INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Treatment Trends, Inc. 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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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) 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 and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of personnel records, it was determined that one employee hired as a clinical supervisor did not meet the qualification requirements for the position.
Employee #3 was promoted to the position of clinical supervisor on April 25, 2022 and was current in that position at the time of the inspection. At the time of promotion, the employee had a qualifying bachelor ' s degree, but only two years of clinical experience, not the required minimum of three years.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3 will be placed in the role of Lead Counselor until she meets the 3 year requirement. To ensure future applicants for the Clinical Supervisor Role meet the educational and experience the Program Director will review resume and degree to ensure it aligns with the standard.
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel files, the facility failed to ensure that one applicable clinical supervisor had completed a core curriculum in clinical supervision which is a requirement for the position.
Employee #3 was hired as the clinical supervisor on April 25, 2022 and is current in that position. Employee #3 had not functioned for 2 years as a supervisor in the provision of clinical services or completed a core curriculum in clinical supervision. The core curriculum was not completed until December 16, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor was unable to accommodate the clinical supervision training offered in June due to a scheduling conflict. She registered for and attended the next available training. She completed the training December 16, 2022.
To address this deficiency, any staff hired in the role of clinical supervisor will be notified of training requirement and time frame requirement upon hire and Program Director will monitor attendance to ensure compliance within time frame and document communication, registration and attendance confirmation. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to maintain documentation that counselor assistants received direct observation of the provision of counseling services as part of their close supervision, in four of four applicable records reviewed.
Employee # 5 was hired as a bachelor ' s level counselor assistant on December 30, 2021. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision.
Employee # 6 was hired as a high school level counselor assistant on September 8, 2022. The supervision notes provided at the time of the inspection did not indicate that direct observation for the first three months of the provision of counseling services and that direct observation was a part of the close supervision thereafter.
Employee # 7 was hired as a bachelor ' s level counselor assistant on August 4, 2022. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision.
Employee # 8 was hired as a bachelor ' s level counselor assistant on October 18, 2022. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address this deficiency for Employee(s) #5, #6, #7 and #8 supervision periods will be re-instituted and a discussion of the direct observation will be included in the corresponding supervisory note weekly, for the purpose of planning, oversight, monitoring and evaluating of activities. The supervision notes will be maintained in a log kept in the Clinical Supervisor's office and in the staff record.
For future counselor assistants, their supervision will be completed by the clinical supervisor and/or other qualified staff who will keep a log of the hours spent directly observing and/or closely observing clinical services. This log will be kept in the Clinical Supervisor's office and in the staff record. The log will be completed weekly, in accordance with § 704.1 (c) for the purpose of planning, oversight, monitoring and evaluating their activities. This log will be audited by the Program Director or designee. |
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 staff schedules and CPR certifications provided by the facility, the facility failed to ensure that at least one person certified in CPR was onsite during the project's hours of operations. The 12:00 a.m. - 08:00 a.m. shifts Saturday and Sunday shifts did not have staff certified in CPR.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to staffing issues and changes, there was a period of time when employees' CPR certification was missing/lapsed. To address: CPR certification will be recommended but not required at the time of hire. An outside vendor is scheduled to complete CPR training on 2/24/23 for all outstanding staff needing training.
When the monthly schedule is created, staff who are CPR trained are designated and identified and are scheduled accordingly. The House Manager/or designee will monitor to ensure that CPR trained staff coverage is present for all shifts. House Manager/or designee and Program Director will have access to an updated and current list of all CPR trained staff. In the event a CPR person calls off, the House Manager/or designee will utilize the list of CPR trained staff for coverage. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on documentation provided by the facility, the facility failed to conduct unannounced fire drills at least once a month, as no fire drills were conducted during the 2022 months of May and September.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills will be completed by the house manager or their designee. Completed drills tracked by Program Director and Operations Manager. After the drill is completed and accepted, it is forwarded to the Quality Assurance Coordinator for filing in Administration.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 and a discussion with facility staff, the facility failed to ensure that two personnel were trained to perform assigned tasks during emergencies prior to being on shift.
Employee #6 was hired on September 8, 2022 and is current in that position. Employee #6 began working shifts on September 8, 2022 but was not trained to perform assigned tasks during emergencies until November 21, 2022.
Employee #7 was hired on August 4, 2022 and is current in that position. Employee #7 began working shifts on August 4, 2022 but was not trained to perform assigned tasks during emergencies until November 7, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address this deficiency, all new employees will be trained to perform tasks during emergencies, otherwise known as the Emergency Preparedness Plan. This training will occur upon hire. The training will be conducted by the House Manager or designee and monitored by the Program Director. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from January 2022 through November 2022, the facility failed to conduct fire drills during sleeping hours at least every six months.
Based on the program schedule provided by facility staff, the unit sleeping hours are 11:00 P.M. through 06:30 A.M. No fire drills between May 2022 and November 2022 were conducted between those hours.
This is a repeat citation from the January 27, 2022 annual licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address this deficiency, the Program Director will review "sleeping hour" drill times with the House Manager. The House Manager will ensure that a sleeping hours fire drill occurs in congruence with the fire-drill schedule; current practice is that a sleeping hours drill is scheduled once per quarter. The House Manager will bring all completed fire activity logs to the Program Director for review, and then submit the report(s) to the Quality Assurance Coordinator for final review/file. |
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 seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client #3 was admitted on June 1, 2022 and was discharged on August 3, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on August 3, 2022, with no client signed consent to release information form signed by the client.
Client #4 was admitted on September 14, 2022 and was discharged on October 18, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on October 18, 2022, with no client signed consent to release information form signed by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director met with Admissions Coordinator on January 17, 2023 and provided training/supervision to ensure all proper documentation is listed on each release of information, including but not limited to releasing personally identifying information to the Department of Human Services without client signed consent. The Program Director and Utilization Review Coordinator reviewed all current charts to ensure releases on record are in compliance with the confidentiality standard. The Program Director, Quality Assurance Department, and/or delegate will be conducting randomized audits to ensure confidentiality is being upheld through proper releases of information. |
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 physical plant inspection on January 6, 2023, the facility failed to ensure that drugs for external use were stored separately from oral drugs as a tube of topical medication was stored with oral medications in the med cart. Additionally, the facility failed to ensure removal of outdated drugs as medications for a client who discharged three weeks prior were still stored within the facility.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure compliance with medication storage policy the Staff Nurse will create a checklist for medication storage which will be reviewed with tech staff and included in the Medication Training as well as being posted in the med room. The Medical Service Specialist will check med cart weekly and sign off on the location/storage of medication. The medical team will schedule a time weekly to reconcile recently discharged clients and medication disposal. This will occur Tuesdays. Program Director will review monthly with medical staff. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of seven client records, the facility failed to ensure that intake procedures included documentation of physical examinations within 7 days of admission in three records reviewed.
Client #1 was admitted on February 15, 2022 and was discharged on April 5, 2022.
Client #4 was admitted on September 14, 2022 and was discharged on October 18, 2022.
Client #5 was admitted on November 3, 2022 and was active at the time of the inspection.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
TTI policy is that a physical exam is to be completed within 7 days of admission to our residential program(s). If there is an instance where an individual will not be seen by an in-house provider, they will be referred to a local community partner for that physical exam. Documentation will be secured and uploaded into the chart, along with a Patient Communication as to why they were seen by an outside provider.
Staff Nurse will maintain a list of weekly admissions, utilize a tracking calendar and document when physical exam occurs. This weekly report will be reviewed by Program Director to ensure compliance. |
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 a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in two of six applicable records reviewed.
Client #2 was admitted on March 17, 2022 and was discharged on May 2, 2022. The individual treatment and rehabilitation plan was completed on March 25, 2022, and the treatment plan update was due no later than April 25, 2022; however, the update was not completed until May 2, 2022.
Client #3 was admitted on June 1, 2022 and was discharged on August 3, 2022. The individual treatment and rehabilitation plan was completed on June 6, 2022, and the treatment plan update was due no later than July 6, 2022; however, there was no update documented in the record at the time of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Treatment plans are to be reviewed and updated every 30 days. It is the responsibility of the counselor to update the treatment plan collaboratively with the client in session. Update due dates are sent daily by the Program Secretary. Progress on updates are tracked during individual and group supervision. Charts are audited by the Clinical Supervisor, Program Director and Quality Assurance Coordinator periodically for adherence to the expectation.
All active client records will be audited to ensure that treatment plan updates are current. Moving forward, all treatment plan update due dates will be discussed in weekly staff meeting and tracked by the Senior Program Administrator on the daily census. |
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 a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information in two of four applicable records reviewed.
Client #2 was admitted on March 17, 2022 and was discharged on May 2, 2022. The client record did not contain documentation of follow-up information.
Client #4 was admitted on September 14, 2022 and was discharged on October 18, 2022. The client record did not contain documentation of follow-up information.
This is a repeat citation from the January 27, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address this deficiency the Program Director met with Utilization Review Coordinator on 1/10/2023 and provided training and supervision to incorporate that will conduct follow-up calls for all discharged clients within 7 days of discharge and note. He will provide all information from the follow up calls to Senior Administrative Assistant for tracking and data collection. Senior Administrative Assistant will upload information into client EMR. Program Director, Clinical Supervisor, Quality Assurance Coordinator, and/or delegate will be conducting randomized audits to ensure follow-up calls are being conducted and documented |