INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 14, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, American Treatment Network 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)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a discussion with facility staff and submitted documents, the facility failed to complete an overall plan for addressing staff training needs based on the assessment of staff training needs for the current training year.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
The Project and Facility Directors along with input from both the Clinical Supervisor and employee(s) will develop an overall staffing training needs plan based on the organization's needs as well as licensure requirements. The training plan will encompass but not limited to the employee's previous education, experience, current job functions, and performance. Based on that assessment, the employee will be assigned the appropriate General and Continuing Professional Development (CPD) trainings that meets the minimum required hours for the primary position. The training plan will be completed by 12/1/22 and reviewed at least annually by the Leadership Team. Facility and Compliance Directors will perform random monthly audits on at least 20% of the staff training plans to ensure they are current and address the identified needs assessment.
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a discussion with facility staff and submitted documents, the facility failed to complete an annual evaluation of the overall training plan for the preceding training year.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
Clinical Supervisor and Facility Director will customize and provide an overall staff training plan to ensure it is being followed and implemented for compliance. This overall training plan will be monitored and evaluated on a monthly basis to ensure compliance. It will be monitored for compliance by the Clinical Supervisor and Facility Director.
This annual evaluation will measure the effectiveness of the past year's plan and determine the improvements needed for the next year's overall training plan. The training plan will be completed on 12/1/22 by the Facility Director and Clinical Supervisor.
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704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to ensure the Full Time Equivalent (FTE) counselor caseload did not exceed 35 active clients.
The counselor FTE is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.
Employee #11 was hired a counselor on March 8, 2022 and was still in the position at the time of the inspection. The employee was reported to have 9 hours per week devoted to their 8 clients on their caseload. Employee 11 ' s FTE counselor's caseload calculation is as follows: 9/40 = 0.22(FTE); 8/0.22 = 36, which equals to a client/counselor ratio of 36:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director immediately reviewed the caseload requirements for employee #11 and reduced caseload by one client. Employee #11 to 35:1.
Facility Director and Clinical Supervisor will develop a documented monthly process/system that reviews each FTE's caseload as well as pending new admissions and discharges to ensure staff are not assigned more than 35 active clients at a time. Monthly caseload reports will be run by the Facility Director in the Electronic Health Record to show evidence of compliance for this 35:1 requirement. |
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 a review of eleven personnel files, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in eight records reviewed.
Employee #4 was hired as a counselor on March 28, 2022 and was due to be trained in the use of fire extinguishers by April 4, 2022; however, fire extinguisher training was not documented in the record as of the date of the inspection.
Employee #5 was hired as a counselor on March 24, 2022 and was due to be trained in the use of fire extinguishers by March 31, 2022; however, fire extinguisher training was not completed until October 15, 2022.
Employee #6 was hired as a counselor on July 25, 2022 and was due to be trained in the use of fire extinguishers by August 1, 2022; however, fire extinguisher training was not completed until October 17, 2022.
Employee #7 was hired as a counselor on August 8, 2022 and was due to be trained in the use of fire extinguishers by August 15, 2022; however, fire extinguisher training was not completed until October 17, 2022.
Employee #8 was hired as a counselor on July 25, 2022 and was due to be trained in the use of fire extinguishers by August 1, 2022; however, fire extinguisher training was not completed until October 17, 2022.
Employee #9 was hired as a counselor on September 5, 2022 and was due to be trained in the use of fire extinguishers by September 12, 2022; however, fire extinguisher training was not completed until October 17, 2022.
Employee #10 was hired as a counselor on February 15, 2022 and was due to be trained in the use of fire extinguishers by February 22, 2022; however, fire extinguisher training was not completed until October 17, 2022.
Employee #11 was hired as a counselor on March 8, 2022 and was due to be trained in the use of fire extinguishers by March 15, 2022; however, fire extinguisher training was not documented in the record as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 was hired as a counselor on March 28, 2022 and fire safety training was conducted on October 15,2022.
Employee #5 Employee #5 was hired as a counselor on march 28, 2022 and fire safety training was conducted on October 15,2022.
Employee #6 was hired as a counselor on March 28, 2022 and fire safety training was conducted on October 17,2022.
Employee #7 was hired as a counselor on March 28, 2022 and fire safety training was conducted on October 17,2022.
Employee #8 was hired as a counselor on March 28, 2022 and fire safety training was conducted on October 17,2022.
Employee #9 was hired as a counselor on March 28, 2022 and fire safety training was conducted on October 17,2022.
Employee #10 was hired as a counselor on march 28, 2022 and fire safety training was conducted on October 17,2022.
Employee #11 was hired as a counselor on march 28, 2022 and fire safety training was conducted on October 15,2022.
Fire Safety Training will be a requirement for all new employees upon employment. The Facility Director and Clinical Supervisor will review each individualized staffing plan on a monthly basis to monitor that the staffing trainings are assigned and being completed on time. Compliance Director will perform random monthly audits on at least 20% of the staff training plans to ensure the fire extinguisher trainings are completed upon employment.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill logs, the facility failed to conduct unannounced fire drills at least once a month during the months of August 2022 and September 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director conducted a monthly fire drill on October 12, 2022 and November 15, 2022.
Facility Director will conduct and document monthly unannounced fire drills to ensure this requirement is being implemented.
Compliance Director will also conduct a monthly audit at this location to ensure unannounced fire drills are completed per the requirement.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's December 2021 through July 2022 fire drill logs, the facility failed to ensure that a fire alarm or a smoke detector was set off for every drill conducted during the period reviewed.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the December 1, 2021 annual licensing inspection.
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Plan of Correction
A Waiver dated 10/13/22 was submitted to address this finding for Facility # 237111 ? The Division of RA-licensuredivision@PA.gov granted approval due to the nature of not disturbing other occupants suffering from disabilities in the building.
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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 documents submitted, the project failed to 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.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
A Wavier was submitted on 11/8/2022 by facility Director to RA-licensuredivision@pa.gov - awaiting response on requesting a wavier to 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.
If ATN is denied the Wavier, they will request the third party accounting firm to perform the financial audit and provide results by January 1, 2023 |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that personnel records included a reviewed and signed annual written staff performance evaluation in one of three applicable records.
Employee # 1 was hired as the Project Director on January 1, 2021 and is still in the position. The personnel record did not include documentation of an annual performance evaluation.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee number # 1 annual performance evaluation was completed and signed on November 11, 2022.
A documented system (Bambee) will be implemented to capture date of hire and notify supervisors of when staff's performance evaluations are due. This notification will be provided in advance of the due date.
Facility Director will review and monitor employee staff files to ensure performance evaluations are being completed on a annual basis.
Compliance Director will perform a monthly audit on Bambee date of hire and evaluations due to ensure performance evaluations are being done on time and meeting the requirements of the program.
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709.28 (c) 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.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information in one record reviewed.
Client #1 was admitted to the Outpatient level of care on October 26, 2021 and was discharged on January 20, 2022. The record did not include a consent to release information form to the funding source; however, the record had documented evidence of billing through the date of discharge.
These findings were discussed with facility staff during the licensing process.
This is a repeat citation from the December 1, 2021 annual licensing inspection.
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Plan of Correction
Facility Director met with clinical staff to add a new ROI form for the funding source for each client on his/her caseload to address this finding.
In the intake process of every new referral, a ROI for funding sources has been added to the intake checklist. Each client will receive an ROI for funding source during the pre-admission phase. Also, each clinical staff has been provided clinical supervision of this requirement.
Facility and Compliance Directors will audit 20% of the client charts to verify that the ROI for the funding source is in place and complying with this requirement.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the dated signature of the client in one record reviewed.
Client #7 was admitted on July 12, 2022 and was active at the time of the inspection. The record included consent to release information forms to the funding source, another treatment provider, and a probation officer signed by the witness on July 21, 2022; however, all the forms were missing the dated signature of the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #7 will review and sign off on all appropriate consents and ROI's by 11/23/2022 by primary therapist.
Facility Director met with clinical staff to inform staff of having a written documented dated signature for all ROI.
Facility Director will audit 10% of client charts to ensure clients are providing documented dated signatures for all ROI as well as all other documentation.
Compliance Director implemented a Patient Portal in the Electronic Health Record for all clients to have the ability to view, access, share, and provide written signatures for ROI's and other documents. For those clients not able access the Patient Portal, they will be scheduled for in-person appointments in order to provide written dated signatures for compliance. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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:
(3) Proposed type of support service.
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Observations
Based on a review of seven client records, the facility failed to ensure that individual treatment and rehabilitation plans included documentation of the proposed type of support services in two of four applicable records reviewed.
Client # 6 was admitted on March 21, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan signed by the client on March 21, 2022 did not include the proposed type of support services.
Client # 7 was admitted on July 12, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan signed by the client on July 21, 2022 did not include the proposed type of support services.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client # 6 and client # 7 treatment plans were both updated to include type and frequency of treatment, type of service intervention based on assessment and needs list.
Clinical Supervisor will communicate with clinical team to ensure the proposed type of services are consistently included in treatment plans for all clients.
Clinical Supervisor will hold monthly supervision meetings with each staff member to review a random selection of treatment plans to ensure that each clients treatment plan has the type and frequency of treatment services and type of support services are included and documented in all treatment plans.
Facility Director will ensure clinical supervisor has a treatment plan check list to ensure all requirements of the treatment plan are being documented and understood by all staff members. |
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 seven client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in five of six applicable records reviewed.
Client #3 was admitted on October 20, 2021 and was discharged on May 26, 2022. The individual treatment and rehabilitation plan was completed on October 20, 2021 and a treatment plan update was due to be completed by December 20, 2021; however, no treatment plan updates were completed prior to the client's discharge.
Client #4 was admitted on January 10, 2022 and was discharged on August 30, 2022. The individual treatment and rehabilitation plan was completed on January 10, 2022 and a treatment plan update was due to be completed by March 10, 2022; however, the update was not completed until May 26, 2022. Additionally, the next treatment plan update was due to be completed by July 26, 2022, however, there were no additional treatment plan updates completed prior to the client's discharge.
Client #5 was admitted on June 8, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 8, 2022 and a treatment plan update was due to be completed by August 8, 2022; however, no treatment plan updates were completed prior to the client's discharge.
Client #6 was admitted on March 21, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 10, 2022 and a treatment plan update was due to be completed by March 21, 2022; however, the update was not completed until October 5, 2022.
Client #7 was admitted on July 12, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 21, 2022 and a treatment plan update was due to be completed by September 21, 2022; however, no treatment plan updates were completed prior to the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 1, 2021 annual licensing inspection.
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Plan of Correction
Client #6 will meet with primary therapist to review and update treatment plan by 11/23/2022.
Client #7 will meet with primary therapist to review and update treatment plan by 11/23/2022.
Facility Director will work with clinical staff to set up a spreadsheet or tracking tool that shows his or her caseload of each treatment plan date and upcoming due date.
Clinical Supervisor will review spreadsheet or tracking tool with the clinical staff to make sure all treatment plans are in compliance meeting the at least sixty day requirement.
Compliance Director will audit at least 20% of charts per month for compliance of this requirement.
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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 seven client records, the facility failed to ensure a complete client record on an individual, which is to include case consultation notes, in three of four applicable records reviewed.
Client #2 was admitted on July 1, 2021 and discharged on April 1, 2022. The client record did not include documentation of case consultation notes.
Client #3 was admitted on October 20, 2021 and was discharged on May 26, 2022. The client record did not include documentation of case consultation notes.
Client #4 was admitted on January 10, 2022 and was discharged on August 30, 2022. The client record did not include documentation of case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client # 2, client #3, and client # 4 were reviewed by clinical supervisor and facility director. Clinical supervisor held clinical supervision with clinical team to conduct case review with these three clients and case consultation was documented in clinical rounds.
Clinical supervisor will conduct a case consultation for each client within 30 days of enrollment into the facility during Monday's clinical rounds. Clinical rounds are conducted weekly on Mondays from 12 to 1 pm. These meetings include therapists, supervisors, and medical staff.
Compliance Director will ensure all case consultation requirements are being met.
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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 a review of client records, the facility failed to maintain a complete client record, which is to include follow-up information, in three of four applicable client records reviewed.
Client #1 was admitted on October 26, 2021 and was discharged on January 20, 2022. There was no documentation of follow-up information in the record as of the date of the inspection.
Client #2 was admitted on July 1, 2021 and discharged on April 1, 2022. There was no documentation of follow-up information in the record as of the date of the inspection.
Client #4 was admitted on January 10, 2022 and was discharged on August 30, 2022. There was no documentation of follow-up information in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 1, 2021 annual licensing inspection.
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Plan of Correction
Client #3, #4 client, and client # 2, were contacted by the clinical supervisor by phone and interaction was documented in a case management note in facilities EMR system.
Clinical supervisor during rounds, notified all clinical staff of the new discharge process. Clinical team will contact all clients on their case load who have been discharged within 30 days for discharge follow up and check in with clients. These interactions will be documented in a case management note.
Clinical supervisor will audit charts to ensure compliance and the discharge follow up requirements will be followed
Facility Director will monitor charts to ensure discharge follow up is being followed.
Compliance Director will audit 10% of charts to ensure compliance with the discharge follow up procedure.
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