INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 17, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, TREHAB was found not 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(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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee.
Employee #1 was hired on April 19, 1995, as a Project Director and was still in the position as of the date of the inspection. There was no documentation of a training plan for the 2023-2024 training year in this employee ' s file.
This is a repeat citation from the March 29, 2023, licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In order to comply with regulation 704.11 (b) (1) Licensure: 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, the following plan of correction will be implemented: On July 11, 2024, Drug and Alcohol departmental staff and Executive Director will meet to review the 2023-2024 departmental training plan and create the 2024-2025 departmental training plan. Also during the meeting, each individual employee will create their individual training plans to ensure all plans are created, signed, and appropriately filed in a timely manner. Moving forward, all individual and departmental training plans will be completed during staff meetings scheduled for the 2nd Thursday of July. This will ensure that the training plans will completed at the same time/date every year, and with the date being the 2nd Thursday of July, it will not interfere with the 4th of July holiday. |
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
Based on a review the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training within the regulatory timeframe.
Staff #5 was hired as support staff on July 9, 2018, and was due to have the HIV/AIDS training no later than July 9, 2020. There was no documentation of Staff #5 completing the HIV/AIDS training.
This is a repeat citation from the March 29, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In order to comply with regulation 704.11 Staff development program (general training requirements. (1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics using a department approved curriculum, the following plan of correction will be implemented: Client care coordinator completed the HIV/AIDS training on January 24, 2024. To ensure that all D&A staff are in compliance with required DDAP trainings, Clinical Supervisor and QM Coordinator will review what D&A department staff need to complete any required trainings. If a staff is out of compliance, they will complete the training by June 28, 2024. If any identified trainings are not available prior to June 28, 2024, this deadline will be extended to September 30, 2024. This will be assessed on an individual basis. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the Project Director.
Employee #1 was hired as a Project Director on April 19, 1995, and was still in the position at the time of the onsite inspection. The reviewed facility's training year was from July 1, 2022, through June 30, 2023. Employee #1's employee record did not document any training hours for this period.
This is a repeat citation from the March 29, 2023, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with regulation 704.11. Staff development program. (d) Training requirements for project directors and facility directors. (2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as: (i) Fiscal policy. (ii) Administration. (iii) Program planning. (iv) Quality assurance. (v) Grantsmanship. (vi) Program licensure. (vii) Personnel management. (viii) Confidentiality. (ix) Ethics. (x) Substance abuse trends. (xi) Developmental psychology. (xii) Interaction of addiction and mental illness. (xiii) Cultural awareness. (xiv) Sexual harassment. (xv) Relapse prevention. (xvi) Disease of addiction. (xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous, the following plan of correction will be implemented:
Clinical Supervisor and Quality Management Coordinator will review the status of Facility Director's training plan/training hours during scheduled monthly Quality Management meetings. Clinical Supervisor and Quality Management Coordinator will inform Facility Director of upcoming trainings during these meetings as well as provide him with email correspondence outside of meetings to facilitate completion of 12 hours of training annually. A section has been added to the QM Meeting Agenda titled: "Training Plan / Training Hours Review" with subtitles (categories) of, "Counseling Staff Training Status," "Support Staff Training Status," and "Facility Director Training Status." This consistent agenda item will prompt monthly review, allow for scheduling appropriate training and facilitate completion of hours.
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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 document treatment plan updates within the regulatory timeframe in three out of six applicable records reviewed.
Client #1 was admitted on November 9, 2023, and was still active at the time of the inspection. A treatment plan update was completed on November 15, 2023, and the next update was due no later than January 15, 2024; however, there were no additional treatment plans documented in the client record.
Client #3 was admitted on June 14, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was completed on July 11, 2023, and the next update was due no later than September 11, 2023; however, it was completed on September 27, 2023.
Client #5 was admitted on June 15, 2023, and discharged on October 19, 2023. A comprehensive treatment plan was completed on June 29, 2023, and the next update was due no later than August 29, 2023; however, it was completed on August 31, 2023.
This is a repeat citation from the March 29, 2023, licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In order to comply with regulation 709.92 (b) Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at lease every 60 days, the following plan of correction will be implemented: During a clinical staff meeting scheduled for February 27, 2024, Clinical Supervisor will review this regulation and citation with all clinical staff. Clinical staff will be directed by Clinical Supervisor to complete treatment plan updates every 45-50 days to ensure this regulation is being met. During weekly case consultation meetings, clinical staff will review their client caseload reports, which includes the dates that treatment plans are to be updated, to ensure that we are in compliance with this regulation. In addition, the electronic health record now provides a listing of what treatment plans are due for each clinician. This list is on the home page of the electronic health record so clinicians can see what documents are due. |
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 provide a complete client record, which is to include an aftercare plan in one out of two applicable records reviewed.
Client #6 was admitted on September 14, 2023, and was discharged on November 27, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with regulation 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, the following plan will be implemented:
Trehab will update the electronic health record system to include the Aftercare plan to ensure that this document is completed for each successfully discharged client. This form will be added to the electronic health record system by June 30, 2024. Adding the aftercare plan to the electronic health record will ensure its completion because this form will have to be completed in order to close a successfully discharged client chart.
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