INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25, 2023, 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 LLC 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.
Employee # 5 was hired as a counselor on March 20, 2023 and was current in that position at the time of the inspection. At the time of hire, the employee had a qualifying bachelor's degree but not the required one year of clinical experience for a bachelor's level counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide one hour of individual and one hour of direct observation of supervision with employee #5, whose position is counselor assistant.
Employee #5, counselor assistant will have these two required supervisions from the Clinical Supervisor on a weekly basis for the duration of at least 3 months to meet the standard of one year (a minimum of 1,820 hours) of required supervision in order to meet the competency in chemical dependency.
These supervisions will be documented in employee # 5's staff development plan.
The Facility Director will monitor these two weekly supervisions to make sure this corrective action plan has been met and documented as evidence.
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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 a review of personnel records, the facility failed to provide a written individual training plan for each employee, that documented it was developed annually with input from both the employee and the supervisor in three out of five personnel records reviewed.
Employee # 3 was promoted to the position of clinical supervisor on May 1, 2023. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee # 4 was hired as a counselor on March 13, 2023. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee # 5 was hired as a counselor on March 20, 2023. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and employee #3 have jointly discussed and reviewed the staff development training plan to properly identify the appropriate skills needed for the position as well as the personal development expressed by employee #3.
This has been documented in the staffing training plan and signed off by both the supervisor and employee #3.
Clinical Supervisor and employee #3 will review this plan monthly and annually (based on hire date) to document any changes or addition needed for business or professional development purposes.
Clinical Supervisor and employee #4 have jointly discussed and reviewed the staff development training plan to properly identify the appropriate skills needed for the position as well as the personal development expressed by employee #4.
This has been documented in the staffing training plan and signed off by both the supervisor and employee #4.
Clinical Supervisor and employee #4 will review this plan monthly and annually (based on hire date) to document any changes or addition needed for business or professional development purposes.
Clinical Supervisor and employee #5 have jointly discussed and reviewed the staff development training plan to properly identify the appropriate skills needed for the position as well as the personal development expressed by employee #5.
This has been documented in the staffing training plan and signed off by both the supervisor and employee #5.
Clinical Supervisor and employee #5 will review this plan monthly and annually (based on hire date) to document any changes or addition needed for business or professional development purposes.
The Facility Director will monitor and document staff development training plans on a monthly basis to verify plans are being done jointly and complying with this requirement. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of five personnel records, the facility failed to demonstrate that a sufficient number of staff persons had CPR certification as only one full-time staff member was certified in CPR between May 2023 and the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor provided all staff with available dates for CPR Certification and First Aid Trainings so that the site will have at least one person trained in these skills during hours of operation.
Completion date for this training is due by 11/15/23.
Clinical Supervisor is currently CPR certified and on site from 8 AM until 5 PM.
New Hire Counselor start date 9/18/2023 is CPR certified date verified on 10/20/2022 expiration date on 10/20/2024. New Hire is on site from 5 PM until 8 PM. |
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 eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in three records reviewed.
Client # 1 was admitted to the Outpatient level of care on June 2, 2023 and was discharged on August 1, 2023. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing. Additionally, the record contained documentation of a disclosure of information to a government agency on June 9, 2023, and the record contained no client signed consent to release information form to the agency.
Client # 2 was admitted to the Outpatient level of care on July 19, 2023 and was discharged on September 15, 2023. The record contained documentation of a disclosure of information to a government agency on August 2, 2023, and the record contained no client signed consent to release information form to the agency.
Client # 5 was admitted to the Outpatient level of care on April 14, 2023 and was discharged on July 20, 2023. The record contained documentation of a disclosure of information to a government agency on June 6, 2023, and the record contained no client signed consent to release information form to the agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Director will develop an orientation checklist for staff to utilize that will include all the required consent to release information forms, including the funding source for clients to review and sign.
- The orientation checklist will be stored in the EHR.
- Compliance Director will conduct a monthly audit on 20% of new admissions and current clients to ensure all clients are reviewing and signing all the appropriate release information forms, including the funding source.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of eight client records, the facility failed to document that a client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.
Client # 2 was admitted to the Outpatient level of care on July 19, 2023 and was involuntarily discharged on September 15, 2023. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Facility Director will review the discharge policy with the staff to educate and make them aware of the policy and the need to document as well as inform the client of the facility's decision to involuntarily terminate the client's treatment. If the staff are unable to reach the client, there needs to be a case management note documented as evidence of doing so.
The Clinical Supervisor will also notify staff of the need to document the follow-up after the 30-day discharge period. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of eight client records, the facility's intake procedures failed to include documentation of disclosure to the client of criteria for admission, treatment, or completion in all eight records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor or Facility Director will provide an orientation checklist and program welcome packet which includes program expectations, criteria for admission, treatment, completion, and discharge for new clients entering into the program.
The checklist and welcome packet will be documented and signed by the client and staff as evidence of meeting this requirement. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type of treatment and rehabilitation services on the individual treatment and rehabilitation plan in all eight records reviewed.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Facility Director will conduct a treatment plan training based on the DDAP standards during group and individual clinical supervision to make sure all staff are documenting the type of treatment and rehabilitation services.
Clinical Supervisor will conduct this training on 10/26/2023 during group clinical supervision. This training will be documented and signed off on as evidence.
The Facility Director will audit 20% of all charts each month to verify this requirement is being consistently met.
The Compliance Director will audit at least 10% of new admissions and current clients to ensure treatment plans document the type of services. |
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 client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in five of eight client records reviewed.
Client # 2 was admitted on July 19, 2023 and was discharged on September 15, 2023. The individual treatment and rehabilitation plan was completed on July 19, 2023; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on July 18, 2023 and was discharged on September 19, 2023. The individual treatment and rehabilitation plan was completed on July 18, 2023; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 5 was admitted on April 14, 2023 and was discharged on July 20, 2023. The individual treatment and rehabilitation plan was completed on April 14, 2023; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 6 was admitted on May 23, 2023 and was still active at the time of the inspection. he individual treatment and rehabilitation plan was completed on May 23, 2023; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 8 was admitted on April 6, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 6, 2023; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Facility Director will conduct a treatment plan training based on the DDAP standards during group and individual clinical supervision to make sure all staff are documenting the type of support services for treatment and rehabilitation plans.
The Clinical Supervisor will conduct group supervision on 10/26/2023.
The Facility Director will audit 20% of all charts each month to verify this requirement is being consistently met.
The Compliance Director will audit at least 10% of new admissions and current clients to ensure treatment plans document the type of support services in the treatment plan.
The Facility Director will monitor at least 25% of client treatment plans to ensure this meets the compliance requirement on a weekly basis.
The Clinical Supervisor reviewed the chart for client # 2 and will provide supervision to staff regarding documenting type and frequency of treatment and rehabilitation services.
The Facility Director will monitor at least 25% of client treatment plans to ensure this meets the compliance requirement on a weekly basis.
The Clinical Supervisor reviewed the chart for client # 3 and will provide supervision to staff regarding documenting type and frequency of treatment and rehabilitation services.
The Facility Director will monitor at least 25% of client treatment plans to ensure this meets the compliance requirement on a weekly basis.
The Clinical Supervisor reviewed the chart for client # 5 and will provide supervision to staff regarding documenting type and frequency of treatment and rehabilitation services.
The Facility Director will monitor at least 25% of client treatment plans to ensure this meets the compliance requirement on a weekly basis.
The Clinical Supervisor reviewed the chart for client # 6 and will provide supervision to staff regarding documenting type and frequency of treatment and rehabilitation services.
The Clinical Supervisor reviewed the chart for client # 8 and will provide supervision to staff regarding documenting type and frequency of treatment and rehabilitation services. Clinical Supervisor updated client # 8 treatment plan to reflect type and frequency of services.
The Facility Director will monitor at least 25% of client treatment plans to ensure this meets the compliance requirement on a weekly basis. |
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 client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed updated at least every 60 days in two of four applicable records reviewed.
Client # 7 was admitted on June 6, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 6, 2023, and a treatment plan update was due to be completed by August 6, 2023; however, the treatment plan update was not completed until August 31, 2023.
Client # 8 was admitted on April 6, 2023 and was still active at the time of the inspection. A treatment plan update was completed on June 15, 2023, and a treatment plan update was due to be completed by August 15, 2023; however, the next treatment plan update was not completed until September 8, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor has implemented a tracking spread sheet to monitor all treatment plan reviews and updates required at least every 60 days.
The tracking tool and results will be discussed at the group and individual clinical supervision meetings.
Each staff member will be responsible tracking and updating his/her case load for documentation dates and due dates, including treatment plans.
The Clinical Supervisor will review upcoming treatment plans during each individual supervision with staff to stay current with documentation due dates.
The Clinical Supervisor will inform staff that for any potential lapse in treatment plans that she will be notified immediately, and a case management note is documented to reflect gap and next steps.
The Facility Director will monitor 20% of the client's treatment plans to ensure that this standard is being implemented.
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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 client records and the facility ' s policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information within seven days of admission, in eight of eight records reviewed.
Client # 1 was admitted on June 2, 2023 and was discharged on August 1, 2023. The case consultation information was not documented until July 26, 2023.
Client # 2 was admitted on July 19, 2023 and was discharged on September 15, 2023. The case consultation information was not documented until August 30, 2023.
Client # 3 was admitted on July 18, 2023 and was discharged on September 19, 2023. There was no documentation of case consultation information in the record.
Client # 4 was admitted on May 26, 2023 and was discharged on August 18, 2023. There was no documentation of case consultation information in the record.
Client # 5 was admitted on April 14, 2023 and was discharged on July 20, 2023. The case consultation information was not documented until May 24, 2023.
Client # 6 was admitted on May 23, 2023 and was active at the time of the inspection. The case consultation information was not documented until June 6, 2023.
Client # 7 was admitted on June 6, 2023 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
Client # 8 was admitted on April 6, 2023 and was active at the time of the inspection. The case consultation information was not documented until May 17, 2023.
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 Compliance Director to review and update the facility's policy and procedure manual to reflect the appropriate timing for case consultation notes for admissions and readmissions.
The update will reflect case consultations being moved from seven days to 30 days for admissions and 60 days for readmissions.
The Clinical Supervisor and Front Desk Personnel will develop and implement an admission tracking to ensure all new or re-admitted clients are receiving case consultations within the specified period identified in the revised policy and procedures manual.
Client # 7 Case Consultation was done on 09/27/23.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in two of two applicable records reviewed.
Client # 3 was admitted on July 18, 2023 and was discharged on September 19, 2023. The client record did not contain documentation of a completed aftercare plan.
Client # 4 was admitted on May 26, 2023 and was discharged on August 18, 2023. The client record did not contain documentation of a completed aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor has communicated and implemented to all clinical staff the requirement of documenting a joint after-care plan that includes the client's involvement for all successful discharges.
The EHR has an after-care document that staff will begin to use for compliance.
The Facility Director will monitor and document all successful discharges to confirm after-care plans are being carried out with the client's involvement.
Client # 3 was called by Clinical Supervisor on 10/19/23 to do an after-care plan. The joint after care plan was documented on 10/19/23.
Client # 4 was called and has been re-admitted to the program on 10/4/2023.
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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 ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in three of three applicable records reviewed.
Client # 1 was admitted on June 2, 2023 and was discharged on August 1, 2023. The client record did not contain documentation of follow-up information.
Client # 3 was admitted on July 18, 2023 and was discharged on September 19, 2023. The client record did not contain documentation of follow-up information.
Client # 4 was admitted on May 26, 2023 and was discharged on August 18, 2023. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor has communicated and implemented for all clinical staff with client's involvement to conduct and document a follow-up engagement for all clients being discharged per policy.
The joint follow up information will be documented in a case management note in EMR.
The Facility Director will monitor at least 20% of discharges on a monthly basis to ensure joint follow-ups are being carried out.
The Clinical Supervisor reached out to client #1 on 10/20/23 for follow up. Case management note entered to reflect outreach.
The Clinical Supervisor reached out to client #3 on 10/19/23 for follow up. Case management note entered to reflect outreach.
The Clinical Supervisor reached out to client #4 on 10/18/23 for follow up. Case management note entered to reflect outreach.
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