INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 2-3, 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:
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Plan of Correction
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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.
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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.
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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. This will be supervised by the Project Director and Facility Directors will assist in the hiring process. The job was posted on 8/30/23 and the agency will be in compliance with this standard as of 12/04/2023 |
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.
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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.
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Plan of Correction
The governing body failed to make the annual report available to the public.
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 share holders. This will be monitored monthly by the Project Director and updated as needed by the website developer. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to maintain a complete personnel record in one of three applicable personnel records, for each employee that must include but are not limited to: annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
Employee #2 was hired September 18, 2017, as the facility director and is still employed in this position. An annual staff performance evaluation was completed January 9, 2023. The evaluation was never reviewed with or signed by Employee #2.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to maintain a complete personnel record in one of three applicable personnel records, for each employee that must include but are not limited to: annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee. Employee #2 had an annual staff performance evaluation completed on January 9, 2023 however it was not reviewed or signed by the employee.
This issue has been reviewed with the new Project Director and the Project Director will be responsible to make sure that all yearly staff performance evaluations are reviewed with and signed by the employee.
The agency will be in compliance with this standard as of 9/12/23 |
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 be limited to, written documentation of type and frequency of treatment and rehabilitation services in five out of seven client records reviewed.
Client #2 was admitted on December 12, 2022, and was still active at the time of the inspection. A comprehensive treatment plan was developed on December 19, 2022, with a frequency of " 1-2x ' s weekly " for individual treatment.
Client #4 was admitted on November 18, 2022, and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 28, 2022, with a frequency of " 1-2x ' s weekly " for individual treatment.
Client #5 was admitted on September 16, 2022, and discharged on March 17, 2023. A comprehensive treatment plan was developed on September 23, 2022, with a frequency of " 1-2x ' s weekly " for individual treatment.
Client #6 was admitted on December 7, 2022, and discharged on May 18, 2023. A comprehensive treatment plan was developed on December 27, 2022, with a frequency of " 1-2x ' s weekly " for individual treatment.
Client #7 was admitted on January 11, 2023, and discharged on June 1, 2023. A comprehensive treatment plan was developed on February 1, 2023, with a frequency of " 1-2x ' s weekly " for individual treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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 five out of seven client records reviewed.
The Facility Director will review with all counselors the proper way to document type and frequency of treatment and rehabilitation services to address this issue.
The Project Director, Facility Director, Clinical Supervisor will monitor compliance with these standards through continued supervision and quality review of client files.
The agency will be in compliance with this standard as of 9/30/2023 |
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 three discharged records reviewed.
Client #5 was admitted on September 16, 2022, and discharged on March 17, 2023.
Client #6 was admitted on December 7, 2022, and discharged on May 18, 2023.
Client #7 was admitted on January 11, 2023, and discharged on June 1, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to provide a complete client record, which is to include follow-up information in three out of three dischar/ged records reviewed.
The Project Director and Facility Director will meet with all counselors to reveiw the policies and procedures for follow-up information required for development of complete client record.
The Project Director, Facility Director, Clinical Supervisor will monitor compliance with these standards through continued supervision and quality review of client files.
The agency will be in compliance with this standard as of 9/30/2023 |