INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Chartiers Community Mental Health and Retardation Center 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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704.11(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 staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in one of two applicable staff records.
Staff #2 was hired as a counselor on July 17, 2023. The TB/STD training was to be completed by July 17, 2024. There was no documentation that this training was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the first 30 days of employment, the Facility Director will be responsible for registering all staff for DDAP-approved training that consists of a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis and sexually transmitted diseases. The Facility Director will be responsible for ensuring that Counselors or Counselor Assistants will complete these trainings within the first year of employment and all other staff shall complete both trainings within the first two years of employment. Signing staff up during the first month of employment will maximize the likelihood of getting the training in a timely manner as there is frequently a waiting list for these trainings. Training requirements and records will be monitored and reviewed at a minimum on a bimonthly basis for all staff through weekly supervision with the Facility Director to ensure adherence to regulatory requirements. Documentation will be kept regarding all attempts to enroll staff in mandatory trainings including both correspondence with Department staff and emails/phone calls documenting a staff member being placed on a wait list for a training. The Facility Director will be required to ensure all staff have received proper training or that trainings have been scheduled prior to the next licensing visit. Supervisory staff have been retrained at this point to ensure that this is a focus going forward within supervision. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services in four of six applicable records.
Client #1 was admitted on April 23, 2024 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on May 7, 2024 however, there was no documentation of type and frequency of services.
Client #3 was admitted on February 8, 2024 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on February 8, 2024 however, there was no documentation of type and frequency of services.
Client #4 was admitted on April 2, 2024 and discharged on August 1, 2024. A comprehensive treatment and rehabilitation plan was developed with the client on April 4, 2024 however, there was no documentation of type and frequency of services.
Client #6 was admitted on March 26, 2024 and discharged on August 1, 2024. A comprehensive treatment and rehabilitation plan was developed with the client on May 26, 2024 however, there was no documentation of type and frequency of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients who complete an intake for the program will develop a treatment plan during intake and said plan will be updated/reviewed at least every 60 days thereafter. All treatment plans and treatment plan reviewed will include, but not be limited to, written documentation of both type and frequency of treatment and rehabilitation services.
Each TX plan will be reviewed and signed by the Facility Facility Director prior to being reviewed and signed off on by the Medical Director. During this review, the Facility Director will ensure that all treatment plans include both the type and frequency of treatment and rehabilitation services within the interventions. If these items are not included within the TX plan, the Counselor will be required to review the treatment plan at the next visit and include all the necessary information.
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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 client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in four of five applicable records.
Client #1 was admitted on April 23, 2024 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on May 7, 2024. A treatment and rehabilitation plan update was due no later than July 7, 2024, but was not completed until July 29, 2024.
Additionally, the next update was due no later than September 29, 2024; however, the update was not completed at the time of the inspection.
Client #2 was admitted on March 20, 2024 and was still active at the time of the inspection. A treatment plan update was completed on July 17, 2024 and the next update was due no later than September 17, 2024; however, the update was not completed until September 30, 2024.
Client #3 was admitted on February 8, 2024 and was still active at the time of the inspection. A treatment plan update was completed on May 28, 2024 and the next update was due no later than July 28, 2024; however, the update was not completed until September 20, 2024.
Client #6 was admitted on March 26, 2024 and discharged on August 1, 2024. A treatment and rehabilitation plan was developed on March 26, 2024. A treatment and rehabilitation plan update was due no later than May 26, 2024, but was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 28, 2023 annual licensing inspection.
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Plan of Correction
By 12/19/2024, all staff will be retrained on the treatment plan review process by the Facility Director. The Facility Director will require Counselors to track and review treatment plan dates and will review these dates during supervision to ensure that all treatment plans are being completed in a timely manner. Retraining will include the process that Counselors will be expected to review treatment plans with each client prior to the plan expiring and get them completed in a timely manner. If this is unable to be achieved, a Review of Treatment Progress will be completed prior to the expiration of the current treatment plan to suffice until a new treatment plan can be updated/completed. The Facility Director will review and monitor this on a weekly basis and review with staff in supervision to ensure all are being completed in a timely manner and that no treatment plans are permitted to expire without a review being completed and a plan in place for when the treatment plan will be updated. |