INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 23, 2020 to January 24, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, 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(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
The facility failed to follow the agency training and staff development procedure. An assessment of staff training needs was not completed for 2018 or 2019.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The facility director will work with the VP of Operations to develop a semi annual assessment of staff training needs. The findings will be reviewed during monthly leadership team meetings. Any staff in need of trainings will then be informed and given time frame which trainings must be completed. |
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
The facility failed to follow the agency training and staff development procedure. An annual evaluation of the overall training plan was not completed for 2018 or 2019.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
At the end of each calendar year, the program director will evaluate trainings completed. The evaluation will assess if staff needs were met and also current state of staff training program/requirements. The evaluation will be presented to the leadership team during the first leadership meeting of each calendar year.
An evaluation of the training plan for 2019 calendar year will be presented to the leadership team by the program director during the 3/2020 leadership meeting. |
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
The facility failed to provide documentation of an individual training plan for the current training year in 7 of 12 employee records reviewed.
Employee # 3 was hired as a counselor on May 2, 2019. There was no documentation of an individual training plan for the current year, which was identified as January 1, 2020 December 31, 2020
Employee # 7 was hired as the director of admissions on May 30, 2017. There was no documentation of an individual training plan for the current year, which was identified as January 1, 2020 December 31, 2020.
Employee # 8 was hired as the office manager on October 22, 2018. There was no documentation of an individual training plan for the current year, which was identified as January 1, 2020 December 31, 2020.
Employee # 9 was hired as a tech on March 19, 2019. There was no documentation of an individual training plan for the current year, which was identified as January 1, 2020 December 31, 2020.
Employee # 10 was hired as a tech on July 15, 2018. There was no documentation of an individual training plan for the current year, which was identified as January 1, 2020 December 31, 2020.
Employee # 11 was hired as the VP of Operations on July 6, 2017. There was no documentation of an individual training plan for the current year, which was identified as January 1, 2020 December 31, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director, in conjunction with, the VP of Operations(HR) has developed an individual training plan for with each employee. A form has been created to include the plan and also signatures of both the employee and the facility director. The plans have been signed and placed in their respective employee files. Training plans will be reviewed semi-annually for progress and completion.
Employee #3 is no longer employed by the facility. |
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
The facility failed to ensure that 2 of 12 employees reviewed received the minimum of 6 hours of HIV/AIDS training and 4 hours of TB/STD training within the regulatory timeframe.
Employee # 7 was hired as the director of admissions on May 30, 2017 and was due to have HIV/AIDS training and TB/STD training no later than May 30, 2019. There was no documentation of the completion of the TB/STD training as of the date of the inspection.
Employee # 11 was hired as the VP of Operations on July 6, 2017and was due to have HIV/AIDS training and TB/STD training no later than July 16, 2019. There was no documentation of the completion of the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The facility director and VP of Operations Staff Training have revised requirements for all staff to include the required 6hrs of HIV/AIDS training and 4hrs of TB/STD training. This training will be completed by all employees no later than 3/1/2020. All new employees will complete training within 6 months of hire date.
The VP of Operations will work with HR to ensure all employee trainings are current. A training audit will be completed semi-annually to ensure compliance. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to ensure that the hot water temperature in each bathroom did not exceed 120 degrees Fahrenheit. On January 24, 2020 at approximately 1:00 p.m., the bathroom sink water temperature in suite E6 was measured at 132 degrees Fahrenheit.
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Plan of Correction
This was completed on 2/3/20. The Facility Director of Sobriety Solutions monitored the completion of this project. The Facility Director has verified the temperature to confirm that it is below the 120F threshold of the regulation.
The VP of Operations will check the temperature of the water one time per month and log the results in the appropriate utility systems log.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document whether the fire alarm or smoke detector was operative during each fire drill for the reviewed time period of January 2019 to December 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has revised the fire drill log format to include missing information regarding the smoke detector and alarm operation and will ensure that all drills will be recorded in accordance with PA Code 705.28. Logs information now include: Date; Start time; End time; Route Used; # evacuated; Problems identified; Recorder initials; SD/Alarm Operation |
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
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Organization did not meet requirements for outside audit until 2019 Fiscal year. Organization is currently sourcing an independent auditor to conduct audit. The CEO will be responsible for selecting agency to complete audit. The VP of Operations will work with the CEO to monitor completion of the audit.
Audits will be conducted at the end of every fiscal year going forward. Organization strives to have audit completed by mid-fiscal year 2020. |
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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in each client record reviewed.
Client # 1 was admitted to the partial hospitalization level of care on January 20, 2020 and was still active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file as of the date of the inspection.
Client # 2 was admitted to the partial hospitalization level of care on January 2, 2020 and was still active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file as of the date of the inspection.
Client # 3 was admitted to the partial hospitalization level of care on January 6, 2020 and was still active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file as of the date of the inspection.
Client # 4 was admitted to the partial hospitalization level of care on January 6, 2020 and was still active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file as of the date of the inspection.
Client # 5 was admitted to the outpatient level of care on December 26, 2019 and was discharged on January 20, 2020. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file.
Client # 6 was admitted to the outpatient level of care on May 20, 2019 and was active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file as of the date of the inspection.
Client # 7 was admitted to the outpatient level of care on July 30, 2019 and was active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file as of the date of the inspection.
Client # 8 was admitted to the outpatient level of care on October 17, 2019 and was active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file as of the date of the inspection.
Client # 9 was admitted to the outpatient level of care on February 2, 2018 and was discharged on July 3, 2018. There was documentation that urine samples were sent to a urinalysis lab numerous times; however, there was no consent to release information on file prior to the disclosure.
Client # 10 was admitted to the outpatient level of care on March 8, 2018 and was discharged on July 11, 2018. There was documentation that urine samples were sent to a urinalysis lab numerous times; however, there was no consent to release information on file prior to the disclosure.
Client # 11 was admitted to the outpatient level of care on April 23, 2019 and was discharged on October 25, 2019. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Consent for Release of Information to funding sources has been implemented and only includes appropriate information to be released to a funding source.
The intake process has been revised to include this Consent for Release of Information and is now being completed for all clients entering treatment(2/4/2020)
The Clinical Director will review all current client charts and assess and current clients in need of new release. All current clients charts will be updated with new release.
The Facility Director will conduct monthly and quarterly audits to ensure documentation compliance in accordance with DDAP Regulations.
All staff were trained on the new form and its purpose, as well as ensuring all clients are offered a copy of the form. This well be reiterated in ongoing weekly staff meetings and/or trainings. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
The facility failed to document the dated signature of a witness on a consent to release information form in 9 of 11 records.
Client # 1 was admitted to the partial hospitalization level of care on January 20, 2020 and was still active at the time of the inspection. Every consent form on file did not include the dated witness signature.
Client # 2 was admitted to the partial hospitalization level of care on January 2, 2020 and was still active at the time of the inspection. Every consent form on file did not include the dated witness signature.
Client # 3 was admitted to the partial hospitalization level of care on January 6, 2020 and was still active at the time of the inspection. Every consent form on file did not include the dated witness signature.
Client # 4 was admitted to the partial hospitalization level of care on January 6, 2020 and was still active at the time of the inspection. Every consent form on file did not include the dated witness signature.
Client # 5 was admitted to the outpatient level of care on December 26, 2019 and was discharged on January 20, 2020. Every consent form on file did not include the dated witness signature.
Client # 6 was admitted to the outpatient level of care on May 20, 2019 and was active at the time of the inspection. Every consent form on file did not include the dated witness signature.
Client # 7 was admitted to the outpatient level of care on July 30, 2019 and was active at the time of the inspection. Every consent form on file did not include the dated witness signature.
Client # 8 was admitted to the outpatient level of care on October 17, 2019 and was active at the time of the inspection. Every consent form on file did not include the dated witness signature.
Client # 11 was admitted to the outpatient level of care on April 23, 2019 and was discharged on October 25, 2019. Every consent form on file did not include the dated witness signature.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All Consent for Release of Information forms have been revised and implemented to include a dated witness signature.
The intake process has been revised to include this updated Consent for Release of Information form/procedure and is now being completed for all clients entering treatment(2/4/2020)
The Clinical Director will review all current client charts and assess and current clients in need of new release. All current clients charts will be updated with new release.
The Facility Director will conduct monthly and quarterly audits to ensure documentation compliance in accordance with DDAP Regulations.
All staff were trained on the new form and its purpose, and its importance, as well as ensuring all clients are offered a copy of the form. This well be reiterated in ongoing weekly staff meetings and/or trainings. |
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
The facility failed to include documentation of a preliminary treatment plan during the intake and admission period in four of seven client records reviewed.
Client # 5 was admitted to the outpatient level of care on December 26, 2019 and was discharged on January 20, 2020.
Client # 7 was admitted to the outpatient level of care on July 30, 2019 and was active at the time of the inspection.
Client # 8 was admitted to the outpatient level of care on October 17, 2019 and was active at the time of the inspection.
Client # 11 was admitted to the outpatient level of care on April 23, 2019 and was discharged on October 25, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical director will conduct admission and clinical staff training on 2/13/2020 which will review treatment plan regulations. The training will include treatment plan timelines, update requirements, level of care changes, and development of preliminary treatment plan.
Preliminary treatment plan development has been added to intake process and will be completed upon client admission for all new clients.
The program director will work with the clinical director to perform monthly chart audits to ensure treatment plan requirements are being met. |
709.93(a) 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:
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Observations
The facility failed to provide a complete client record in five of seven client records.
Client # 6 was admitted to the outpatient level of care on May 20, 2019 and was active at the time of the inspection. The record was missing documentation of the completion of a case consult.
Client # 7 was admitted to the outpatient level of care on July 30, 2019 and was active at the time of the inspection. The record was missing documentation of the completion of a case consult.
Client # 9 was admitted to the outpatient level of care on March 2, 2018 and was discharged on July 3, 2018. The record was missing documentation of the completion of a case consult. Additionally, the record was missing documentation of follow-up.
Client # 10 was admitted on to the outpatient level of care on March 8, 2018 and was discharged on July 11, 2018. The record was missing documentation of the completion of a case consult. Additionally, the record was missing documentation of follow-up.
Client # 11 was admitted on April 23, 2019 and was discharged on October 25, 2019. The record was missing documentation of the completion of a case consult. Additionally, the record was missing documentation of follow-up.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director in conjunction with the clinical director have amended the policies and procedures to include case consultations. Case consultations will be completed at a minimum, every 30 treatment days.
As of 2/7/2020, the clinical director has documented all case consultations during the weekly clinical team supervision meetings.
Case consultations have been added to the monthly chart audits and will be checked during this time. |