INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 1, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Counseling Solutions of the Lehigh Valley, 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:
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Plan of Correction
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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.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff received at least 6 hours of HIV/AIDS training and at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics training within the regulatory time frame in one of one applicable personnel record reviewed.
Employee #4 was hired as a counselor on February 21, 2023. The HIV/AIDS and TB/STD trainings were due no later February 21, 2024; however, both trainings were not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Every staff member will have a scheduled personnel review every 6 months to verify compliance with training requirements. This staff member has been re-scheduled for their required HIV and TB trainings, and the certificate of completion must be submitted prior to December 31, 2024.
The team member responsible to ensure this POC is upheld is the Clinical Supervisor. |
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 a review of client records, the facility failed to document the specific information to be disclosed on a consent to release information form in one of seven client records reviewed.
Client #2 was admitted on April 11, 2024 and was active at the time of inspection. There was a release of information form to a funding source that was signed and dated by the client on April 11, 2024; however, the specific information to be disclosed was not included on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Every release will be verified by the witnessing team member during admission to prevent recurrence, where the information permitted to be disclosed and purpose of the purpose of the disclosure must be clearly stated.
Our QA Support will complete a QA review for every active client to confirm that all required releases are correct in their charts, if any release needs to be updated, this will be completed by the primary counselor at the clients next individual session. This will be completed by 9/30/2024.
The team member responsible to ensure this POC is upheld is the Clinical Supervisor. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a consent to release information form in one of seven client records reviewed.
Client #2 was admitted on April 11, 2024 and was active at the time of inspection. There was a release of information form to a funding source that was signed and dated by the client on April 11, 2024; however, the purpose of the disclosure was not included on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Every release will be verified by the witnessing team member during admission to prevent recurrence, where the purpose of the purpose of the disclosure must be clearly stated.
Our QA Support will complete a QA review for every active client to confirm that all required releases are correct in their charts, if any release needs to be updated, this will be completed by the primary counselor at the clients next individual session. This will be completed by 9/30/2024.
The team member responsible to ensure this POC is upheld is the Clinical Supervisor. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in five of six applicable client records reviewed.
Client #1 was admitted on March 25, 2024 and was active at the time of inspection. A treatment plan update was completed on May 23, 2024 and the next update was due no later than July 23, 2024; however, the update was completed on July 31, 2024.
Client #2 was admitted on April 11, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on April 11, 2024 and the first update was due no later than June 11, 2024; however, there was no update completed as of the date of the inspection.
Client #3 was admitted on April 4, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on April 4, 2024 and the first update was due no later than June 4, 2024; however, the update was completed on July 31, 2024.
Client #4 was admitted on March 21, 2024 and was discharged on July 20, 2024. The individual treatment and rehabilitation plan was completed on March 21, 2024 and the first update was due no later than May 21, 2024; however, the update was not completed prior to discharge.
Client #7 was admitted on October 14, 2023 and was discharged on January 8, 2024. The individual treatment and rehabilitation plan was completed on October 23, 2023 and the first update was due on December 23, 2023; however, the update was not completed prior to discharge.
This is a repeat citation from the August 16, 2023 through August 17, 2023 and September 9, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will schedule a supervision session to complete a thorough case consultation of avery active client with each Counselor to enter any treatment plans is updated within the 60 days required. Moving forward, every new admission and active client will have a reminder set by the Clinical Supervisor on the treatment calendar of when their documentation us due. This will be completed by 9/30/2024.
The team member responsible to ensure this POC is upheld is the Clinical Supervisor. |
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 a maintain a complete client record on an individual, which is to include case consultation notes, in three of four applicable client records reviewed.
Client #1 was admitted on March 25, 2024 and was active at the time of inspection. There was no documentation of case consultation notes at the time of the inspection.
Client #2 was admitted on April 11, 2024 and was active at the time of inspection. There was no documentation of case consultation notes at the time of the inspection.
Client #3 was admitted on April 4, 2024 and was active at the time of inspection. There was no documentation of case consultation notes at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will schedule a supervision session to complete a thorough case consultation of every active client with each Counselor and enter the case consultation documentation within the 90 days required. Moving forward, every new admission and active client will have a reminder set by the Clinical Supervisor on the treatment calendar of when their documentation is due. This will be completed by 9/30/2024.
The team member responsible to ensure this POC is upheld is the Clinical Supervisor. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to review and update treatment and rehabilitation plans at least every sixty days was submitted and approved by the Department for the September 9, 2022 and the August 16, 2023 through August 17, 2023 annual licensing inspections. Failing to review and update treatment and rehabilitation plans at least every sixty days was again found to be a deficiency in the August 1, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To comply with plans of correction that were approved by the Department during the previous inspection. This will be completed by 9/30/2024.
A staff training will be scheduled on documentation and treatment planning by 11/15/2024.
A monthly review of the Plans of Correction will be completed. The team member responsible for ensuring this POC is implemented is the Program Director. |