INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 11-12, 202 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, ADAPPT House 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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704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop a written policy to address relapse of recovering clinical personnel. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Prior to March 31, 2020, the facility director will review GEO policy, 3.2.6 Drug Free Workplace, with a representative from GEO's Human Resources Department and make necessary revisions to ensure the policy addresses the relapse of recovering clinical personnel. By April 15, 2020, the facility director will review the revised policy with all facility employees. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) 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.
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Observations
Based on a review of personnel records, it was discovered that that Employee #7, whom was hired as a counselor on August 30, 2019, did not meet the educational requirements to be a counselor. At the time of the hire, the employee had AAC which is a non-qualifying certification for the position of counselor.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Prior to March 27, 2020, the facility director will seek approval from the GEO's Human Resources Department to change the affected employee's position to "counselor assistant." By April 15, 2020, the facility director will meet with the employee's supervisor to review the requirements for supervision of a counselor assistant. The employee's supervisor will provide supervision and complete the necessary documentation in accordance with the guidelines established in the regulations until the employee demonstrates compliance with the qualifications for the counselor position. |
709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop a policy that identifies project staff having access to records and the methods by which staff gain access. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Prior to March 31, 2020, the facility director will develop a facility policy and procedure to identify project staff having access to and the methods by which staff gain access to records. By April 15, 2020, the facility director will review the revised policy and procedure with all facility employees. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of policy and procedure manual, the facility failed to develop a policy and procedure that addressed the unusual incident of physical assault or sexual assault by staff or a client. These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Prior to March 31, 2020, the facility director will develop an unusual incident policy and procedure describing the facility's response to incidents of physical assault or sexual assault by staff or a client. By April 15, 2020, the facility director will review the revised policy and procedure with all facility employees |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of policy and procedure manual, the facility failed to develop a policy and procedure that addressed the unusual incident of selling or use of illicit drugs on the premises. These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Prior to March 31, 2020, the facility director will develop an unusual incident policy and procedure describing the facility's response to incidents of selling or use of illicit drugs on the premises. By April 15, 2020, the facility director will review the revised policy and procedure with all facility employees |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of policy and procedure manual, the facility failed to develop a policy and procedure that addressed the unusual incident of Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Prior to March 31, 2020, the facility director will develop an unusual incident policy and procedure describing the facility's response to incidents of death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. By April 15, 2020, the facility director will review the revised policy and procedure with all facility employees.
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709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of policy and procedure manual, the facility failed to develop a policy and procedure that addressed the unusual incident of significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Prior to March 31, 2020, the facility director will develop an unusual incident policy and procedure describing the facility's response to incidents of significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. By April 15, 2020, the facility director will review the revised policy and procedure with all facility employees. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of policy and procedure manual, the facility failed to develop a policy and procedure that addressed the unusual incident of theft, burglary, break-in or similar incident at the facility. These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Prior to March 31, 2020, the facility director will develop an unusual incident policy and procedure describing the facility's response to incidents of theft, burglary, break-in or similar incident at the facility. By April 15, 2020, the facility director will review the revised policy and procedure with all facility employees |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of policy and procedure manual, the facility failed to develop a policy and procedure that addressed the unusual incident of an event at the facility requiring the presence of police, fire or ambulance personnel. These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Prior to March 31, 2020, the facility director will develop an unusual incident policy and procedure describing the facility's response to events at the facility requiring the presence of police, fire or ambulance personnel. By April 15, 2020, the facility director will review the revised policy and procedure with all facility employees.
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709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of policy and procedure manual, the facility failed to develop a policy and procedure that addressed the unusual incident of fire or structural damage to the facility. These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Prior to March 31, 2020, the facility director will develop an unusual incident policy and procedure describing the facility's response to incidents of fire or structural damage to the facility. By April 15, 2020, the facility director will review the revised policy and procedure with all facility employees |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of policy and procedure manual, the facility failed to develop a policy and procedure that addressed the unusual incident of Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification. These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Prior to March 31, 2020, the facility director will develop an unusual incident policy and procedure describing the facility's response to an incident of an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification. By April 15, 2020, the facility director will review the revised policy and procedure with all facility employees. |
709.53(a) LICENSURE Complete Client Record
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:
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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 summaries, case consultation notes, progress notes, record of service and follow-up information in client record #'s 1, 3, 4, 5, 6, 7, and 8.Client #1 was admitted on January 8, 2020 and was still active at the time of inspection. The client record did not contain documentation of any group notes since being January 8, 2020. Client #3 was admitted on December 12, 2019 and was still active at the time of the inspection. The client record did not contain documentation of a record of service past January 14, 2020 and Group notes for the week of January 19-25. Client #4 was admitted on December 23, 2019 and was still active at the time of inspection. The client record did not contain documentation of group notes for the weeks of December 29-January 4 and January 5-January 11. The record was also missing a record of service. Client #5 was admitted on December 24, 2019 and was still active at the time of the inspection. The client record did not contain documentation of case consultation notes, record of service or Group notes for all of January 2020. Client #6 was admitted on December 5, 2019 and was discharged on February 5, 2020. The client record did not contain documentation of case consultation notes, a record of service past December 25, 2019 or Group Notes past January 2, 2020. Client #7 was admitted on January 31, 2019 and was discharged on February 17, 2019. The client record did not contain documentation of cased consolation notes and a follow up. Client #8 was admitted on August 9, 2019 and was discharged on September 5, 2019. The client record did not contain documentation of case consultation notes, discharge summary and follow-up information.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Prior to March 27, 2020, the clinical director will develop a file review checklist to include all required items in a complete client record. By April 15, 2020, the clinical director will develop a weekly file review schedule and begin to review active and closed client records. The clinical director will provide direct feedback to counselors regarding corrective actions necessary to complete client records. Beginning April 30, 2020, the clinical director will provide a monthly summary of the client file reviews to the facility director, to include the provision of employee supervision when appropriate |