INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 8, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Way of Life 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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704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to have one FTE counselor for every eight clients.
The facility has an exception approval to operate with one FTE counselor for every ten clients.
The FTE counselor ' s ratio calculation is as follows: 45/40 = 1.125 (FTE); 18/1.125 = 16:1, which equals to a client/counselor ratio of 16:1.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of combined counselor hours devoted to clients by the facilities hours of operation 40. Then, to obtain the counselor/client ratio, the total number of active clients is divided by the FTE.
At the time of the inspection, the facility has a client/counselor ratio of 16:1 which exceeds the approved 10:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure compliance with FTE counselor ratios at New Way of Life, qualified counselors from other Firetree, Ltd. facilities assisted with duties at the New Way of Life program. In the future if this situation would arise additional qualified counselors from other Firetree LTD. facilities will be moved to the NEW Way of Life to ensure compliance. On October 1, 2021 a new counselor started full time employment at the New Way of Life program which now has 3 FTE counselors. The facility director and corporate clinical director will monitor staff ratios to ensure compliance. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
The facility video camera system is located within the group counseling areas.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The security cameras will be immediately disabled and will be fully removed from the counseling area by 10/8/2021. Beginning 10/1/2021 the facility director and corporate compliance officer will ensure this action occurs and will monitor compliance with the DDAP requirement on an on-going basis. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative information, the facility failed to complete an annual financial audit for the fiscal year 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current financial audit is in progress and is anticipated to be completed and received from the independent certified public accountant agency by 9/30/2021. Firetree, Ltd. shall ensure that future annual financial audits do not exceed a one year timeframe. |
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.
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Observations
Based on two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to keep the specific information disclosed limited to 255.5 (a) (6) for an employer.
Client # 2 was admitted on April 23, 2021 and was discharged on July 23, 2021. An informed and voluntary consent signed by the client on June 4, 2021 allowed for the release of more information than is permitted by 255.5 (a)(6).
Client # 5 was admitted on July 26, 2021 and was still active at the time of the inspection. An informed and voluntary consent signed by the client on August 31, 2021 allowed the release of more information than is permitted by 255.5 (a)(6).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff will be trained by 9/24/2021 on how to complete consent releases to employers of halfway house clients. The current client records identified in the finding have been corrected as of 9/24/2021 to ensure compliance and will be completed on all future admissions to the New Way of Life program in this same manner. The clinical supervisor, and corporate compliance department will conduct weekly chart audits to ensure compliance beginning 9/24/2021. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of administrative information, the facility failed to document the inspection of the medication storage area. The last inspection documented was in 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 9/24/2021 the facility director will ensure that drug storage area inspections occur each quarter by the contracted pharmacy representative. Should the pharmacy not be available to conduct the inspection, a trained facility staff member will conduct the inspections until such time as the pharmacy is able to resume normal operations. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on six of seven client records reviewed, the facility failed to assure counseling services are provided according to the individual treatment and rehabilitation plan.
Client # 1 was admitted on February 12, 2021 and was discharged on May 20, 2021. A treatment and rehabilitation plan was developed on February 16, 2021. Treatment plan updates were completed on March 2, 2021, March 26, 2021, and April 23, 2021. All the documents indicated individual sessions are to occur once per week. A review of progress notes indicated sessions were not conducted according to the treatment plan for the weeks of March 15, 29, April 12, 26, May 3 and 10, 2021.
Client # 2 was admitted on April 23, 2021 and was discharged on July 23, 2021. A treatment and rehabilitation plan was developed on April 26, 2021 and indicated individual sessions to occur once per week. Treatment plan updates were completed on May 11, 2021 (individual once per week), June 10, 2021 (individual twice per week), and July 7, 2021 (individual once bi-weekly). A review of progress notes indicated sessions were not conducted according to the treatment plan for the weeks of May 24, June 14, 21, 28, and July 12, 2021.
Client # 3 was admitted on February 1, 2021 and was discharged on April 5, 2021.
A treatment and rehabilitation plan was developed on February 4, 2021. Treatment plan updates were completed on February 19, 2021, and March 16, 2021. All the documents indicated individual sessions to occur once per week. A review of progress notes indicated sessions were not conducted according to the treatment plan for the weeks of March 1, 8, 22, and 29, 2021.
Client # 4 was admitted on February 12, 2021 and was discharged on May 25, 2021. A treatment and rehabilitation plan was developed on February 16, 2021 and indicated individual sessions to occur once per week. Treatment plan updates were completed on March 2, 2021 (individual once per week), March 25, 2021 (individual once bi-weekly), and April 23, 2021(individual once per week). A review of progress notes indicated sessions were not conducted according to the treatment plan for the weeks of March 15, April 26, and May 10, 2021.
Client # 5 was admitted on July 26, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on July 29, 2021 and indicated individual sessions to occur once per week. Treatment plan updates were completed on August 10, 2021 (individual once per week), and September 8, 2021 (individual once bi-weekly). A review of progress notes indicated sessions were not conducted according to the treatment plan for the weeks of August 16 and 30, 2021.
Client # 6 was admitted on August 2, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on August 5, 2021 and indicated individual sessions to occur once per week. A treatment plan update was completed on August 23, 2021 and indicated individual sessions to occur bi-weekly. A review of progress notes indicated a session was not conducted according to the treatment plan for the week of August 16, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff will be trained by 9/24/2021 on how to update the treatment plans appropriately to reflect the clients frequency of sessions, dependent on their phase of treatment. The clinical supervisor, and corporate compliance department will conduct weekly chart audits to ensure compliance beginning 9/27/2021. Clinical staff were trained by 9/24/21 on how to update the treatment plan appropriately to reflect the clients' frequency of sessions, dependent on their phase of treatment. Current client charts were updated by 10/1/2021 to reflect accurate session frequency. |