INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 12, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation, Inc. 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 ensure all counselors met the appropriate qualifications for the position in one of one applicable personnel record reviewed.
Employee # 6 was hired as a counselor on July 17, 2024. The personnel record included documentation of the employee ' s college transcripts; however, there was no conferred degree date on the transcripts and there was no copy of a degree in the record. Additionally, the employee did not obtain any other qualifying certifications or degrees as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to ensure all counselors met the appropriate qualifications for the position in one of one applicable personnel record reviewed. Employee # 6 was hired as a counselor on July 17, 2024. The personnel record included documentation of the employee ' s college transcripts; however, there was no conferred degree date on the transcripts and there was no copy of a degree in the record. Additionally, the employee did not obtain any other qualifying certifications or degrees as of the date of the inspection. Clinical Supervisor will ensure that a copy of a conferred degree is in the employee record if applicable; if there is no conferred degree, other qualifying certifications or degrees will be in the employee record within 7 days of the hire date. Until then, employee #6 will be a counselor assistant. This will be done by training Human Resources staff and through regular personnel record checks. The facility will be compliant by 3/31/2025. |
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 persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of three applicable personnel records reviewed.
Employee # 4 was hired as a counselor on October 25, 2023 and was due to have the HIV/AIDS training and the TB/STD training no later than October 25, 2024. Both the HIV/AIDS training and the TB/STD training 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
The facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of three applicable personnel records reviewed. Clinical Supervisor will ensure all staff persons receive the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe. Employee #4 completed the TB/STD training on June 7, 2024. However, there was technical difficulty and the certificate was not released until recently. Employee #4 will complete the HIV/AIDS training by 3/31/2025. This will be done through training of Human Resources staff and regular personnel records checks. The facility will be compliant by 3/31/2025. |
709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel records included the written verification of qualifying professional credentials in one of one applicable personnel records reviewed.
Employee # 6 was hired as a counselor on July 17, 2024. There was no qualifying professional credentials documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure all personnel records included the written verification of qualifying professional credentials in one of one applicable personnel records reviewed. Employee # 6 was hired as a counselor on July 17, 2024. There was no qualifying professional credentials documented in the personnel record at the time of the inspection. Clinical Supervisor will ensure there is a high school diploma documented in employee #6 personnel record by 2/28/2025 if the college does not release the Bachelor's diploma. Employee #6 will be a counselor assistant until she reaches counselor status. Clinical supervisor will train Human Resources staff to ensure new hires have qualifying professional credentials in their personnel record. The facility will be compliant by 2/28/2025. |
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 client records, the facility failed to document the purpose of the disclosure on release of information forms in two of seven client records reviewed.
Client # 1 was admitted on April 9, 2024 and was still active at the time of the inspection. The release of information form to a probation officer was signed by the client on April 10, 2024, but the form did not include the purpose of the disclosure.
Client # 5 was admitted on May 31, 2024 and was discharged on October 16, 2024. The release of information form to an emergency contact was signed by the client on June 4, 2024, but the form did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document the purpose of the disclosure on release of information forms in two of seven client records reviewed. Clinical Supervisor will ensure the purpose of disclosure on release of information forms is documented. This will be done through regular file checks and training of staff. The facility will be compliant by 2/28/2025. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission procedures, a preliminary treatment and rehabilitation plan in one of two applicable client records reviewed.
Client # 7 was admitted on July 23, 2024 and was discharged on October 4, 2024. There was no preliminary treatment plan documented in the record 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 facility failed to document, as part of their intake and admission procedures, a preliminary treatment and rehabilitation plan in one of two applicable client records reviewed. Clinical Supervisor will ensure that client records include a preliminary treatment and rehabilitation plan as part of the intake and admission procedures. This will be done by training of staff and regular client file checks. The facility will be compliant by 2/28/2025. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of progress notes, in three of seven client records reviewed.
Client # 1 was admitted on April 9, 2024 and was still active at the time of the inspection. The record of service indicated a counseling session was completed on September 24, 2024; however, there was no corresponding progress note documented in the record.
Client # 3 was admitted on September 20, 2024 and was still active at the time of the inspection. The record of service indicated a counseling session was completed on September 30, 2024; however, there was no corresponding progress note documented in the record.
Client # 7 was admitted on February 2, 2024 and was discharged on November 27, 2024. The record of service indicated counseling sessions were completed on August 6, 2024, August 7, 2024, August 12, 2024, August 14, 2024, August 16, 2024, August 20, 2024, August 21, 2024, and August 28, 2024; however, there were no corresponding progress notes for each session documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to maintain a complete client record, which is to include the documentation of progress notes, in three of seven client records reviewed. The Clinical Supervisor will ensure a complete client record is maintained which is to include the documentation of progress notes. This will be done through staff training and regular client file checks. The facility will be compliant by 2/28/2025. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of a discharge summary, in two of four applicable client records reviewed.
Client # 6 was admitted on May 21, 2024 and was discharged on October 16, 2024. There was no discharge summary in the record at the time of the inspection.
Client # 7 was admitted on July 23, 2024 and was discharged on October 4, 2024. There was no discharge summary in the record 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 facility failed to maintain a complete client record, which is to include the documentation of a discharge summary, in two of four applicable client records reviewed. The Clinical Supervisor will ensure a complete client record is maintained which is to include the documentation of a discharge summary. This will be done through staff training and regular client file checks. The facility will be compliant by 2/28/2025. |