INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 6, 2021 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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704.7(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.
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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 #3, who was hired as a counselor on May 3, 2021, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor.
This is a repeat citation from August 31, 2020 annual licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
At the time of Audit, the employee was determined not to have been presented with the correct title as an assistant counselor. The employee as per company policy was given weekly documented supervision by the Facilities director. This supervision is part of the employee's probationary period.
The facilities director failed on the attestation forms to title this employee correctly.
POC is that the employee will receive the title as assistant counselor until she has reached the required 6 months of close supervision. The employee will reach her 6-month supervision date on 11-3-21 The facilities director will make sure to review all employees for their proper designation for the next audit .
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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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to develop a written individual training plan for each employee. The training year is July 1, 2021 through June 30, 2022.
Employees #2 was hired on December 7, 2020 and was still employed at the time of the inspection. The training plan was not completed until September 23, 2021.
Employee #3 was hired on May 3, 2021 and was still employed at the time of the inspection. The training plan was not completed until September 23, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was noted that company Staff training plans were not completed in July of 2021 Due to the resignation of the program director. The new program director implanted the company training plans and had employees sign the new training plans, this explains the late date of the signed training plans.
All employees upon hire are given a DDAP training plan. These include Addictions 101, Confidentiality, Practical application of confidentiality, Ethics , TB/STD Heb and Hiv to complete in the first year of hire . The deficiency was the Facilities director did not document this in the files of the new Employees.
The POC is that the Facilities director will give written documentation to each employee the required trainings as per DDAP along with the Company training Plan . This policy went into effect on Nov-1-2021
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information in two out of seven records reviewed, as there were forms that were missing required information.
Client #1 was admitted on November 25, 2020 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 10, 2021 to an external provider, but the consent form did not include a dated signature of witness.
Client #4 was admitted on July 29, 2020 and was still active at the time of the inspection. There was a consent to release form, signed and dated by the client on August 3, 2020 to two government agencies, a funding source and a lab, but the witness signature was dated July 29, 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It was noted in the inspection that the consents were not filled out properly.
Missing signatures of witness, Dates not coinciding when observed.
POC was that the director reviewed with the staff the proper procedures and requirements for completing all paperwork in the client file. It was stressed that witness signatures are needed on the date of signature to validate that client's signature.
In client #4 chart the date on the release was Dated incorrectly. It is the responsibility of the clinician and the director the audit for these mistakes and correct as needed in the chart.
It is the responsibility of the Facilities director and the lead counselor to review and audit all charts for accuracy. This policy is in effect on Nov 1 2021
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of the client consent was offered to the client with a copy maintained in the client record.
Client #5 was admitted on January 12, 2021 and was discharged on September 1, 2021.
Client #6 was admitted on August 18, 2021 and was discharged on September 21, 2021
This is a repeat citation from August 31, 2020 annual licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This citation was addressed with all staff and educated on the procedures of completing all forms properly . The facilities director and the lead counselor will inspect every file and hold the clinician accountable for not following these procedures. The facilities director will also retrain all staff and new hires on the proper way to complete Releases and the specific information to be released per the type of release signed. This policy was continuing to be implemented on November 1 2021. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the policy and procedures manual and client rights documentation on October 6, 2021, the project failed to include all parts of the client rights regulation. The project failed to include that a client may not be discriminated against creed, sex, color, and national origin in seven out of seven records.
This is a repeat citation from the August 31, 2020, the March 11, 2020 and the September 5, 2019 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The PNP Manual and clients rights documents were updated after the previous inspection . The Facilities director omitted the terms "creed, sex, color,"
The Program director has corrected the PNP and has instructed all Facility directors and staff to update all current clients files with the updated Nondiscrimination policy which is as follows, "The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion"
This policy is in effect 10/25/21
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to document that the client shall have an opportunity for reconsideration of a decision to terminate treatment in one out of two applicable records.
Client #7 was admitted on November 6, 2020 and discharged on June 8, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facilities director noted in this client file that the clinician failed to document in the unsuccessful discharge that the client had a 10 day opportunity to reengage in treatment services as per the company PNP.
On 10-18-21 the entire staff was instructed on proper discharge paperwork. The were also instructed on the PNP regarding Discharge requirements.
It is the responsibility of the clinician to make sure all paperwork is filled out properly before discharge . The clinician will submit the file to the Lead counselor or Facilities director for Audit . Upon completion the Facilities director will submit the file for discharge .
This policy remains in effect Nov 1 2021
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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 three out of seven client records reviewed.
Client #2 was admitted on July 9, 2020 and was still active at the time of the inspection. A treatment plan was completed on September 23, 2020 and the next update was due no later than November 23, 2021; however, the next update was completed on February 25, 2021. Additionally, the next update was due no later than April 25, 2021 and was not completed until July 13, 2021.
Client #3 was admitted on December 16, 2020 and was still active at the time of the inspection. A treatment plan update was completed on February 24, 2021 and the next update was due no later than April 24, 2021; however, there were no more updates.
Client #4 was admitted on July 29, 2020 and was discharged on September 29, 2021. A treatment plan was completed on August 3, 2020 and the next update was due no later than October 3, 2020; however, the next documented update was not until February 11, 2021.
Client #7 was admitted on November 6, 2020 and discharged on June 8, 2021. A treatment plan was completed on November 17, 2021, an update was completed on January 26, 2021 and March 25, 2021; and the next update was due no later than May 25, 2021; however, the were no further updates.
This is a repeat citation from August 31, 2020 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In this citation the TPR's in files #2,#3,#4 and #7 were not performed in the required 60 day time frame. The director reeducated the staff on the requirements for TRP's . The Facilities director continues to implement a policy in which the Facilities Director will oversee all chart audits monthly. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit and continuing through to discharge of a client.
Client #2 will have an updated TPR on his next appointment.
Client #3 was discharged on October 7th so an updated TPR could not be attained
Client #4 was discharged Unsuccessfully due to noncompliance of attendance. His attendance limited the ability to complete an accurate TPR sequence
Client #7 the clients lack of attendance limited the ability to complete an accurate TPR sequence.
In the future Case consults will document and acknowledge these deficiencies in client attendance and their effect on updated required paperwork.
This policy is the responsibility of the Facilities director to maintain accurate update files for all clients .
The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete all admit and discharge file paperwork to comply with DDAP regulations.
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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 a review of client records, the facility failed to document case consultation notes according to their policy of every ninety days in three out of seven records reviewed.
Client #2 was admitted on July 9, 2020 and was still active at the time of the inspection. A case consult was completed on July 9, 2020 and the next case consult was due no later than October 9, 2020; however, the next consult was completed on February 25, 2021. Additionally, the next case consult was due no later than May 25, 2021 and was not completed until July 13, 2021.
Client #3 was admitted on December 16, 2020 and was still active at the time of the inspection. A case consultation was completed on March 18, 2021 and the next case consult was due no later than June 18, 2021; however, there were no more updates.
Client #4 was admitted on July 29, 2020 and was discharged on September 29, 2021. A case consultation was due no later than October 29, 2020; however, the next documented case consultation was not until February 11, 2021 and then not again until August 3, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In this citation the case consults were not performed in the required 90 day time frame as per PNP. The Facilities director reeducated the staff on the requirements for Case Consults . The Facilities director has implemented a policy in which the Facilities Director will oversee all chart audits monthly. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit and continuing through to discharge of a client. All active clients will have their Case consults updated on their next session. Case consults will document and acknowledge these deficiencies.
This Policy was implemented on November 1 2021. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete all admit and discharge file paperwork to comply with DDAP regulations.
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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 document follow-up information according to their policy of seven days, one, three and six months in two out of two applicable records.
Client #5 was admitted on January 12, 2021 and was discharged on September 1, 2021. A follow-up phone call was due on September 8, 2021 and a letter was due October 1, 2021.
Client #6 was admitted on August 18, 2021 and discharged September 21, 2021. A follow-up phone call was due September 28, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was noted that the follow-up discharge information was not in the three filed audited. The PNP states that each client will have A completed aftercare plan , Discharge summary, Follow up , Phone call (7days) 30, 60 and 90 day letters .The follow up documents were not present in the discharged files . All staff will be reeducated on PNP for all aspects of the PNP. Including but not limited to Intake , clearances , proper completion of the client file and discharge and follow up procedures. It is the Clinical supervisors responsibility to Audit all files to determine if they are compliant to PNP and DDap regulations. The facility director will complete a follow up discharge audit of all discharged files. |