INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 12, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Treatment and Healing 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(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 facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a contract counselor on September 18, 2019 and was due to have the communicable disease trainings no later than September 18, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to ensure employee #3 who was a contracted counselor met the training requirements as it relates to HIV/AIDS(6hrs) and TB/STD(4hrs)
The facility director will ensure this deficiency is corrected by monitoring scheduled training with employee #3. In addition to following said employee's annual training plan, the facility director will also implement segments of weekly supervision related to but not limited to required training needs to allow for compliance with this standard. The facility director, project director, and human resource manager will continue to monitor all training needs associated with required employee training in order to prevent this deficiency in the future. This facility has also purchased/added the Relias training portal as another training resource for the contracted staff to complete the required training. The facility director will be responsible to monitor the completion of the identified training denoted in this deficiency.
The contracted staff is scheduled to attend TB/STD training on 9/19/22.
The contracted staff is scheduled to attend HIV/AIDS training on 9/15/22. |
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 client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of seven records reviewed. There was no consent to release information form for the funding source. Facility staff confirmed billing had occurred.
Client #3 was admitted on March 17, 2022 and was still active at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to obtain consent to release information for the funding source for client #3
Upon completion of the intake procedure, counseling staff will immediately give the intake packet to the facility director for review before invoicing. The facility director will also audit new and existing client charts during weekly supervision to ensure all required paperwork is appropriately completed. In addition, the facility director will conduct monthly chart audits to ensure this standard is met and ongoing.
The counseling staff was able to obtain consent for the funding source on 8/18/22. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of the client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the clients that recorded the date, event, or condition upon which the consent will expire in one out of seven records reviewed.
Client #6 was admitted on August 5, 2021and was discharged on February 25, 2022. A release of information form dated August 5, 2021 was to a lab.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to obtain informed and voluntary consent from the clients that recorded the date, event, or condition upon which the consent will expire for client #6.
Upon completion of intake procedures, the counseling staff will immediately give the intake packet to the facility director for review and approval. The facility director will also incorporate a segment of time during weekly supervision with counseling staff to review client charts as it relates to required paperwork and procedures as it relates to completing forms accurately. In addition, the facility director will conduct monthly chart audits reviewing this standard to ensure ongoing compliance.
The facility is in compliance with this standard as of 8/30/22
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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 a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of six applicable records reviewed.
Client #3 was admitted on March 17, 2022 and was still active at the time of the inspection. A treatment plan was completed on April 1, 2022 and the update was due no later than June 1, 2022; however, no update had been completed as of the time of the inspection.
Client #6 was admitted on August 5, 2021 and discharged on February 25, 2022. A treatment plan update was completed on December 3, 2021 and the next update was due no later than February 3, 2022; however, it was not completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to document treatment plan updates within the regulatory timeframe for client #3 and client #6.
The facility director through weekly and monthly chart audits will ensure this standard is met and maintained. Counseling staff will also have an internal flowchart as well as an agency master list to aid with compliance with this regulation and the timeframe associated with this standard. The facility director will also review this regulation during weekly supervision with counseling staff to ensure immediate and ongoing compliance with this standard.
The facility is in compliance with this standard as of 8/30/2022 |
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 facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of seven records reviewed.
Client #2 was admitted on March 29, 2022 and was still active at the time of the inspection. The treatment plan dated April 19, 2022 indicated one hour of group therapy per week and one hour of individual sessions per week. There was no documentation of the client receiving individual therapy between July 14, 2022 through August 11, 2022.
Client #4 was admitted on May 9, 2022 and was still active at the time of the inspection. The treatment plan dated May 23, 2022 indicated one hour of group therapy per week and one hour of individual sessions per week. There was no documentation that the client received group therapy between May 23, 2022 through August 11, 2022.
Client #6 was admitted on August 5, 2021 and was discharged on February 25, 2022. The treatment plan dated August 17, 2021 indicated one hour of group therapy per week and one hour of individual sessions per week. There was no documentation that the client received group therapy between August 25, 2021 through August 11, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to ensure that the clients received counseling services according to their individual treatment plan.
The facility director will review the recommended counseling interventions on a weekly basis during supervision with the assigned counseling staff to ensure recommendations, as it relates to counseling interventions, are being followed. In the event counseling interventions deviate from the initial recommendation, counseling staff will document the reasons why the client was not able to fulfill their recommended counseling requirements. The facility director will also review client counseling interventions with counseling staff during treatment plan reviews and case consultations to allow for but not limited to appropriate interventions as it relates to the recommended counseling services. In addition, the facility director will conduct random monthly chart audits to ensure this standard is met and ongoing.
The facility is compliant with this standard as of 9/1/22.
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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 a review of client records, the facility failed to provide a complete client record, which is to include an aftercare plan in two out of three discharged records reviewed.
Client #6 was admitted on August 5, 2021 and was discharged on February 25, 2022.
Client #7 was admitted on February 17, 2022 and was discharged on June 3, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to complete the client records which is to include an aftercare plan in two out of the three discharge records reviewed.
The facility director will utilize weekly supervision with counseling staff reviewing discharge-required documentation. In addition, the counseling staff will utilize a flowchart that is specific for each client as it relates to timeframes associated with the required documentation including but not limited to the aftercare plan.
Random monthly chart audits conducted by the facility director will also occur to review this standard. Counseling staff will also review all discharge paperwork with the facility director to ensure this standard is met and is ongoing. The agency has also incorporated a master list of all current and discharged clients to assist with maintaining this standard.
The facility is in compliance with this standard as of 9/2/22
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in one out of three discharged records reviewed.
Client #6 was admitted on August 5, 2021 and was discharged on February 25, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to provide a complete client record, which is to include a discharge summary.
The Facility Director will meet with counseling staff prior to client(s) last session to review the required paperwork. Weekly supervision between the facility director and counseling staff will also occur to review all clients' pending discharge and the required paperwork. The counseling staff will also utilize the flow chart which is part of all client records enrolled in treatment as a reminder as to the paperwork needed upon discharge. The facility director will also use this tool to assist with maintaining needed documentation upon intake through discharge. In addition, the agency master list will also include timeframes and required paperwork for discharge clients. Monthly random audits by the facility director of client charts will serve as another measure to ensure this standard is met and ongoing.
This facility is compliant with this standard as of 9/12/22 |
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 provide a complete client record, which is to include follow-up information in three out of three discharged records reviewed.
Client #5 was admitted on August 5, 2021 and was discharged on February 1, 2022.
Client #6 was admitted on August 5, 2021 and was discharged on February 25, 2022.
Client #7 was admitted on February 17, 2022 and was discharged on June 3, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to provide a complete client record, which is to include follow-up information in discharge records.
The facility director will utilize weekly supervision with counseling staff reviewing this standard for discharged clients. The facility director and counseling staff will also utilize the flow chart that is part of every client record as a tool to assist with timelines associated with discharge paperwork as well as the required documentation for discharge clients to include but not limited to follow-up information. The agency master list will also be utilized as an additional measure in complying with and maintaining this standard.
This facility is in compliance with this standard as of 9/13/22 |