INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 12, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, LaRocco Counseling 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(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a supervisory review of the facility ' s Staffing Requirement Facility Summary Report (SRFSR) form, the clinical staff FTE equated to 9 full time equivalent clinical staff. The FTE calculation for the number of clinical supervisors needed is as follows:
The total # of hours project-wide devoted to D&A clients divided by the project ' s standard workweek, or 367 hours / 40 hours = 9 FTE
The project must have a full-time clinical supervisor on staff for every 8 FTE clinical staff and based on the SRFSR, the facility does not employ a full-time clinical supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LaRocco Counseling INC is in the process of and will be hiring a full time Clinical Supervisor. The individual hired will meet all the neededrequirements. |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of counselor assistants supervision notes and personnel records not indicating a full-time clinical supervisor, the facility failed to have counselor assistants supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7.
Employee # 9 was hired on July 5, 2019 and promoted to a counselor assistant position on February 21, 2020. The supervision notes provided indicated supervision was being documented by the project/ facility director who also provides clinical services.
Employee # 10 was hired on March 29, 2018 and promoted to a counselor assistant position on July 3, 2019. The supervision notes provided indicated supervision was being documented by the project/ facility director who also provides clinical services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LaRocco Counseling INC is in the process of and will be hiring a full time Clinical Supervisor. The individual hired will meet all the needed requirements, including client ratio. The clinical supervisor will be in charge of supervison and completion of supervision notes for counselor assistant. |
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 the staffing requirements facility summary report and personnel records reviewed, the facility failed to provide documentation of staff persons and volunteers receiving a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in the regulatory timeframe.
Employee # 3 was hired as a counselor on March 27, 2019 and was still in this position at the time of the inspection. TB/STD training was due to be completed no later than March 27, 2020.
Employee # 10 was hired March 29, 2018 and promoted to a counselor assistant on July 3, 2019 and was still in this position at the time of the inspection. HIV/AIDS training was due to be completed no later than July 3, 2020.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 8, 2019 annual inspection.
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Plan of Correction
LaRocco Counseling will be incorporating these reqiurements into individual training plans as well as inital orientation of staff responsibilites. The monitoring of this will be done by by the Project Director to ensure all staff are recieving the valuable and reqiured training. A lot of trainings were cancelled due to pandemic, in the event that happens again LaRocco Counseling will seek giudance from SCA and DDAP on other available options.
Employee 3 has completed reqiured trainings already.
Employee 10 is schedualed for June, which is closest date for the training in our area.Employee 10 was registered during this review; however training was cancelled and reschedualed |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill log from January 2020 through December 2020, the facility failed to provide documentation of a fire drill being conducted for the month of April 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LaRocco Counseling has put into policy that regardless of status of the building that a minimum of 1 observed and documented fire drill will take place on a monthly basis. All fire drills will meet all regulatory standards. This is in effect immediatly |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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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 to include the specific information disclosed to remain within the limits of 255.5 (c).
Client # 5 was admitted on October 1, 2020 and was discharged on November 16, 2020. An informed and voluntary consent from the client for the disclosure of information to an employer dated October 1, 2020 allowed for the release of Client prognosis, Nature of the project, a brief description of the clients progress, and a short statement as to whether the client has relapsed into drug abuse and frequency of such relapse.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LaRocco Counseling has educated and trained staff to understand the guidlines and limits of pa code Title 4, Chapter 255, pa code 255.5 Release of information to any employer will be limited to the fact of wheather the client is or is not in treatment. No other information will be allowed to be consented under the relase of information regarding an employer.This is effective immediatly. |
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 three of six client records reviewed, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client # 2 was admitted on October 5, 2020 and was still active at the time of the inspection. A treatment plan update occurred on December 7, 2020 and February 10, 2021 that indicated individual sessions one time weekly. A review of progress notes and record of service determined individual sessions did not occur the week of January 31-February 6 and February 21-27, 2021.
Client # 3 was admitted on May 18, 2020 and was still active at the time of the inspection. A treatment plan update occurred on October 2, 2020, November 30, 2020 and February 16, 2021 that indicated individual sessions one time weekly and group sessions weekly. A review of progress notes and record of service determined individual sessions did not occur the week of October 18-24, 25-31, January 3-9, 2021, 17-25, 24-30, 31-February 6, 7-13, and no group sessions December 21, 2020-February 16, 2021.
Client # 4 was admitted on July 21, 2020 and was still active at the time of the inspection. A treatment plan update occurred on December 9, 2020 and February 3, 2021 that indicated individual sessions one time weekly and group sessions weekly. A review of progress notes and record of service determined individual sessions did not occur the week of December 20-26, 2020 and February 21-27, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LaRocco Counseling is implementing a process facility wide to improve our documention when a client is not in attendance for treatment. Accuratly reporting on the contact record will clarify reasoning on why the client was not in treatment as well as why treatment goals and treatment scheduales were not being met. This is in place immediatly. |