INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Peniel Drug & Alcohol Residential Treatment Facility 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 one of six personnel records reviewed, the facility failed to provide documentation of the required twenty-five annual training hours for the training year January 2020-December 2020 for employee # 5.Employee # 5 was hired as a counselor on July 29, 2019 and was still in this position at the time of the inspection. Employee # 5 had only fifteen hours of annual training documented for the training year January 2020-December 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The corrective action was completed on July 21, the day of the site inspection. The Clinical Supervisor met with employee #5 and rehearsed with them that at least 25 clock hours of training annually is required. Employee #5 also received a written memorandum from the clinical supervisor re-stating the requirement of 25 training hours annually in areas such as: (i) Client recordkeeping (ii) Confidentiality (iii) Pharmacology (iv) Treatment planning (v) Drug and alcohol assessment (vii) Codependency (viii) Adult children 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. The clinical supervisor will frequently contact all counseling staff to review their individual progress toward meeting the 25 training hour annual requirement. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to keep water temperatures from exceeding 120 degrees Fahrenheit in the men's dorm bathroom. The water temperature in the men's dorm bathroom was 130 degrees Fahrenheit.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The corrective action was completed on July 21, the day of the site inspection. The vocational staff lowered the water temperature in the men's dormitory bathroom from 130F degrees to 120F to meet the requirement that the water temperature in the bathroom will not exceed 120F. To ensure that the water temperature is maintained at 120F in the men's dormitory a Water Temperature Log has been developed. The vocational staff will take the water temperature in the men's dormitory on a weekly basis and will enter that information into the log. |
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 the facility records, there was no documentation of 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 provided by an independent certified public accountant for the fiscal year ending December 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The corrective action was completed on July 21, the day of the site inspection. The Fiscal Manager made contact by phone with the certified public accountant who is responsible for this facilities' annual financial audit of activities associated with the project's drug/alcohol abuse services. The fiscal manager made the request to the certified public accountant that Peniel annual audits should be completed by the end of March each year. The certified public accountant said that they will make every effort to comply with this time frame. |
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 two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 2 and # 5.Client # 2 was admitted on May 6, 2021 and was still active at the time of the inspection. There was not an informed and voluntary consent from the client for the disclosure of information to a funding source prior to payment authorizations.Client # 5 was admitted on February 4, 2021 and was discharged on April 13, 2021. There was not an informed and voluntary consent from the client for the disclosure of information to a funding source prior to payment authorizations.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Per the citation, the error related to Confidentiality, it was found that Client records for Client #2 and #5 who are in treatment through a court contract did not have Release of Information forms signed for this funding source.
The corrective action was completed on July 21, the day of the site inspection. All current clients including client records for Client #2 and #5 who have their treatment funded through the court contract have signed and dated a Release of Information form for this specific source and the form has been placed in each of their client files. The Clinical Supervisor has also notified all staff who use the Release of Information form of this new requirement.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on four of seven client records reviewed, the facility failed to document written acknowledgement by clients that they have been notified of their rights to include that the project may not discriminate in the provision of services on the basis of creed, ethnicity, marital status, sexual orientation, or religion. Client # 1 was admitted on April 5, 2021 and was still active at the time of the inspection. The client rights acknowledgement document signed by the client did not include creed, ethnicity, marital status, sexual orientation, and religion.Client # 2 was admitted on May 6, 2021 and was still active at the time of the inspection. The client rights acknowledgement document signed by the client did not include creed, ethnicity, marital status, sexual orientation, and religion.Client # 4 was admitted on February 16, 2021 and was still active at the time of the inspection. The client rights acknowledgement document signed by the client did not include creed, ethnicity, marital status, sexual orientation, and religion.Client # 6 was admitted on January 25, 2021 and was discharged February 24, 2021. The client rights acknowledgement document signed by the client did not include creed, ethnicity, marital status, sexual orientation, and religion.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As it relates to Client Rights, it was found that the files for Clients #1, Client #2, Client #4 and Client #6 did not have the updated Client Rights form in their file.
The corrective action was completed on July 21, the day of the site inspection. The Clinical Supervisor made the correction by having the updated Client Rights form signed and dated for the client files of Client #1, Client #2, Client #4 and Client #6. The correct Client Rights form was placed in their file directly behind the old form. In addition to this corrective action, the clinical supervisor also destroyed all electronic and hard copies of the old Client Rights form and replaced them with the new updated Client Rights form. The Clinical Supervisor has also notified all counselors of the error and all counselors were given the new Client Rights form for future use.
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