INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 28, 2023 through March 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, MCP/Caring Together 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)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to collect feedback on completed trainings in four of four applicable personnel records reviewed.
Employee #1 was hired as the Project Director on January 23, 2017. All the completed trainings, during the training year reviewed, did not have documented feedback in the record.
Employee #2 was hired as a counselor on December 7, 2015. All the completed trainings, during the training year reviewed, did not have documented feedback in the record.
Employee #4 was hired as a counselor on December 20, 2019. All the completed trainings, during the training year reviewed, did not have documented feedback in the record.
Employee #6 was hired as a counselor on January 1, 2020. All the completed trainings, during the training year reviewed, did not have documented feedback in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon successful completion of all trainings, staff will submit a copy of the training certificate to the Project Director. At that time, the Project Director will provide a Training Feedback Form to be completed and returned. This certificate and feedback form will be placed in the staff's training manual and monitored monthly by the Project Director. |
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 document an annual written individual training plan for each employee, appropriate to that employee's skill level and with input from both the employee and the supervisor, in six of six personnel records reviewed.
Employee #1 was hired as the Project Director on January 23, 2017. The individual training plan was completed on June 7, 2022; however, there was no documentation the plan was developed with the input of the supervisor.
Employee #2 was hired as a counselor on December 7, 2015. The individual training plan was completed on June 7, 2022; however, there was no documentation the plan was developed with the input of the supervisor.
Employee #3 was hired as a counselor on October 8, 2022. The individual training plan was completed on October 2, 2022; however, there was no documentation the plan was developed with the input of the supervisor.
Employee #4 was hired as a counselor on December 20, 2019. The individual training plan was completed on June 7, 2022; however, there was no documentation the plan was developed with the input of the supervisor.
Employee #5 was hired as a counselor on December 13, 2022. The individual training plan was completed on December 13, 2022; however, there was no documentation the plan was developed with the input of the supervisor.
Employee #6 was hired as a counselor on January 1, 2020. There was no individual training plan documented in the personnel record at the time of the inspection.
This is a repeat citation from the April 20, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will survey the staff to determine trainings of interest for the upcoming training year. The Project Director will engage in a discussion with each employee during individual supervision to determine desired and appropriate trainings to enhance skills. The Project Director will utilize this information, along with feedback from the Medical Director to develop the annual individual training plan. This training plan will note input from the employee and supervisor. This training plan will be placed in the employee training file. This process will be monitored by the Project Director & Medical Director. |
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 each counselor completed at least 25 clock hours of training annually during the facility's July 1, 2021 through June 30, 2022 training year in two of three personnel records reviewed.
Employee #4 was hired as a counselor on December 20, 2019. The personnel record documented 19 hours of training received during the reviewed training year.
Employee #6 was hired as a counselor on January 1, 2020. The personnel record documented 18.5 hours of training received during the reviewed training year.
This is a repeat citation from the April 17, 2019, April 8, 2021, and April 20, 2022 annual renewal licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An annual training spreadsheet is being developed to monitor training hours. The Project Director will review this spreadsheet monthly to ensure that employees are scheduled for trainings throughout the year. The Project Director will provide each employee a copy of the spreadsheet to aid in monitoring the required training hours.
The Project Director will provide employees with training announcements throughout the year and employees will be encouraged to peruse resources for additional trainings. All counselors are aware of the need to complete 25 hours of trainings annually. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the facility-submitted Staffing Requirements Facility Summary Report, the facility failed to ensure that the Full Time Equivalent (FTE) counselor caseload for counseling in outpatient programs did not exceed 35 active clients in two of six personnel records reviewed.
The FTE is determined by dividing the total number of counselor hours devoted to clients by the facility's standard workweek. Then, to obtain the individual ratio, the total number of active clients is divided by the FTE.
Employee #1, the FTE calculation is as follows: 10/40 = .25(FTE); 9/.25 = 36, which equals an FTE counselor/client ratio of 36:1.
Employee # 2, the FTE calculation is as follows: 40/40 = 1 (FTE); 36/1 = 36, which equals an FTE counselor/client ratio of 36:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director is responsible for monitoring the caseload for all counselors. Based on the staff to client ratio, an additional counselor has been hired with a start date of 5/8/2023. The hiring of the additional counselor will aid in ensuring the adherence of the mandatory staff to client ratio.
The Project Director will review caseload census prior to assigning clients to counselor to ensure compliance with staff to client ratio. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all heaters were permanently mounted or installed. There was a space heater located in the daycare room at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director has informed all employees that space heaters that are not mounted or installed are forbidden for use in the clinic. Employees are permitted to adjust the thermostat to ensure appropriate heating. Employees should also dress appropriately to ensure warmth.
Project Director or designee will perform a monthly unannounced inspection to ensure that unmounted heaters are not onsite. |
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection, the facility failed to maintain protective caps over each electrical outlet for a facility that provides custodial care.
There was one outlet, located in the child-care room, that did not have protective caps allowing for possible electrical shock hazard at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director or Designee will perform a monthly inspection of the child care area to ensure a safe environment. This inspection will include monitoring of protective caps over electrical outlets.
The uncovered electrical outlet has been capped. Additional caps have been purchased and stored in the supply cabinet.
A log of the child care area inspections will be maintained. |
711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for developing an individual's comprehensive treatment and rehabilitation plan was submitted and approved by the Department for the April 8, 2021 and April 20, 2022 annual licensing inspections, and November 2, 2022 provisional licensing inspection. Developing and documenting an individual's comprehensive treatment and rehabilitation plan was again found to be a deficiency in the March 28-29, 2023, licensing inspection.
A plan of correction for ensuring counselors receive at least 25 clock hours of training annually were submitted and approved by the Department for the April 17, 2019, April 8, 2021, and April 20, 2022 annual licensing inspections. The 25 clock hours of training annually for counselors were again found to be a deficiency in the March 28-29, 2023, licensing inspection.
A plan of correction for ensuring that a copy of a client consent was offered to the client was submitted and approved by the Department for the April 8, 2021, April 20, 2022 annual licensing inspections, and November 2, 2022 provisional licensing inspection. Ensuring that a copy of a client consent was offered to the client was again found to be a deficiency in the March 28-29, 2023, licensing inspection.
This is a repeat citation from the April 20, 2022 and November 2, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Approved Plans of Corrections will be reviewed with the Project Director during monthly supervision session to monitor compliance. These supervision sessions will occur monthly with the Medical Director of the Chief Clinical Officer.
The Project Director will begin monitoring all active charts monthly for compliance as noted in the plan of corrections. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) 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 develop an individual treatment and rehabilitation plan with the client in three of eight client records reviewed.
Client #4 was admitted on December 21, 2022 and was active at the time of inspection. The comprehensive treatment plan was not documented in the record at the time of the inspection.
Client #5 was admitted on December 27, 2022 and was discharged on March 6, 2023. The comprehensive treatment plan was not documented in the record at the time of the inspection.
Client #6 was admitted on January 9, 2023 and was discharged on March 13, 2023. The comprehensive treatment plan was not documented in the record at the time of the inspection.
This is a repeat citation from the November 2, 2022, April 20, 2022, and April 8, 2021 annual renewal licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will provide additional individual training regarding the timeliness of treatment plans.
Although there is a new Electronic Medical Record (EMR), counselors will utilize the paper version of the treatment plans until this document is fully developed electronically.
The monthly monitoring of all active charts by Project Director will aid in ensuring that treatment plans are completed timely. |
711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) 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 properly document the proposed type of support services in the client's individual treatment plan in five of five applicable client records reviewed.
Client #1 was admitted on December 12, 2022 and was active at time of inspection. The comprehensive treatment plan was completed on January 12, 2023; however, the plan did not include proposed type of support services.
Client #2 was admitted on December 22, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on February 15, 2023; however, the plan did not include proposed type of support services.
Client #3 was admitted on December 8, 2022 and was active at time of inspection. The comprehensive treatment plan was completed on January 6, 2023; however, the plan did not include proposed type of support services.
Client #7 was admitted on January 23, 2023 and discharged on March 13, 2023. The comprehensive treatment plan was completed on February 6, 2023; however, the plan did not include proposed type of support services.
Client #8 was admitted on December 20, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on January 10, 2023; however, the plan did not include proposed type of support services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An additional Treatment Plan Training will be held to ensure that all counselors are trained to document the type of proposed support services. A review of available proposed support services will be discussed during the training.
The training will be facilitated by the Project Director. The Project Director will monitor charts monthly to ensure that proposed support services are noted. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) 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 are reviewed and updated at least every sixty days in one of two applicable client records reviewed.
Client #1 was admitted on December 12, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on January 12, 2023, and the first update was due no later than March 13, 2023; however, the update was completed on March 16, 2023.
This is a repeat citation from the April 20, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will facilitate an additional treatment plan training. A primary focus of this training will be timeliness of completing the treatment plan. Staff will be encouraged to schedule the completion of the plan early with the client.
The new EMR team are working to create the plans with alerts to inform staff and Project Director of plans that are coming due.
Monthly monitoring all active charts by the Project Director will aid in ensuring timeliness. |
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in two of five applicable client records reviewed.
Client #3 was admitted on December 8, 2022 and was active at the time of inspection. The comprehensive treatment plan dated January 6, 2023, indicated weekly individual counseling sessions. There was no documentation, in the client record, of individual counseling sessions occurring during the weeks of January 22, 2023 - January 28, 2022, February 5, 2023 - February 11, 2023, and February 19, 2023 - February 25, 2023.
Client #8 was admitted on December 20, 2022 and was active at the time of inspection. The comprehensive treatment plan dated January 10, 2023, indicated weekly individual counseling sessions. There was no documentation, in the client record, of individual counseling sessions occurring during the week of February 19, 2023 - February 25, 2023.
This is a repeat citation from the April 20, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training will be facilitated by the Program Director that will note the importance of engaging in and documenting counseling services as noted in the treatment plan. If there is a deviation from the treatment plan, due to unforeseeable events such as illness, the counselors will be directed to note the reason for lack of engagement.
Monitoring of monitoring charts monthly will aid in ensuring that counselors are in compliance. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include an aftercare plan, in one of one applicable client record reviewed.
Client #7 was admitted January 23, 2022 and discharged on March 13, 2023. There was no documentation of an aftercare plan, in the client record, at the time of inspection.
This is a repeat citation from the April 20, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Discharge Aftercare Planning Training will be facilitated by the Project Director. This is a mandatory training for all counselors. All new counselors hired after this training will receive individual direction in completion of Aftercare Plans.
Counselors will be trained to begin planning aftercare with the client prior to the discharge. The aftercare plan will include ongoing services if warranted. For clients on medication, the plan will note where and when clients will receive meds.
Aftercare plan will be reviewed and signed of by Project Director. |
711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
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Observations
Based on a physical plant inspection, the facility failed to maintain the confidentiality of client identity and records.
There were several client records located in boxes and on shelves in two separate counselors' offices. Additionally, there were client-related documents located throughout the peer specialist's office.
This is a repeat citation from the April 20, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff have received counseling regarding the need to secure charts and documents in order to maintain confidentiality.
To ensure compliance, Project Director or Designee will facilitate unannounced facility walkthroughs. The walkthrough will be documented in the Facility Inspection Logbook. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of eight client records reviewed.
Client #3 was admitted on December 8, 2022 and was active at the time of inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This is a repeat citation from the April 20, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will conducted another training regarding the completion of the Release of Information Forms. The training will include the timeliness of the document. These documents are initially completed at the time of the intake and should be updated as needed.
Charts will be monitored after the initial intake to ensure that the Release of Information Forms are completed appropriately at the time of admission. |
711.93(c)(2)(i) LICENSURE Name of person/agency/organization
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(i) The name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on a release of information form in one of eight client records reviewed.
Client #2 was admitted on December 22, 2022 and was active at the time of inspection. There was a blank release of information form signed and dated by the client on December 22, 2022; however, the form did not include the name of the person, agency, or organization to whom the disclosure was to be made.
This is a repeat citation from the April 20, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The planned training by the Project Director in the Release of Information will address the appropriate completion of the document. The inappropriateness of blank forms will be included in the training.
The monitoring of the charts at the completion of the intake and monthly will aid in ensuring compliance. |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client on release of information forms in two of eight client records reviewed.
Client #2 was admitted on December 22, 2022 and was active at the time of inspection. There were release of information forms to an emergency contact, a funding source, a transportation service, and a physician signed and dated by the client on December 22, 2022; however, there was no documentation that a copy of any of the release of information forms were offered to the client.
Client #3 was admitted on December 8, 2022 and was active at the time of inspection. There was a release of information form to a government agency signed and dated by the client on December 8, 2022; however, there was no documentation that a copy of the form was offered to the client.
This is a repeat citation from the November 2, 2022, April 20, 2022, and April 8, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The planned training for the completion of the Release of Information Form will include notation of offering a copy to the client.
The form includes an area to acknowledge offering a copy of the document to the client. The counselors will be directed to complete the entire form.
Monitoring of the chart after intake and monthly by the Project Director will aid in ensuring compliance. |
711.94(e) LICENSURE Follow-up Policy
711.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to develop a written client follow-up policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a written follow-up policy that will be reviewed and approved by the Medical Director. The policy will encompass the criteria as noted by DDAP. The policy will be housed in the Policy & Procedure manual
The clinical team will be trained by the Project Director on the policy and associated documents.
The Project Director will monitor compliance with this policy. |
711.95(b) LICENSURE Efficient Retrieval of Data
711.95. Uniform Data Collection System.
(b) A data collection system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
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Observations
Based on an administrative review, the facility failed to develop a data collection system that allows for the efficient retrieval of data needed to measure the project's performance at the time of the inspection.
The facility was unable to produce client records in an efficient manner after the DDAP representative requested them. The facility took approximately two hours to provide all of the client records requested.
This is a repeat citation from the April 20, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has met with IT to discuss electronic access to records. A guest login will be issued to the Project Director from IT upon request. This login provides access to client electronic medical records. The Project Director will provide access to a Drexel Medicine computer to access the medical record using the login. |