INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 6, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Evolution Counseling Services LLC 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide a written individual training plan to include documentation of input from both the employee and the supervisor for employee # 3.Employee # 3 was hired as a support staff on May 1, 2020 and was still in this position at the time of the inspection. There was no written individual training plan to include documentation of input from both the employee and the supervisor provided in the employee record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L0063: As stated in the Evolution Counseling Substance Outpatient Services policy manual under training requirements as per 28 Pa. Code §704.11. Employee 3 and the Project Director have worked together to create an individual training log that addressed the required trainings for employee 3's job title. Employee 3's individual training log will be assessed and reviewed with the Project Director on a monthly basis that highlights trainings that are applicable to employee's 3 job title. The Project Director's prevention plan is to continue to discuss and assess upcoming trainings and training needs on a monthly basis. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee # 3 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee # 3 was hired as a support staff on May 1, 2020 and was still in this position at the time of the inspection. Employee # 3 was due to have the communicable disease trainings no later than May 1, 2022. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training 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
L0067: The Project Director has had employee 3 complete the HIV/AIDS training on April 11th, 2023. Employee 3 has also completed the TB/STD/Hepatitis training on April 17th, 2023, and Substance Use Disorder Confidentiality training on April 18th, 2023. The Project Director will meet monthly with employees and volunteers to evaluate upcoming trainings, training interests, training evaluations and employee training needs and will document the supervisions and place it in the employee's training binder for continued monitoring and employee access. |
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 two of five applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records # 2 and # 3.Client # 2 was admitted on August 24, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on December 30, 2022. A treatment and rehabilitation plan update was due no later than March 2, 2023. There was no documentation of a treatment plan update in the client record.Client # 3 was admitted on September 23, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on September 28, 2022. A treatment and rehabilitation plan update was due no later than November 28, 2022. A treatment and rehabilitation plan update did not occur until January 25, 2023.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 10, 2022 annual licensing inspection.
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Plan of Correction
L1883: The Project Director had reviewed the Substance Outpatient Policy Manual for the Treatment/Rehabilitation Management Policy code 28 Pa Code §709.24 with the counselor and Employee 3. Project Director and counselor will start tracking on the client open/close excel sheet the initial treatment plan dates and treatment plan updates that are needed for each client. The excel sheet will list dates of when the treatment plans are initially due and when the updated treatment plans are due; the excel sheet will also track signatures needed by the client, the counselor and by the doctor. The excel sheet will be reviewed in monthly supervisions to make sure treatment plan signatures are being obtained. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on four of seven client records reviewed, the facility failed to provide a complete client record to include a record of service that is reflective of the client ' s progress notes in client records # 1, 2, 3, and 4.Client # 1 was admitted on June 7, 2022 and was still active at the time of the inspection. A review of progress notes indicates an individual session occurred on March 24, 17, 3, February 24, 10, 3, and January 27, 20, 2023. These dates were not documented on the client record of service.Client # 2 was admitted on August 24, 2022 and was still active at the time of the inspection. There was not a record of service provided in the client record.Client # 3 was admitted on September 23, 2022 and was still active at the time of the inspection. A review of progress notes indicates an individual session occurred on March 22 and 15, 2023. These dates were not documented on the client record of service.Client # 4 was admitted on November 28, 2022 and was still active at the time of the inspection. A review of progress notes indicates an individual session occurred on March 21, 14, and 7, 2023. These dates were not documented on the client record of service.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L1895: The Project Director and the counselor have determined that the introduction of the new EMR system, TherapyNotes, that is being utilized by Evolution Counseling Services and the Substance Outpatient Program will allow for the Project Director and the counselor to have improved communication on the completion of progress notes needing completed for each client. The Project Director would be able to monitor the counselor's client's session, schedules and incomplete/completed progress notes on a regular basis and address any delayed completion of progress notes in supervision with the counselor. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on three of seven client records reviewed, the facility failed to provide a complete client record to include progress notes that are reflective of the clients record of service in client records # 1, 3, and 7.Client # 1 was admitted on June 7, 2022 and was still active at the time of the inspection. A review of the record of service indicates an individual session occurred on January 3, 2023. There was no progress note for that date in the client record.Client # 3 was admitted on September 23, 2022 and was still active at the time of the inspection. A review of the record of service indicates an individual session occurred on February 24, 2023. There was no progress note for that date in the client record.Client # 7 was admitted on August 1, 2022 and was discharged on October 18, 2022. A review of the record of service indicates an individual session occurred on September 29, 2022. There was no progress note for that date in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and the counselor have determined that the introduction of the new EMR system, TherapyNotes, that is being utilized by Evolution Counseling Services and the Substance Outpatient Program will allow for the Project Director and the counselor to have improved communication on the completion of progress notes needing completed for each client. The Project Director would be able to monitor the counselor's client's session, schedules and incomplete/completed progress notes on a regular basis and address any delayed completion of progress notes in supervision with the counselor. |
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 three of four applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a case consultation to occur at least quarterly.Client # 1 was admitted on June 7, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than September 7, 2022, another on December 7, 2022, and March 7, 2023. There were no case consultations documented in the client record.Client # 2 was admitted on August 24, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than November 24, 2022 and February 24, 2023. There were no case consultations documented in the client record.Client # 3 was admitted on September 23, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than December 23, 2023 and March 23, 2023. There were no case consultations documented in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director had reviewed the Substance Outpatient Policy Manual for the Treatment/Rehabilitation Management Policy code 28 Pa Code §709.24 under Case Consultations. The Project Director and counselor will meet quarterly to review every client that is open in the SOS program. The Project Director will utilize TherapyNotes to document in each individual client's online file, a consultation note that can be accessed at any time by the counselor and the Project Director. |