INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 9, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Monroe County 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of one personnel record, the facility failed to ensure that each employee had a training plan completed annually.
Employee # 1 was hired as the Project and Facility Director on February 1, 2017 and was still in that position at the time of the inspection. The most recent training plan in the record was completed in February 2020.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director reviewed the individual training plan and updated the clerical error regarding the February 2020 date; it should have been 2021. Additionally, on December 19th, 2021 The Project Director updated Employee #1 training plan for the upcoming year. The plan includes an alert mechanism to ensure training is tracked in a timely manner. This plan was incorporated into employee #1's Personnel Record. |
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.
|
Observations
Based on a review of one personnel record, the facility failed to ensure that staff received at least four hours of TB/STD and 6 hours of HIV/AIDS training.
Employee # 1 was hired as the Project and Facility Director by the facility on February 1, 2017 and was still in that position at the time of the inspection. The employee was due to have the TB/STD and HIV/AIDS trainings no later than February 1, 2018. There was no documentation in the personnel file of the completion of the TB/STD and HIV/AIDS trainings as of the date of the inspection.
This is a repeat citation from the December 18, 2019 and December 1, 2020 licensure renewal inspections.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director prioritized TB/STD and HIV/AIDS training. Employee completed 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training with the Lehigh SCA on December 7, 2021. The Project Director is scheduled for HIV training on Feb. 8-9, 2022. As part of Employee #1's, mandated training, The Project Director has set up an alert mechanism to ensure that mandated training be completed in a timely manner. |
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.
|
Observations
The project failed to ensure that a sufficient number of staff persons were certified in CPR. Based on the review of the Staffing Requirements Facility Summary Report and one personnel record, there was no documentation that the sole employee had current CPR certification.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director has prioritized CPR training. In fact Employee #1 completed an online certified CPR-First Aid training Program on 1/20/22. As part of Employee #1's mandated training requirements, the Project Director has set up an alert mechanism to ensure that CPR mandated training is completed in a timely manner in the future. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of one personnel record, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Employee # 1 functions as the Project Director, Facility Director and counselor since being hired on February 1, 2017. The facility's training year that was reviewed was from February 1, 2020 through January 31, 2021. Employee #1 ' s employee record only documented 6 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director prioritized training for the current and upcoming training year for Employee#1 to ensure that the completion of 25 clock hours of annual training be completed in a timely manner. Since the Survey Exit Date, the Project Director was able to obtain an additional thirteen hours of DDAP approved training. The Project Director will continue to monitor Employee #1's training schedule in order to comply annually with this directive. The goal is for Employee #1 to complete all the necessary training by March 30, 2022. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on a physical plant inspection on November 9, 2021, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The tag on the fire extinguisher located by the front entrance indicated with the most recent inspection and approval occurred on October 15, 2020.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director immediately met with the Landlord after the Survey Exit Date. The Landlord immediately replaced the expired fire extinguisher with two new ones that meet the inspection requirements. The Project Director immediately set up a tickler file to track to ensure they are inspected and approved annually by the local fire department or fire extinguisher company. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
|
Observations
Based on a review of nine client records, the facility failed to follow policy and procedures to maintain confidentiality of client identity and records in two records reviewed. The facility used recycled paper which had assessments and identifying information of previous clients on one side, and two clients were given the backside of the paper to add their own information.
Client #4 was admitted on May 20, 2021 and discharged on July 20, 2021.
Client #9 was admitted on March 24, 2021 and discharged on April 24, 2021.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director reviewed all nine records and other similar records and removed, copied the relevant information to non-recycled paper and/or redacted the recycled paper. Effective immediately the Project will ensure not to utilize any recycled paper of closed out records with all new clients. |
709.28 (c) 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.
|
Observations
Based on a review of nine client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client #3 was admitted September 18, 2021 and discharged October 28, 2021. The record contained documentation of a letter sent to a legal entity that exceeded the specific information to be disclosed according to the consent to release information form signed by the client. The consent form signed on September 12, 2021 only allowed the facility to disclose the client's presence in treatment. However, a letter sent on September 27, 2021 also disclosed the diagnosis and information about treatment history.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Regarding Client #3, it was an oversight to not have obtained or revised the existing consent form that would have allowed to duly release the information that was forwarded to Client #3's Probation Officer. Effective immediately the Project Director will ensure that no correspondence will be sent to any third parties without having a new consent executed specifically citing the information to be shared. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
|
Observations
Based on a review of nine client records, the facility failed to ensure that consent to release information forms included specific information to be disclosed in one record reviewed.
Client #2 was admitted December 28, 2020 and discharged on February 25, 2021. The record contained a consent to release information form to a courthouse signed by the client on December 28, 2020, that did not indicate the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director reviewed Client #2's chart and discovered the oversight. The Project Director immediately developed a checklist to be reviewed before any correspondence is sent out on all future clients. The checklist was implemented as of the Survey Exit Date. The Project Director will ensure that all correspondence information to third parties coincide with the Release Information Consent Form. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to ensure a complete client record, to include an aftercare plan, in one of three applicable records.
Client #4 was admitted on May 20, 2021 and discharged on July 20, 2021.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Not all clients agree to sign Aftercare Plans. We make it available to them but we don't always document their refusal to sign. Client #4 refused to sign. In the future, the Project Director will immediately begin documenting all signed After Care Plans signed or unsigned and make it part of the Client record in order to comply with this directive. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure a complete client record, to include follow-up information, in four of five applicable records.
Client #1 was admitted on December 9, 2020 and discharged on February 9, 2021.
Client #2 was admitted December 28, 2020 and discharged on February 25, 2021.
Client #4 was admitted on May 20, 2021 and discharged on July 20, 2021.
Client #9 was admitted on March 24, 2021 and discharged on April 24, 2021.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director developed a new Client Follow up system and implemented it effective immediately to ensure that all discharged clients receive either follow up letters and/or calls with "how are you doing" questions. The Project director will ensure that all follow contacts or lack thereof are documented on the appropriate forms and become part of the client's record. |