INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Treatment and Healing 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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704.9(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.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide close observation by a trained counselor or clinical supervisor for at least the first 6 months of employment.
Employee #4 was hired as a Counselor Assistant on May 18, 2022 and was still employed at the time of the inspection. She had no documentation of close supervision, including no documentation of direct observation at least one hour per week.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Employee #4 supervision documentation failed to document her "close supervision, including no documentation of direct observation at least one hour per week."
This supervision and the required documentation is the responsibility of the Facility director. The facility director failed to properly document all supervision including direct observation of clinician. The Facility Director reviewed the regulations (704.9) in regards to direct and close observation of all assistant counselors and the documentation required.
This corrective action plan was implemented on Sept 1 2022
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705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical site inspection, the facility failed to provide either individual paper towels or a mechanical dryer in the men's bathroom located in the basement.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
It is the responsibility of all agency staff to inspect the bathrooms daily, to maintain adequate consumables
and to assure the bathrooms are functioning properly.
This corrective action plan was the staff was trained and implemented on Sept 1 2022
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #2 was hired on October 8, 2021 as a counselor and was moved to lead counselor on May 2, 2022 and was still in the position as of the date of the inspection. The training was completed on March 8, 2022.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director established emergency Policies and procedures. Those procedures were implemented July 1 2022. It is the responsibility of the Project Director and the Facility director to Instruct all agency staff upon hire and bi-annually of the Policies and procedures concerning emergency and Fire emergency protocols. This policy was reviewed by staff and implemented on September 1 2022 |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Employee #2 was hired on October 8, 2021 as a counselor and was moved to lead counselor on May 2, 2022 and was still in the position as of the date of the inspection. The training was completed on March 8, 2022.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director established Fire safety and fire drills . Those procedures were implemented July 1 2022. It is the responsibility of the Project Director and the Facility director to Instruct all agency staff upon hire and bi-annually of the Policies and procedures concerning emergency and Fire emergency protocols. This policy was reviewed by staff and implemented on September 1 2022 |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents and an interview with the Project Director, the project failed to document an annual financial audit for the fiscal year ending June 30, 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PA Treatment & healing has implemented the following corrective actions in order to comply with the
fiscal management requirement:
Contracted with an independent accounting firm specializing in nonprofits.
Contracted with an independent IT consultant to recover as much data as possible that was lost
due to our accounting server crashing and flooding in our corporate office.
Restructured the accounting department by hiring more staff for proper distribution of workflow.
Establishing new fiscal policies and procedures to ensure a proper system of checks and balances is in place.
These steps are being monitored by President, and Director of Finance,an internal audit was completed on 9/14/2022
Our timeline for completion is December 31 2022.
IRS determines the exact date for the actual audit date.
The corrective action plan was reviewed with Agency staff and implemented on 9/1/2022
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical site inspection, the facility failed to secure hard copy client records within locked storage containers. The room in the basement where discharged files are stored was unlocked.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
during the onsite inspection it was observed that a storage room that houses the facility Router was unlocked . This room was also the storage room for old client files pending shredding. The door was unlocked to gain access to the router . The corrective action plan is to instruct facility staff that all storage room containing any clients files remain locked . It is the facility directors responsibility to assure this policy is being implemented daily .
This corrective action was implemented September 1 2022
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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 a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in three out of seven client records reviewed.
Client #2 was admitted on January 7, 2022 and was still active at the time of the inspection. Updated treatment plans were developed on May 19, 2022 and July 5, 2022 with no type or frequency identified.
Client #3 was admitted on February 24, 2022 and was still active at the time of the inspection. Updated treatment plans were developed on May 20, 2022 and July 22, 2022 with no type or frequency identified.
Client #4 was admitted on April 11, 2022 and was still active at the time of the inspection. An updated treatment plan was developed on June 27, 2022 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director established Master Treatment Planning Policies and procedures. Proper completion of required intake paperwork including but not limited to "Type and frequency of treatment and rehabilitation services.." Those procedures were implemented July 1 2022.
It was observed that clinicians failed to document type and frequency of treatment on the client Treatment plan reviews. A new treatment plan review document was developed that made clear that type and frequency must be filled out for the review to be signed. This policy went into effect on 9/1/2022 and will be updated in the Addictions treatment manual as an amendment.
It is the project directors responsibility to disseminate the new directive and the facility directors responsibility to enforce its implementation. The corrective action plan was reviewed with Agency staff and implemented on 9/1/2022
All client files will have the new TRP documentation updated on their next review date .
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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 a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven records reviewed.
Client #1 was admitted on March 8, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 22, 2022 and the next update was due no later than May 22, 2022; however, the next update was completed on July 22, 2022.
Client #3 was admitted on February 24, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 3, 2022 and the next update was due no later than May 3, 2022; however, it was completed on May 20, 2022.
Client #5 was admitted on June 17, 2021 and discharged on April 21, 2022. A treatment plan update was completed on December 23, 2021 and the next update was due no later than February 23, 2022; however, it was completed on March 3, 2022.
Client #7 was admitted on October 8, 2021 and discharged on July 11, 2022. A treatment plan update was completed on February 15, 2022 and the next update was due no later than April 15, 2022; however, it was not completed until April 25, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director established Treatment Plan Reviews Policies and procedures. Proper completion of required intake paperwork including but not limited to "Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days." Those procedures were implemented July 1 2022
In all client files observed the clinician failed to document their Treatment plan reviews in regards to policies and procedures.
It is the responsibility of the Facility to train existing new staff on proper PNP.
Client # 1 will have an updated TRP on their next scheduled appointment.
Client #3 will have an updated TRP on their next scheduled appointment.
Client #5 will have an updated TRP on their next scheduled appointment.
Client #7 will have an updated TPR on their next scheduled appointment
The corrective action plan was implemented and The staff was retrained on policies on 9-1-2022 as a review of the audit
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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 in three out of seven applicable client records. The facility's policy and procedure states that clients will have their treatment reviewed at a minimum quarterly.
Client #1 was admitted on March 8, 2022 and was still active at the time of the inspection. A case consultation was due not later than June 8, 2022; however, none was completed as of the date of the inspection.
Client #2 was admitted on January 7, 2022 and was still active at the time of the inspection. A case consultation was due on April 7, 2022; however, it was not completed until May 6, 2022.
Client #3 was admitted on February 24, 2022 and was still active at the time of the inspection. A case consultation was due on May 24, 2022; however, none was completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director established Intake Policies and procedures. Proper completion of required intake paperwork including but not limited to "Case consultation notes." Those procedures were implemented July 1 2022.
It is the responsibility for the facility director to instruct all agency staff on proper policies and procedures of Case consultation . Pg 57 in the addictions manual clearly conveys the policy of frequency of case consultation "It is the policy of the PATH Licensed Outpatient Drug and Alcohol Program to
review each client's progress every 90 days at a case conference consisting of representatives from the various client service components. Case Consultations can include just the clinical staff person and one other clinician (Facility Director). Case Consultation notes are documented on the Case Consultation Form."
The project director has instructed the facilities director to update all case consultations for all active clients and document that in the clients' charts. If the client has been discharged, then no further update is possible.
Client#2 Case consultation will be completed on His next appointment 8/29/2022
Client #3 Case consult will be completed on 8/12/2022
The corrective action plan was implemented and The staff was retrained on policies on 9-1-2022 as a review of the audit
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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 as per the policy and procedure after 30, 60, and 90 days in one out of two applicable discharged records reviewed.
Client #5 was admitted on June 17, 2021 and was discharged on April 21, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project director established a New Policies and Procedures program that was implemented , those policies included client follow up procedures. Those procedures were implemented July 1 2022
The counselor failed to provide copies of the discharge letters that were to be mailed out in 30, 60 , and 90 days after discharge . The policy is that those letters are printed out and a copy is to remain in the clients discharge file as proof of the follow up procedure . The other copy is given to secretarial staff and mailed out in the appropriate time tables at the beginning of every month for all discharged clients .
A review of this policy was conducted on 9/1/2022 with all agency staff .
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