INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15, 2024, through October 16, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, AWJWI LLC d/b/a Sobriety Solutions Pennsylvania 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(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.
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Observations
Based on the review of personnel records, the project failed to document a written initial individual training plan for each employee, appropriate to that employee's skill level with input from both the employee and the supervisor in three out of seven records reviewed.
Employee #4 was hired on March 11, 2024, and was to have an initial individual training plan documented by April 11, 2024; however, it was not documented in the personnel record until September 2, 2024.
Employee # 6 was hired on December 5, 2023, and was to have any initial individual training plan documented by January 5, 2024; however, there was no training plan documented in the personnel record at the time of the inspection.
Employee #7 was hired on January 15, 2024, and was to have an initial individual training plan documented by February 15, 2024; however, it was not documented in the personnel record until July 15, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Per DDAP regulation. 704.11(b)(1), Leadership team will review any new hires and ensure program directors have completed an initial training plan for each employee and with input from employee and supervisor a plan will be completed within first 30 days of employment. Leadership team will review any new hire and ensure that the initial training plan is completed within the first 30 days. A training plan was completed for employee #6. |
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 the review of seven personnel records, the project failed to ensure that one employee received a minimum of six hours of HIV/AIDS and at least four hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum.
Employee #4 was employed as a counselor on August 25, 2022, and was to have the communicable disease training by August 25, 2023; however, there was no documentation in the personnel file of the completion of a Department approved HIV/AIDS training and TB/STD training as of the date of the inspection.
This is a repeat citation from the January 30, 2018, January 24, 2020, October 21, 2020, October 22, 2021, December 12, 2022, June 27, 2023, and December 19, 2023 annual licensing renewal inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Pursuant to DDAP regulation 704.11(c)(1), new hires will be trained with at least 4 hours of TB/STD and at least 6 hours of HIV/AIDS when hired or will be asked to provide these trainings upon start date. If a new hire has not been trained or does not having training documentation, the new employee will be required to complete these trainings. During weekly clinical meetings with Clinical Director and Chief Clinical officer, CD will identify any new staff members and have them complete these required trainings if these have not already been completed. Leadership Team will meet monthly and review new hires' training needs to ensure that all new staff have been trained. Employees 1, 3 and 8 will complete their TB/STD trainings by 11/14/2023. Employee 4 has completed the 6 hour HIV/AIDS and the 4 TB/STD training pursuant to regulation 704.11(c)(1). Staff TB/STD trainings and HIV/AIDS training requirements will be on the monthly leadership meeting agenda in effort to ensure compliance for regulation 704.11(c)(1) |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of seven personnel records and staff training records, the project failed to instruct all staff in the use of the fire extinguisher upon employment.
Employee #6 was hired as a counselor on December 5, 2023, and was to have instruction on the use of the fire extinguisher upon employment; however, the employee was not instructed on the use of the fire extinguisher until January 10, 2024.
Employee #7 was hired as the counselor on January 15, 2024, and was to have instruction on the use of the fire extinguisher upon employment; however, the employee was not instructed on the use of the fire extinguisher until January 30, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Pursuant to 705.28 (c) (4), employees #6 and #7 completed use fire extinguisher training on 11/8/2024. Leadership reviewed onboarding documentation and have included FireExtinguisher Training in onboarding documentation packet. HR will review all new hire onboarding and will report to leadership when onboarding is complete for all new employees including completion of Fire Extinguisher Training upon hire. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of seven personnel records and staff training records, the project failed to ensure that two personnel are trained to perform assigned tasks during emergencies upon working a shift.
Employee #6 was hired as a counselor on December 5, 2023, and was to be trained to perform assigned tasks during emergencies upon working a shift; however, the employee did not receive this training until January 10, 2024.
Employee #7 was hired as a counselor on January 15, 2024, and was to be trained to perform assigned tasks during emergencies upon working a shift; however, the employee did not receive this training until January 30, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Pursuant to 705.28 (d) (3), it was found that employees #6 and #7 were not trained upon hire and they were trained in January of 2024.
Leadership will meet monthly to review all new hires and ensure necessary training has been completed. Upon hiring of new employees, the employee will be trained to perform assigned tasks during emergencies. HR will review all new hire documentation utilizing New Hire Checklist in each employee's HR file. HR will report to CFO of any outstanding training and/or documentation to ensure all new staff is trained appropriately. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on the review of the policy and procedure manual, the project failed to develop written procedures for the management of treatment/rehabilitation services for clients that included timeframes on the completion of client case consultations.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CCO revised the facility's Policies and Procedures to address lack of timeframes regarding case consultations.
Leadership discussed the revision which stated that "case consolations will be complete for each client prior to discharge."
Case consultations were added to EMR system and all clinical staff has been updated and trained on case consultations, the timeframe outlined in the Policies and Procedures and how to initiate the form in EMR system as of 11/1/2024. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records, the project failed to offer a copy of the release of information forms in one of fourteen client records reviewed.
Client #5 was admitted on June 24, 2024, and was discharged on July 16, 2024. There was no documentation that the client was offered a copy of the release of information forms for the funding source, emergency contact and mental health provider, all signed and dated by the client on June 24, 2024.
This is a repeat citation from the December 19, 2023, annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Each new admission will be offered a copy of release of information which is part of the intake documentation. Admissions staff has been advised of client #5 not having a signed document offering a copy of releases. This form has been added to EMR to automatically load during admission forms.
Admissions Director met with COO, CD and CCO to identify and correct this deficiency.
CD and AD will review all new intake forms for new clients to ensure that a copy of releases was offered over regulation 709.28 (d). |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of the seven applicable client records reviewed.
Client #9 was admitted on August 27, 2024, and was a current client at the time of the licensing inspection. The individual treatment and rehabilitation plan was completed on September 5, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #10 was admitted on August 30, 2024, and was a current client at the time of the licensing inspection. The individual treatment and rehabilitation plan was completed on September 16, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #11 was admitted on January 11, 2024, and was discharged on May 13, 2024. The individual treatment and rehabilitation plan was completed February 15, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #14 was admitted on August 5, 2024, and was discharged on September 4, 2024. The individual treatment and rehabilitation plan was completed August 21, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CCO and CD held a treatment team meeting on 11/1/2024 and incorporated a Treatment Planning Training following the treatment team meeting.
CCO and CD review Treatment Planning SOPs including the need to capture type and frequency of treatment and rehabilitation services. CCO and CD provided examples of documentation regarding type and frequency of treatment and rehabilitation services based on an individuals level of care whether PHP, IOP or OP.
CD met with primary therapists of client's #9, #10, #11 and #14. Clinical staff added type and frequency of treatment and rehabilitation services based on the individual's current level of care.
CD will review all treatment plans and sign off ensuring that regulation 709.82(a)(2) has been followed. |
709.83(a)(11) LICENSURE Client records
709.83. 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.
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Observations
Based on the review of partial hospitalization client records, the project failed to document a complete client record on an individual that included follow-up contact notes in four of four applicable client records reviewed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Pursuant to regulation 709.83(a)(11), it was found that follow up contact was not documented for 4 of 4 partisan hospitalization clients charts reviewed.
Leadership team met and will complete all follow up contacts in CRM to be completed by Alumni Coordinator.
COO will review all portal hospitalization discharges weekly and audit CRM of partial hospitalization discharged clients to ensure follow up contacts are made.
This policy will be on the weekly business development agenda to ensure follow up contact is being made and that facility its in compliance with regulation 709.83(a)(11) |
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 the review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in four of seven records reviewed.
Client #1 was admitted on June 10, 2024, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan was documented in the record on June 19, 2024, and the update was due no later than August 19, 2024; however, there was no updated plan documented in the record until September 18, 2024.
Client #2 was admitted on April 23, 2024, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan was documented in the record on May 8, 2024, and the update was due no later than July 8, 2024; however, there was no updated plan documented in the record until September 26, 2024.
Client #3 was admitted on February 26, 2024, and was a current client at the time of the licensing inspection. An updated treatment and rehabilitation plan was documented in the record on June 18, 2024, and the next update was due no later than August 18, 2024; however, there was no updated plan documented in the record at the time of the inspection.
Client #4 was admitted on January 16, 2024, and was discharged May 20, 2024. An updated treatment and rehabilitation plan was documented in the record on February 14, 2024, and the next update was due no later than April 14, 2024; however, there was no updated plan documented in the record at the time of the inspection.
This is a repeat citation from the December 12, 2022, June 27, 2023, and December 19, 2023, annual licensing renewal inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CCO and CD held a treatment team meeting on 11/1/2024 and incorporated a Treatment Planning Training following the treatment team meeting.
Clinical staff were trained on the regulations of 709.92(b) requiring a treatment and rehabilitation plan to be updated at least every 60 days.
CD reviewed clients #1, #2, #3 and #4 with their primary therapist and completed an update by 11/8/2024.
CD initiated an alert in EMR calendar to remind therapists of updates. It was suggested that treatment plans be opened at the start of each individual session for good practice and to ensure primary therapists are alerted of an upcoming updates.
CD will review client charts weekly to review and sign off on treatment plans and updates. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 a review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in three of seven client records reviewed.
Client #1 was admitted on June 10, 2024, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on June 19, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the week of September 16, 2024, through September 20, 2024.
Client #2 was admitted on April 23, 2024, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on May 8, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of July 22, 2024 through July 26, 2024, August 5, 2024 through August 9, 2024, August 19, 2024 through August 23, 2024, August 26, 2024 through August 29, 2024, September 9, 2024 through September 13, 2024, September 30, 2024 through October 4, 2024 and October 7, 2024 through October 11, 2024.
Client #3 was admitted on February 26, 2024, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on April 8, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of August 19, 2024 through August 23, 2024, August 26, 2024 through August 29, 2024, September 9, 2024 through September 13, 2024, September 23, 2024 through September 27, 2024 and October 7, 2024 through October 11, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Treatment team met and reviewed policies and procedures as well as regulation 709.92(c). Clients #1, #2, and #3 were identified as lacking an individual session documentation for client #1 and multiple individual documentations for clients #2 and #3.
Clinical staff will continue to meet weekly and Clinical Director will audit all charts and individual sessions. Clinical staff was advised that documentation is needed if a weekly individual session has not been completed for a client, clinical staff is to complete a note stating an individual session was not completed and reasons for the missed session.
Clinical Director has made this part of the weekly clinical team meeting agenda item and to be reviewed in weekly chart audits to ensure compliance. |
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 the review of outpatient client records, the project failed to document a complete client record on an individual that included case consultation notes in six of six applicable client records reviewed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Pursuant to regulation 709.93(a)(8), the Policies and Procedures were amended to identify the timeframe for case consultations.
CCO and CD met with clinical team to review all current clients and case consultation form has been added to EMR system.
Clinical staff has begun to complete case consultations for all current clients prior to discharge.
Clinical Director will conduct weekly audits of charts identifying any clients who have not has a case consultation and are to be completed prior to client discharge. |
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.
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Observations
Based on the review of outpatient client records, the project failed to document a complete client record on an individual that included follow-up contact notes in three of three applicable client records reviewed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Pursuant to regulation 709.93(a)(11), it was found that follow up contact was not documented for 3 of 3 clients charts reviewed.
Leadership team met and will complete all follow up contacts in CRM to be completed by Alumni Coordinator.
COO will review discharges weekly and audit CRM of discharged clients to ensure follow up contacts are made.
This policy will be on the weekly business development agenda to ensure follow up contact is being made and that facility its in compliance with regulation 709.93(a)(11) |
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 personnel and client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to ensure that 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 was submitted and approved by the Department for the January 1, 2018, January 24, 2020, October 21, 2020, October 22, 2021, December 16, 2022, June 27, 2023 and December 19, 2023 licensing inspections. Failing to ensure that 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 was again found to be a deficiency in the October 16, 2024 licensing inspection.
A plan of correction for failing to document that treatment plans were reviewed and updated at least every 60 days was submitted and approved by the Department for the December 16, 2022, June 27, 2023, and December 19, 2023 licensing inspections. Failing to document that treatment plans were reviewed and updated at least every 60 days was again found to be a deficiency in the October 16, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Leadership Team will review all new hires during the monthly leadership meeting. The onboarding documentation includes the request of any training documents including the 6 hour HIV/AIDS training and the 4 hour TB/STD trainings. If a new hire lacks any supporting documentation of said trainings, each new employee will be required to complete these within their first year of employment and is part of the initial training plan.
CD will meet with clinical team weekly and will conduct a weekly chart audit. Clinical team will review all treatment plans to ensure clinical staff and supervisors are aware of any and all treatment plan updates to be completed. Clinical staff will complete an audit of charts and identify clients who had treatment plan updates conducted each week. |