INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Laure Rohrs Gargano 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project director, who was a sole proprietor during the January- December 2022 training year, completed at least 25 clock hours of training annually.
Employee #1 was hired as the project director November 1, 2012 and was still current in that position. Employee #1 only completed 14 clock hours of training during the 2022 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will update the policy 704.11 to reflect a change in the training year. The agency will move from calendar year to fiscal year (July to June). |
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 personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in one of two records reviewed.
Employee #2 was hired as a counselor on January 1, 2023 and is still current in that position. There was no documentation in the record that employee #2 had been instructed in the use of the fire extinguisher at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will add the fire safety training to employee orientation and onboarding process. Within the first seven days of employment, new staff members will be trained and their signature and date of training will be secured and stored in employee file. |
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 a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one of two records reviewed.
Employee #2 was hired as a counselor on January 1, 2023 and is still current in that position. There was no documentation in the record that employee #2 had been trained to perform assigned tasks during emergencies at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will add emergency tasks training to employee orientation and onboarding process. Within the first seven days of employment, new staff members will be trained and their signature and date of training will be secured and stored in employee file. |
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 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in six out of seven records reviewed.
Client #1 was admitted on April 20, 2022 and discharged on January 4, 2023. The client record had a note dated April 20, 2022 that the client gave verbal permission to contact a funder. There was not an informed and voluntary consent from the client for the disclosure of information for the funder in the record.
Client #3 was admitted on February 28, 2023 and discharged on May 11, 2023. There was an email to a funder on April 25, 2023, however there was not an informed and voluntary consent from the client for the disclosure of information for the funder in the record.
Client #4 was admitted on April 24, 2023 and discharged on May 23, 2023. There was not an informed and voluntary consent from the client for the disclosure of information for the funder in the record, but the facility confirmed billing had occurred.
Client #5 was admitted on July 12, 2022 and is still current. There was an informed and voluntary consent to disclose information to the funder dated March 20, 2023, however the facility confirmed billing had occurred since intake.
Client #6 was admitted on March 15, 2023 and was still current at the time of the inspection. The client record had a note, that was undated, that the client gave verbal permission to contact a funder. There was not an informed and voluntary consent from the client for the disclosure of information for the funder in the record.
Client #7 was admitted on February 28, 2023 and was still current. The client record had a note, that was undated, that the client gave verbal permission to contact a funder. There was not an informed and voluntary consent from the client for the disclosure of information for the funder in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will create a release of information for client funder, referral and probation if appropriate. Add this form to the online intake process to secure clients signature. The ROI(s) will uploaded to the client file upon completion of the intake packet.
At the time of the intake session, the clinician providing care will review if the online intake/ROI's have been complete. If not, the providing clinician will have client review and sign hard copy of: consent to treatment, ROI's for referral and funder at that time.
Project director will review all current client files to ensure ROI's for referral and funder are present. For those clients whom are missing the ROI, project director will have clinicians complete the necessary ROI's with clients face to face; virtual clients will receive the ROI via HELLOSIGN to secure electronic signature. All current charts will be compliant by August 30, 2023
The project director will review all new admissions for 90 days to ensure compliance. After the 90 days, reviews will be completed quarterly for compliance. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to have written documentation that an individual treatment and rehabilitation plan was developed with the client in five out of seven records reviewed.
Client #1 was admitted on April 20, 2022 and discharged on January 4, 2023. An individual treatment and rehabilitation plan dated May 2, 2022 did not include written documentation that the plan was developed with the client.
Client #2 was admitted on January 24, 2023 and discharged on May 15, 2023. An individual treatment and rehabilitation plan dated January 24, 2023 did not include written documentation that the plan was developed with the client.
Client #3 was admitted on February 28, 2023 and discharged on May 11, 2023. An individual treatment and rehabilitation plan dated February 28, 2023 did not include written documentation that the plan was developed with the client.
Client #4 was admitted on April 24, 2023 and discharged on May 23, 2023. An individual treatment and rehabilitation plan dated April 24, 2023 did not include written documentation that the plan was developed with the client.
Client #5 was admitted on July 12, 2022 and is still current. An individual treatment and rehabilitation plan dated August 2, 2022 did not include written documentation that the plan was developed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project director will update the policy 709.92 to include: clinicians will document in the creation of the treatment plan with client in the progress note on the date when treatment was created. Clinician will print a hard copy of the treatment plan for the client to sign and upload to client file while the treatment plan is pending supervisory signature.
Once the supervisory signature is secured, both clinician and client will sign the electronic copy of the treatment plan
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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 have a complete client record on an individual which includes information relative to the client's involvement with the project including a discharge summary, within seven days of discharge per facility policy, in three out of four applicable record s reviewed.
Client #1 was admitted on April 20, 2022 and discharged on January 4, 2023. Per facility policy a discharge summary should have been documented by January 11, 2023, however it was not signed until February 17, 2023.
Client #3 was admitted on February 28, 2023 and discharged on May 11, 2023. Per facility policy a discharge summary should have been documented by May18, 2023, however it was not signed until May 20, 2023.
Client #4 was admitted on April 24, 2023 and discharged on May 23, 2023. Per facility policy a discharge summary should have been documented by May 30, 2023, however there was no documentation in the client record that a discharge summary was completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This was a learning curve for the agency; it was unknown that when a file is closed, and then reopened for any reason (printing notes, entering final payments; entering follow up contacts) the date of the DOC automatically updated to the date the file was re-opened.
The Project Director will update 709.93 to include specific instructions paying attention to the DOD on the file when cases are re-opened for any reason - to ensure the correct DOD is reflected on the signed treatment plan |