INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 16, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Persad 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(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the facility's staff development program, the facility failed to develop an assessment of the staff training needs for the current training year, July 1, 2021 through June 30, 2022.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By October 31, 2022, the Facility Director will develop an assessment tool/survey and circulate among DnA staff to determine training needs for the July 1, 2022 - June 30, 2023 fiscal year. A summary of the surveys will be used to develop each DnA staff member's training plan for the next fiscal year.
The Facility Director will set a reminder in their Outlook calendar one month prior to the end of the fiscal year so that the assessment tool/survey can be completed and individual training plans can be completed for each staff member by the start of the next fiscal year. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's staff development program, the facility failed to develop an overall training plan for the current training year, July 1, 2021 through June 30, 2022.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By October 31, 2022 the Facility Director will complete the overall training plan for PERSAD's DnA staff for fiscal year July 1, 2022 through June 30, 2023.
In their Outlook Calendar, the Facility Director will set a reminder to complete the annual, overall training plan one week before the end of the fiscal year and a second reminder the day it is due. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the facility's staff development program, the facility failed to complete an annual evaluation of the overall training plan for training year July 1, 2020 through June 30, 2021.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
By October 31, 2022 the Facility Director will utilize the DnA staff training evaluations to compile and summarize the the overall training plan for training year July 1, 2021 to June 30, 2022.
The Facility Director will schedule the completion of the training evaluation summary in their Outlook calendar, which provides reminders at 2 weeks prior to due date. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project directors.
Employee #1 was hired as a project director on May 1, 2018 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2021 through June 30, 2022. Employee # 1's record only document six hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director is scheduled to complete 24 hours of training on October 6, 7 and 8 2022.
The Facility Director has reviewed the requirements for training and has developed a plan to complete 12 training hours for the July 1, 2022 through June 30, 2023 training year.
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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.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Employee #4 was hired as a counselor on May 4, 2020 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2021 through June 30, 2022. Employee # 4's record only document five hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director has reviewed the training hour requirements with Employee #4. Employee #4's Individual Training Plan outlines a plan for completing 25 hours of training in the July 1, 2022 through June 30, 2023 training year.
Furthermore, Employee #4 has just completed a DDAP training for 6 credits hours on September 15, 2022.
Employee #4 enrolled in a 4 hour monthly training on Advanced Couples Therapist runs until June 30, 2023.
Facility Director will review/monitor the completed training hours in weekly supervision with Employee #4. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to provide annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee on two employees.
Employee #3 was hired on April 12, 2021 as a counselor and was still in the position as of the date of the inspection.
Employee #4 was hired on May 4, 2020 as a counselor and was still in the position as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By October 31, 2022 the Facility Director will review annual performance evaluations with Employee #3 and Employee #4. Both employees will sign their performance evaluations and the signed performance evaluations will be placed in their personnel file.
The Facility Director will schedule the performance evaluation and the review with staff on their Outlook calendar, which provides reminders at 2 weeks prior to due date. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of client in two out of five applicable records reviewed.
Client # 6 was admitted on May 28, 2021 and discharged on May 2, 2022. A release of information dated March 11, 2022 was to a funding source.
Client #7 was admitted on April 22, 2021 and was discharged on June 20, 2022. A release of information form dated April 18, 2022 was to a funding source.
This is a repeat citation from the October 20, 2021 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PERSAD uses an EHR and all consents are completed out of the EHR.
From 9/22/22 on any consents for DnA clients will be completed in the EHR and signed, in-person by the client.
An email was sent to DnA therapists on 9/22/22 reviewing this policy and the plan of correction.
The Facility Director or their designee will review DnA files quarterly to ensure consents are being completed and signed correctly. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan within the regulatory timeframe in one out of three applicable records reviewed. The facility's policy and procedures manual states that the preliminary treatment plan must be completed at the time of intake.
Client #1 was admitted on November 8, 2021 and was still active at the time of the inspection. A preliminary treatment plan was due no later than November 8, 2021; however, the preliminary treatment plan was dated November 11, 2021.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 9/22/22 an email was sent by the Facility Director to DnA staff which reviewed the policy and procedures for completing a preliminary treatment plan for DnA clients at the time of intake.
By 10/31/22 the Preliminary Treatment plan template will be inserted into the EHR and will become a part of the required intake documentation. Admission to OP Drug and Alcohol treatment can not be processed unless all intake documentation is completed.
The Facility Director or their designee will review DnA files quarterly to ensure that preliminary treatment plans are being completed at the time of intake. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in three out of seven records reviewed.
Client #1 was admitted on November 8, 2021 and was still active at the time of the inspection. The treatment plans were dated November 29, 2021, January 6, 2022, March 3, 2022, May 10, 2022 and July 12, 2022.
Client #3 was admitted on October 1, 2021 and discharged on March 23, 2022. The treatment plan was dated December 9, 2021.
Client #5 was admitted on April 30, 2021 and discharged on February 16, 2022. The treatment plan was dated December 3, 2021.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 9/22/22 the Facility Director sent an email to DnA staff reviewing the policy and procedure for documenting proposed type of support services on every DnA client's treatment plan. By 10/31/22 The Drug and Alcohol Treatment plan will be altered in the EHR so that it can not be completed or saved until the support services are listed.
Client #1's next treatment review and any subsequent treatment plan reviews will include the proposed type of support services on their treatment plan.
Clients #3 and #5 have already been discharged. |
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 six out of six applicable records reviewed.
Client #1 was admitted on November 8, 2021 and was still active at the time of the inspection. A treatment plan update was completed on March 3, 2022 and the next update was due no later than May 3, 2022; however, the next update was completed on May 10, 2022. The next update was due no later than July 10, 2022; however, the next update was completed on July 12, 2022.
Client #2 was admitted on February 4, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 12, 2022 and the next update was due no later than July 12, 2022; however, it was completed on July 15, 2022.
Client #3 was admitted on October 1, 2021 and discharged on March 23, 2022. A comprehensive treatment plan update was completed on December 9, 2021 and the next update was due no later than February 9, 2022; however, there was no documentation that an update was completed at the time of the inspection.
Client #5 was admitted on April 30, 2021 and discharged on February 16, 2022. A treatment plan update was completed on December 3, 2021and the next update was due no later than February 3, 2022; however, there was no documentation that an update was completed at the time of the inspection.
Client #6 was admitted on May 28, 2021 and discharged on May 2, 2022. A treatment plan update was completed on December 4, 2021 and the next update was due no later than February 4, 2022; however, was completed on March 12, 2022.
Client #7 was admitted on April 22, 2021 and discharged on June 20, 2022. A treatment plan update was completed on November 13, 2021 and the next update was due no later than January 13, 2022; however was completed on January 18, 2022. A treatment plan update was completed on March 18, 2022 and the next update was due no later than May 18, 2022; however, was completed on May 21, 2022.
This is a repeat citation from the October 20, 2021 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 9/22/22 the Facility Director reviewed the policy and procedure for completing treatment plan updates within the regulatory timeframe (every 60 days.) Therapists were reminded to complete the review by the due date with or without the client being present. Our EHR sends reminders/prompts to the therapist when plans are coming due to ensure that they are completed on time In addition, the EHR will now send a message via the therapist message board with a reminder of due date.
Any and all future treatment plan reviews for Client #1 and Client #2 will be done within the 60 day time frame.
Clients #3, #5, #6 and #7 have been discharged.
The Facility Director or their designee will review DnA files quarterly to ensure that preliminary treatment plans are being completed according to the regulatory timeframe.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations within the regulatory timeframe based on the facility's policy and procedures manual of every ninety days in seven out of seven client records.
Client #1 was admitted on November 8, 2021 and still active at the time of the inspection. A case consultation was due no later than February 8, 2022, May 8, 2022 and August 8, 2022; however, there was no documentation of case consultations in the client record.
Client #2 was admitted on February 4, 2022 and was still active at the time of the inspection. A case consultation was due no later than May 4, 2022 and August 4, 2022; however, there was no documentation of case consultations in the client record.
Client #3 was admitted on October 1, 2021 and discharged on March 23, 2022. A case consultation was due no later than January 1, 2022; however, there was no documentation of a case consultation in the client record.
Client #4 was admitted on September 29, 2021 and discharged on January 21, 2022. A case consultation was due no later than December 29, 2021; however, there was no documentation of a case consultation in the client record.
Client #5 was admitted on April 30, 2021 and discharged on February 16, 2022. A case consultation was due no later than July 30, 2021, October 30, 2021 and January 30, 2022; however, there was no documentation of case consultations in the client record.
Client #6 was admitted on May 28, 2021 and discharged on May 2, 2022. A case consultation was due no later than August 28, 2021, November 28, 2021, and February 28, 2022; however, there was no documentation of case consultations in the client record.
Client #7 was admitted on April 22, 2021 and discharged on June 20, 2022. A case consultation was due no later than July 22, 2021, October 22, 2021, January 22, 2022 and April 22, 2022; however, there was no documentation of case consultations in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 9/22/22 the Facility Director sent an email to DnA staff reminding them of the policy and procedure for completing case consultation notes every 90 days for all DnA clients.
Client #1 and Client #2 will have Case Consultation notes completed by 10/31/22 and completed every 90 days thereafter.
By October 31, 2022 our EHR manager will set a reminder for all case consultations thereby alerting the therapist via their calendar and the message board of the due date.
Clients #3-#7 have all been discharged.
The Facility Director or their designee will review DnA files quarterly to ensure that case consultations are being completed every 90 days. |
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 five discharged records reviewed.
Client #5 was admitted on April 30, 2021 and discharged on February 16, 2022.
Client #6 was admitted on May 28, 2021 and was discharged on May 2, 2022.
Client #7 was admitted on April 22, 2021 and discharged on June 20, 2022.
This is a repeat citation from the October 20, 2021 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/22/22 the Facility Director reviewed the policy and procedure for completing a follow-up contact within 30 days of discharge. DnA staff were informed that follow up can be documents via a letter if phone contact fails.
By October 31, 2022 the EHR Manager will set a reminder in the EHR to alert the therapist via their calendar and the EHR message board when case consultations are due.
Clients #5 and #7 have re-engaged with Mental Health treatment at PERSAD.
Client #6 has moved out of the area and is seeking treatment in another county. This is documented in their discharge summary.
The Facility Director or their designee will review DnA files quarterly to ensure that follow up contacts are being completed 30 days following discharge. |