INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on August 10, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Centre Counseling Associates 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(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of employee records and an interview with the Project Director, the facility failed to ensure that sufficient staff had documentation of CPR and First Aid to ensure coverage during all operational hours.
The finding included:
The personnel and training information for the Project Director, who is a sole proprietor, was reviewed during the onsite licensure renewal inspection of August 12, 2012. No documentation of First Aid was included in any of the Project Director's record.
Based on an interview with the Project Director, he stated that he had First Aid training but he was not able to produce documentation to support his contention.
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Plan of Correction
The Project director has taken numerous first aid courses in the past but was unable to find appropriate documentation at the time of the inspection. He will continue to search for the documentation but if unable to locate it he will attend an appropriate first aid couse in the State College area as soon as possible. This would be within 90 days of the inspection if not sooner. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ensure that each bathroom was ventilated by a working exhaust fan or window.
The finding includes:
The physical plant was inspected as part of the August 10, 2012 licensure renewal inspection.. The men's bathroom did not have a working exhaust fan and the window was screwed shut so that it could not be opened. The finding was reviewed with the Project Director and was not disputed.
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Plan of Correction
The Project Director has spoken with the maintenance man in the building that the office is located in about the defective ventalation fan in the rest room and was told that it would be addressed with the owner and apprpriate repair would be facilitated. |
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on the physical plant inspection, the facility failed to maintain a minimum of one operable smoke detector on each floor.
The finding includes:
The physical plant inspection was conducted during the onsite licensing inspection of August 10, 2012. There was one smoke detector in the suite occupied by the Project. The smoke detector, a battery operated type, was lying on a shelf and was not mounted on a wall. When Division staff inspected the detector it was not operable as a result of not having a functioning battery.
The finding was reviewed with the Project Director and was not disputed.
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Plan of Correction
A new battery was obtained and replaced in the smoke detector. It was tested and has been found to be fully funtional. The battery status shall be checked during the scheduled monthly fire drills. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of the facility policy and procedure manual, administrative materials, and an interview with the Project Director, the facility failed to conduct an annual audit.
The finding includes:
The facility policy and procedure manual and administrative documents were reviewed during the onsite licensing renewal inspection of August 10 ,2012. Documentation of an audit or an exception to the audit approved by the Division was not among the materials available for review.
The findings were reviewed with the Project Director and he acknowledged that the audit or exception were not documented.
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Plan of Correction
The project director sent a letter to the Dept. Of Health requesting a waiver from auditing for several reasons that were outlined in past discussions with the Dept. of Health. The letter was addressed to Cheryl Williams and was received by her. She has responded with a request for some clarification of some details and the project director shall be in contact with her to provide such details and clarifications as requested. Witin 30 days.
If the request for a waiver is not granted then an audit shall be conducted by 12/31/2012 |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records and a physical plant inspection, the facility failed to demonstrate or document that clients were informed of their rights.
The finding includes:
One D&A client record was all that was available for review during the onsite licensure renewal inspection of 8/10/12. There was no documentation in the client record that the client had been informed of his rights. A physical plant inspection was conducted and no postings were documented to inform clients of their rights.
The finding was reviewed with the Project Director and was not disputed.
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Plan of Correction
The Project Director explained at the time of inspection that as a routine part of any intake, the client is verbally informed by the therapist, and the Project Director is the only therapist, working at the facility of the clients rights. Also There are copies of the various client rights, policy and procedures that impact the client are made available upon any question or query. The Project Director shall, as was the procedure in the past, have a separate copy of all of these relevant documents in plain sight within the inner office. These documents will be reviewed in depth with the client at the time of intake. A line will be added to the informed consent intake form to attest that the client has been informed of all of these issues and has been offered copies to review or discuss. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of the one D&A client record available and a physical plant inspection, the facility failed to document that the client was informed of the criteria for admission, treatment, completion and discharge.
The finding includes:
One D&A client record was available for review during the annual onsite licensure renewal inspection of August 10 , 2012. The client was admitted on 12/15/10 and last treated on 8/8/12. No documentation was included in the client record informing the client of the criteria for admission, treatment, completion and discharge.
A Physical plant inspection was also conducted. No postings were observed informing clients of project policies.
The finding was reviewed with the Project Director and was not disputed.
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Plan of Correction
The Project Director explained at the time of inspection that as a routine part of any intake, the client is verbally informed by the therapist, and the Project Director is the only therapist, working at the facility of the clients rights. Also There are copies of the various client rights, criteria for addmission, treatment, completion, and discharge and/or any policy and procedures that impact the client are made available upon any question or query. The Project Director shall, as was the procedure in the past, have a separate copy of all of these relevant documents in plain sight within the inner office. These documents will be reviewed in depth with the client at the time of intake. A line will be added to the informed consent intake form to attest that the client has been informed of all of these issues and has been offered copies to review or discuss |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of the one D&A client record available and a physical plant inspection, the facility failed to document that the client was informed of project policies.
The finding includes:
One D&A client record was available for review during the annual onsite licensure renewal inspection of August 10 , 2012. The client was admitted on 12/15/10 and last treated on 8/8/12. No documentation was included in the client record informing the client of project policies. A Physical plant inspection was also conducted. No postings were observed informing clients of project policies.
The finding was reviewed with the Project Director and was not disputed.
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Plan of Correction
The Project Director explained at the time of inspection that as a routine part of any intake, the client is verbally informed by the therapist, and the Project Director is the only therapist, working at the facility of the clients rights. Also There are copies of the various client rights, criteria for addmission, treatment, completion, and discharge and/or any policy and procedures that impact the client are made available upon any question or query. The Project Director shall, as was the procedure in the past, have a separate copy of all of these relevant documents in plain sight within the inner office. These documents will be reviewed in depth with the client at the time of intake. A line will be added to the informed consent intake form to attest that the client has been informed of all of these issues and has been offered copies to review or discuss |
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 the one D&A client record available, the facility failed to document treatment plan updates which identified client progress during treatment during treatment .
The finding includes:
One D&A client record was available for review during the annual onsite licensure renewal inspection of August 10 , 2012. The client was admitted on 12/15/10 and last treated on 8/8/12. The treatment plan was formulated on 1/19/11. Treatment plan updates failed to document progress the client made during the course of treatment. Treatment plan updates were documented on the following dates during the year under review: 5/19/11, 7/19/11, 9/19/11, 11/19/11, 1/19/12, 3/19/12, 5/19/12 and 7/19/12. In each case the only comments on the client's progress in treatment were the abbreviations GIP- (goal in progress) There was no evidence of a discussion regarding the client's progress during the reporting period or the need to make goal modifications due to lack of progress.
The finding was reviewed with the Project Director and was not disputed.
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Plan of Correction
The Project Director has reviewed the file in it's entirety and has consulted with the client to discuss this issue. The treatment plan shall from 9/18/2012 reflect the progress toward goals as being positive or negative according to the client and counselor's's discussions in sessions and upon the bimonthly treatment plan review.
The treament plan had not been updated as to any changes in the goals because of the nature of the client's particular situation. This being long-term suboxone treatment and maintenance at another facility and the client being on permanent SSI disablity because of a back injury. Both of these factors have been constant and relevant through the course of treament and the individual sessions would be classified more as a maintenance therapy and a requirement of the ancillary suboxone clinic. The client has maintained a steady level of compliance with these two goals. |
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 the review of the one client record that was available, the facility failed to provide treatment services in accordance with the frequency documented on the client's individual treatment plan.
The finding includes:
One D&A client record was available for review during the annual onsite licensure renewal inspection of August 10 , 2012. The client was admitted on 12/15/10 and last treated on 8/8/12. The treatment plan was formulated on 1/19/11. The individual treatment plan stated that the client would attend individual counseling to work on his stated treatment goals two times per month. Based on the documentation on the client record, the client only attended one session per month during the following months in 2012: January, February, March, April, May, June and July. In 2011 the client only attended one session per month in the following months: August, September, October, November and December.
The finding was reviewed with the Project Director and was not disputed.
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Plan of Correction
The Project Director has reviewed the client file and made the necessary correction, with the client's participation, the treatmet plan has been revised to reflect one session per month rather than the two that were listed. The sessions were dropped from twice per month to once per month at the client's request in accordance with the counselor and the requirements of a program that he is a participant in.
These changes were made for the months of January, February, March, April, May, June and July,2012 and in August, September, October, November and December 2011.
The treatment plan now reflects 1 session per month. |