A treatment and rehabilitation plan update was due no later than September 22, 2024, however this was not completed prior to discharge.
Client #5 was admitted on November 2, 2024 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on November 26, 2024. A treatment and rehabilitation plan update was due no later than December 26, 2024, 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
The Facility Director will write a policy detailing the clinical documentation process for clinical staff (currently defined as Clinical supervisor, Facility Director, and Drug and Alcohol Counselors). This will include when and how to often to complete treatment plans, ASAM, and other clinical documents in a client's electronic record. This policy will be written by 4/4/2025. All clinical staff will have the policy reviewed with them, sign off, and taught how and where to document in the client's electronic record. This training to the staff will be completed by the Clinical Supervisor. They will report to the Facility Director. This training will be completed by 4/30/2025. Clinical Supervisor and Facility Director will monitor charts on a weekly basis. Any issues will be discussed with the clinician during weekly supervision. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in four of four records. The policy and procedure manual indicates follow-up contact must be made at seven, thirty, sixty, and ninety days after discharge.
Client #1 was admitted on June 25, 2024 and was discharged on December 20, 2024. There was no documentation of follow-up in the record.
Client #2 was admitted on May 16, 2024 and was discharged on October 17, 2024. There was no documentation of follow-up in the record.
Client #3 was admitted on July 15, 2024 and was discharged on November 20, 2024. There was no documentation of follow-up in the record.
Client #4 was admitted on May 17, 2024 and was discharged on November 4, 2024. There was no documentation of follow-up in the record.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the January 18, 2024 annual licensing inspection.
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Plan of Correction
The Facility Director will write a policy about completing follow up calls to the clients once they have left the facility. This policy will be completed by 4/4/2025. All staff will then review this policy and be trained how to complete this task and where to document it in the client's electronic record. This training to the staff will be completed by the Clinical Supervisor and the Program Manager. They will both report to the Facility Director. This will be completed by 4/30/2025. Clinical Supervisor and Facility Director will audit charts on a weekly basis. Any deficiencies found in not completing these calls will be addressed during the weekly/bi-weekly supervision with staff. |