INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 15, 2021 through November 16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mid-Atlantic Rehabilitation Services - A.T.P. 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to maintain documentation that the high school level counselor assistant only counseled clients under direct supervision for the first three months and close supervision thereafter in one of one applicable record.
Employee # 13 was hired as a counselor assistant on August 24, 2020 and was promoted to a counselor on April 13, 2021.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee #13 was an intern with MARS. The Clinical Supervisor has provided an attestation to the facility director that this individual as an intern was under direct supervision for the first 3 months and close supervision thereafter prior to being hired as a counselor upon completion of internship and degree in a related field. MARS will continue to provide appropriate direct and close supervision to all interns. MARS Facility director will review requirements for documentation of close/direct supervision with all MARS clinical directors by 1/31/22 and have them sign a document showing completion of this review. Facility and/or clinical director will review documentation for all those assigned the designation of counselor assistant quarterly to ensure compliance with documentation requirements.
|
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.
|
Observations
Based on a review of seventeen personnel records, the facility failed to ensure that staff received at least four hours of TB/STD training and 6 hours of HIV/AIDS training in three records.
Employee # 13 was hired by the facility on August 24, 2020 as a counselor assistant and has since been promoted to a counselor. The employee was due to have the TB/STD and HIV/AIDS trainings no later than August 24, 2021. There was no documentation in the personnel file of the completion of the TB/STD or HIV/AIDS trainings as of the date of the inspection.
Employee # 14 has been in the position of counselor since April 9, 2020 and was due to have the TB/STD and HIV/AIDS trainings no later than April 9, 2021. There was no documentation in the personnel file of the completion of the TB/STD or HIV/AIDS trainings as of the date of the inspection.
Employee # 15 was hired as a counselor on September 16, 2019 and was due to have the TB/STD and HIV/AIDS trainings by at least September 16, 2020. There was no documentation in the personnel file of the completion of the TB/STD or HIV/AIDS trainings as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director will schedule an internal tb/STI/Hep and Basic HIV training during January requesting all staff who had not completed these required trainings to attend. Facility Director and/or designated HR staff will audit all personnel files quarterly to ensure future compliance. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of seventeen personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in two records reviewed.
Employee # 15 was hired as a counselor on September 16, 2019. The facility's training year that was reviewed was from January 1, 2020 through December 31, 2020. Employee #15 ' s record only documented 12.25 hours of training for the period reviewed.
Employee # 16 was hired as a counselor on April 23, 2018. The facility's training year that was reviewed was from January 1, 2020 through December 31, 2020. Employee #16 ' s record only documented 6 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All counseling staff will be required to sign an attestation identifying that they are aware of the 25 hour per year annual requirement for training by 1/31/2021. Training hours will be reviewed in quarterly audits of personnel files by the facility director and/or designated HR staff. |
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.
|
Observations
Based on a review of fourteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client #11 was admitted to the February 5, 2021 and discharged August 31, 2021. The record contained documentation of a letter sent to a treatment provider on May 25, 2021, to whom the record contained no consent to release information form signed by the client.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
During our annual training plan development and in-service all staff will be required to review confidentiality policies and sign a document acknowledging completion this in-service by 1/31/2022. Clinical Director and supervisors will discuss within supervision sessions confidentiality standards. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on a review of fourteen client records, the facility failed to ensure that consent to release information forms included the name of the person, agency, or organization to whom disclosure is made in two records reviewed.
Client #6 was admitted on August 31, 2021 in the Intake, Evaluation, and Referral activity. The record contained a consent to release information form signed by the client on August 31, 2021 that was missing the name of the person, agency, or organization to whom disclosure is made.
Client #7 was admitted on September 30, 2021 in the Intake, Evaluation, and Referral activity. The record contained a consent to release information form signed by the client on September 30, 2021 that was missing the name of the person, agency, or organization to whom disclosure is made.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
During our annual training plan development and in-service all staff will be required to review confidentiality policies and sign a document acknowledging completion this in-service by 1/31/2022. Clinical Director and supervisors will discuss within supervision sessions confidentiality standards |
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.
|
Observations
Based on a review of fourteen client records, the facility failed to ensure that consent to release information forms included specific information to be disclosed in one record reviewed.
Client #11 was admitted February 5, 2021 and discharged on August 31, 2021. The record contained a consent to release information form to another treatment provider signed by the client on July 21, 2021, that did not indicate the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
During our annual training plan development and in-service all staff will be required to review confidentiality policies and sign a document acknowledging completion this in-service by 1/31/2022. Clinical Director and supervisors will discuss within supervision sessions confidentiality standards |
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.
|
Observations
Based on a review of fourteen client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in five records reviewed.
Client #8 was admitted on November 20, 2020 and discharged on October 13, 2021. A treatment plan update was completed on March 11, 2021 and the next one was due by May 11, 2021; however, the next update was not completed until May 27, 2021. An update to the treatment plan update completed on May 27, 2021 was due by July 27, 2021; however, no additional treatment plan updates were completed prior to the client ' s discharge.
Client #9 was admitted on October 28, 2020 and discharged on February 20, 2021. The comprehensive treatment plan was completed on November 23, 2020 and a treatment plan update was due to be completed by January 23, 2021; however, no treatment plan updates were completed prior to the client ' s discharge.
Client #10 was admitted on October 26, 2020 and discharged on March 5, 2021. The comprehensive treatment plan was completed on November 21, 2020 and a treatment plan update was due to be completed by January 21, 2021; however, no treatment plan updates were completed prior to the client ' s discharge.
Client #12 was admitted on January 18, 2021 and was an active client at the time of the inspection. The comprehensive treatment plan was completed on March 30, 2021 and a treatment plan update was due to be completed by May 30, 2021; however, no treatment plan updates were completed prior to the time of the inspection
Client #13 was admitted on July 6, 2021 and was an active client at the time of the inspection. A treatment plan update was completed on August 27, 2021 and another treatment plan update was due by October 27, 2021; however, no additional treatment plan updates were completed prior to the time of the inspection
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Director will provide an in-service on completion of treatment plan updates to all counselors by 1/31/2022. Counselors will sign acknowledgement that they have completed this in-service. 10% of active medical records will be reviewed quarterly to ensure compliance with policy on completion of treatment plan updates. Facility Director or their designated quality improvement staff will complete quarterly audit. |