INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 7, 2023, 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:
|
Plan of Correction
|
704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
|
Observations
The drug and alcohol treatment project failed to provide documentation of a full-time clinical supervisor for every eight full-time counselors based on a review of the Staffing Requirements Facility Summary Reports for the four facilities within the project. The Staffing Requirements Facilities Summary Reports for the facilities were dated July 24, 2023 (Milton,) July 25, 2023 (E. Stroudsburg,) July 6, 2023 (Honesdale) and July 5, 2023 (Altoona) documented a total of 8.25 full-time counselors employed by the project. This number of
full-time counselors would require a minimum of one full-time clinical supervisor.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The position of clinical supervisor has been posted both internally and externally by the company. The clinical supervisor will be mobile and will conduct group supervision and 1-1 supervision with all clinical staff. They will also be responsible for the oversight and training of all counselor assistants. |
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.
|
Observations
Based on a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.
Employee #4, who was hired as a counselor on January 2, 2023, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have the one year of clinical experience required to be a counselor with a bachelor's degree.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Due to this deficiency the identified employee is reclassified effective 9/12/23 to counselor assistant. The Facility Director and/or Project Director will provide the individual with weekly supervision and observation for the remaining 5 months, until she is eligible to be evaluated and transitioned to a counselor role.
Moving forward, all new hires will be stringently compared to the DDAP staffing regulations and assigned job roles in conjunction with those regulations. This will be completed by the Facility Directed and overseen by the Project Director to ensure that such a situation does not arise again. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
|
Observations
Based on a physical site inspection, it was determined that the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
It was observed, by DDAP Licensing staff, that the rear exit to the right of the reception area, one of three means of egress, was obstructed by garden hoses and refuse which could present a slip, trip or fall hazard.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director will ensure this standard is met and maintained through daily, weekly, and monthly observations to ensure all egress points are free from obstructions. In addition to the facility director, counseling and supervisory level staff will conduct random checks to assist with maintaining this standard. The correction to this deficiency was completed upon the conclusion of the licensing audit on the indicated date. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
|
Observations
Based on a review of the facility's administrative actions, the governing body failed to make the annual report available to the public.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will contact the website developer to address the noted issues. The annual report link will be updated with a section to include the names of board members, directors, and any other invested shareholders. This will be monitored monthly by the Project Director and updated as needed by the website developer. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
|
Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent, in three out of seven client records, 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 the date, event, or condition upon which the consent will expire.
Client #2 was admitted on May 10, 2023, and was still an active client at the time of the inspection. A consent to release form dated May 10, 2023, for an emergency contact did not include documentation of an expiration date or condition. Additionally, a consent to release form dated May 10, 2023, for the SCA did not include documentation of an expiration date or condition.
Client #3 was admitted on June 2, 2023, and was still an active client at the time of the inspection. A consent to release form dated June 2, 2023, to a medical provider did not include documentation of an expiration date or condition.
Client #5 was admitted on April 28, 2023, and was discharged on July 11, 2023. A consent to release form dated April 28, 2023, to a medical provider did not include documentation of an expiration date or condition.
This is a repeat citation from the August 12, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 8/9/23, The facility director met with counseling staff regarding facility findings as they relate to confidentiality in which this location failed to indicate the condition upon which the consent will expire.
The facility director and or the project director will ensure this standard is maintained through weekly supervisions and audits regarding but not limited to this standard. In addition, the agency project director and facility director will also conduct random audits relating to this deficiency on a monthly basis.
|
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.
|
Observations
Based on a review of client records, the facility failed to complete a preliminary treatment plan, in four of seven client records, in accordance with its policy which requires the preliminary treatment plan to be completed during the first session.
Client #1 was admitted on January 30, 2023, and was still active at the time of the inspection. As per the facility's policy the preliminary treatment plan was due to be completed on January 30, 2023. The preliminary treatment plan was not completed until February 6, 2023.
Client #2 was admitted on May 10, 2023, and was still active at the time of the inspection. As per the facility's policy the preliminary treatment plan was due to be completed on May 10, 2023. The preliminary treatment plan was not completed until June 2, 2023.
Client #3 was admitted on June 2, 2023, and was still active at the time of the inspection. As per the facility's policy the preliminary treatment plan was due to be completed on June 2, 2023. The preliminary treatment plan was not completed until June 13, 2023.
Client #6 was admitted on December 20, 2022 and discharged on March 28, 2023. As per the facility's policy the preliminary treatment plan was due to be completed on December 20, 2022. The preliminary treatment plan was not completed until December 28, 2022.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director met with counseling staff to review this deficiency on 9/4/2023.
The facility director and or project director will ensure this standard is met and maintained through weekly supervision with counseling staff. In addition, weekly and monthly random chart audits conducted by the facility director and or the project director will ensure this standard is met and ongoing. |
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.
|
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 be limited to, written documentation of type and frequency of treatment and rehabilitation services in four out of seven client records reviewed.
Client #1was admitted on January 30, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on March 1, 2023, with a frequency of "1-2x's weekly" for individual treatment.
Client #2 was admitted on May 10, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 9, 2023, there was no frequency of treatment noted on the document.
Client #3 was admitted on June 2, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 13, 2023, there was no frequency of treatment noted on the document.
Client #6 was admitted on December 20, 2022, and discharged on March 28, 2023. A comprehensive treatment plan was developed on January 20, 2023, with a frequency of "1-2x' s weekly " for individual treatment.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director met with counseling staff on 9/12/2023 to review this deficiency. Counseling staff were educated on the importance of clearly identifying the specific type and frequency of treatment and rehabilitation services.
This standard will be met and maintained through weekly supervision conducted by the facility director and or project director. In addition, the facility director and or project director will conduct random weekly and monthly chart audits to ensure this standard is met and ongoing. |
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.
|
Observations
Based on a review of outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in three out of seven charts reviewed.
Client #1 was admitted on January 30, 2023, and was still active at the time of the inspection. The comprehensive treatment plan dated March 1, 2023 indicated one to two individual outpatient sessions per week; additionally, it also indicated a group session one time weekly. The record of service and progress notes indicated that the client received no individual sessions during the weeks of February 19, 2023, March 5, 2023 and March 12, 2023; additionally, the client received no group sessions from February 5, 2023 through February 25, 2023.
Client #2 was admitted May 10, 2023, and was still active at the time of the inspection. The comprehensive treatment plan, dated June 9, 2023, indicated a group session one time weekly. The record of service and progress notes indicated that the client had not received any group sessions from June 9, 2023 through July 31, 2023.
Client #7 was admitted on December 29, 2022, and was discharged on April 20, 2023. The comprehensive treatment plan, dated January 27, 2023, indicated one individual outpatient sessions per week; additionally, it also indicated a group session one time weekly. The record of service and progress notes indicated that the client received no individual sessions during the weeks of March 5, 2023, and March 12, 2023; additionally, the client received no group sessions during the weeks of March 12, 2023 and March 19, 2023.
This is a repeat citation from the August 12, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director met with the counseling staff on 9/12/23 to review this deficiency. Counseling staff were educated on the importance of clearly identifying the specific type and frequency of treatment and rehabilitation services.
This standard will be met and maintained through weekly supervision conducted by the facility director and or project director. In addition, the facility director and or project director will conduct random weekly and monthly chart audits to ensure this standard is met and ongoing. |
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.
|
Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy states that case consultations must be completed within thirty days of the intake session.
Client #2 was admitted on May 10, 2023, and was still active at the time of the inspection. The initial case consultation dated May 10, 2023, was signed only by the clinician. There was no secondary review or sign-off.
Client #4 was admitted on admitted on May 25, 2023, and was still active at the time of the inspection. The initial case consultation dated May 25, 2023, was signed only by the clinician. There was no secondary review or sign-off.
Client #6 was admitted on December 20, 2022, and discharged on March 28, 2023. The initial case consultation dated December 20, 2022 was signed only by the clinician. There was no secondary review or sign-off.
Client #7 was admitted on December 29, 2022, and discharged on April 20, 2023. The initial case consultation dated December 29, 2022, was signed only by the clinician. There was no secondary review or sign-off.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The facility director and or project director will review and sign off on all case consultations including but not limited to the intake case consult. The agency will utilize a flow chart as well as an electronic calendar denoting new clients entering treatment to aid with maintaining this standard. Weekly supervisions conducted by the facility director and or the project director will focus on this standard to ensure compliance is met and ongoing. |