INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, LaRocco Counseling 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to document a mechanism to consistently collect feedback on completed training in one of eight personnel records reviewed.
The findings include:
On January 5, 2016, one personnel record was reviewed for training completed within the facility's last complete training year, for the period of 4/30/14 - 4/30/15. This personnel record required documentation of feedback on completed training. The facility failed to document feedback on completed training in personnel record # 1.
Employee # 1 has been in the Project/Facility Director position since 4/30/14. The employee's personnel record failed to document feedback on completed training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.11 (a)(3) Licensure
Training Feedback
In regard to this finding the Project Director has trained the staff on the new training feedback form. This form was instituted immediately and all staff must turn this form in directly to the Project Director following any attended training for evaluation. This form will be housed in the employee file upon completion. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one client records.
The findings include:
One client record requiring written notification to the client of facility's decision to involuntarily terminate the client's treatment was reviewed on 1/5/16. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the facility in client record # 4.
Client # 4 was admitted into treatment on 1/15/15 and was involuntarily terminated from the facility on 9/21/15. There was no documentation of written notification to the client of the facility's decision to involuntarily terminate the client's treatment as of the date of the on-site inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director of LaRocco Counseling assumes responsibility for maintaining compliance with this standard. The Project Director has already trained staff on when a termination letter is required and what should be addressed and specified in the letter. LaRocco Counseling has created and implemented a termination letter to be sent to all individuals involuntarily discharged from the facility, with a description to include the reason behind the discharge.All discharge charts go to the director for review at time of discharge. At this time the Director will ensure this is being done. |
709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to ensure that a complete record was documented in five of five client records reviewed.
The findings include:
Five client records were reviewed for documentation of a complete client record during the renewal inspection on 1/5/16. The facility failed to document a complete record in client records # 1, 2, 3, 4, and 5.
Client # 1 was admitted into treatment on 8/13/15 and was still active at the time of the inspection. The record of service for the client failed to document the provider (counselor) for individual and group counseling sessions attended by the client.
Client # 2 was admitted into treatment on 10/22/15 and was still active at the time of the inspection. The record of service for the client failed to document the provider (counselor) for individual and group counseling sessions attended by the client.
Client # 3 was admitted into treatment on 5/11/15 and was still active at the time of the inspection. The record of service for the client failed to document the provider (counselor) for individual and group counseling sessions attended by the client.
Client # 4 was admitted into treatment on 1/15/15 and was discharged on 9/21/15. The record of service for the client failed to document the provider (counselor) for individual and group counseling sessions attended by the client.
Client # 5 was admitted into treatment on 6/9/15 and was discharged on 12/10/15. The record of service for the client failed to document the provider (counselor) for individual and group counseling sessions attended by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director is responsible for maintaining compliance with ensuring the counselor's name providing the service is included on the record of service. The Project Director has already trained staff on this matter and took the following action: LaRocco Counseling has added a line on the client's record of service to specify the counselor that provided that particular service. Charts will be monitored quarterly by the Project Director and also at time of discharge to ensure compliance. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on all treatment plans, as imposed by 55 Pa. Code Part III, in four of five client records reviewed.
The findings include:
Five client records were reviewed on 1/5/16. All five client records required the documentation of a physician signature on treatment plans, as treatment for these five clients was funded through the Medical Assistance program (CCBH). The facility failed to consistently obtain a physician signature on treatment plans for four of five client records reviewed, specifically client records # 1, 3, 4, and 5.
Client # 1 was admitted into treatment on 8/13/15 and was still active at the time of the inspection. Treatment plan updates completed for the client, dated 10/8/15 and 12/3/15, were not signed by a physician.
Client # 3 was admitted into treatment on 5/11/15 and was still active at the time of the inspection. Treatment plan updates completed for the client, dated 7/20/15, 10/14/15, 12/2/15, and 12/9/15, were not signed by a physician.
Client # 4 was admitted into treatment on 1/15/15 and was discharged on 9/21/15. A treatment plan updated completed for the client, dated 8/20/15, was not signed by a physician.
Client # 5 was admitted into treatment on 6/9/15 and was discharged on 12/10/15. Treatment plan updates completed for the client, dated 8/20/15 and 10/15/15, were not signed by a physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director of LaRocco Counseling is responsible for maintaining compliance with the physicians signature being added to the treatment plan updates and submitted to physician for review. The Project Director has trained all staff in this matter and has instituted this process to begin immediately. Moving forward, the physician will be reviewing all treatment plan updates and signing off on that review |