INITIAL COMMENTS
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This report is a result of an onsite, provisional license, follow-up inspection and complaint investigation conducted on March 10-11, 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 onsite follow-up inspection, PA Treatment and Healing was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The complaint investigation identified no deficiencies and no plan of correction is required for the complaint. 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
A review of personnel records was conducted on August 28, 2019 at the PA Treatment and Healing Scranton facility. During the review, it was discovered that employee #1 did not have an annual individual training plan.
Employee #1 was hired as the project director on June 3, 2019 and was still in the position as of the date of the onsite inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The previous facilities director resigned effective December 4th, 2019. The current lead counselor at the time was then promoted to Facilities Director on January 24, 2020. The results and POC of the previous audit dated 9/5/2019 were only made available to the New Facilities Director on January 10th, 2020. The new Facilities director immediately began to establish a policy to address the deficiencies. Some of which were already being implemented before the Follow up inspection on March 10-11, 2020. All the deficiencies have been addressed and new polices have been implemented on or before May 1, 2020.
0063,
This deficiency was at another location, and under the supervision of individuals who are no longer employed with the facility. The new Facilities director who took over on November 24, 2019 Implemented a new Policy dated 5/1/2020 that all new employees in their first month of employ will complete a training evaluation program to identify which trainings to be implemented in the following year. It is the responsibility of the Facilities Director to oversee and document this new Policy within the first month of the employees' probationary period.
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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
During the onsite inspection, the Facility Director provided staff hours and caseloads to the auditor for review. Employee #5 was hired as a counselor on September 8, 2014 and was still acting in that position at the time of the inspection. Employee #5 was reported to have 15 hours per week devoted to their 14 clients on their caseload.
The counselor Full-Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility ' s work week hours, which at this facility is 40 hours. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
The counselor ' s caseload calculation is as follows: 15/40 = .375 (FTE); 14/.375 = 37.3, which equals to a client counselor ratio of 38:1.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 5, 2019 annual licensing inspection.
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Plan of Correction
This deficiency was addressed as follows; the plan of correction is that this location will not hire Fee for service counselors starting 5/1/2020. All client loads will remain below 35 clients for a full time Counselor. It is the Facilities Director's responsibility to monitor all case loads to remain within compliance on a weekly basis to prevent an overloaded case load. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
A review of the October 2019 through February 2020 fire drill logs was conducted during the onsite inspection. The facility failed to conduct any unannounced drills during this timeframe.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 5, 2019 annual licensing inspection.
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Plan of Correction
This Citation was the result of the former Facilities Director not informing the new Facilities director of this Procedural requirement. The New Facilities Director instituted a fire drill Policy to comply with the DDAP regs on March 1, 2020. In that the Facilities Director or other appointed staff will over see and conduct random unannounced Fire drills Monthly. A log of the fire drill containing time location of drill and number of attendees will be maintained in the facilities director's office. |
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 the review of client records on March 10-11, 2020, the facility failed to document an informed and voluntary consent to release information form prior to releasing information in client record #3.
Client #3 was admitted on December 19, 2019 and discharged on February 18, 2020. There was no consent to release information form for the funding source. According to the client ' s record, contact was made with the funding source on December 12, 2019.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 5, 2019 annual licensing inspection.
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Plan of Correction
This citation could not be addressed in client #3 due to discharge. It was revealed during the Audit of 9/8/19 that the chart audits were not being performed in a timely manner. The new Facilities director has implemented a new policy in which the Director will over see all chart audits on a monthly basis. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit. This Policy was implemented on 3/15/2020. The facilities director will also retrain all staff and new hires on the proper way to complete Releases and the specific information to be released per the type of release signed. The facilities director will then inspect every file. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of client records on March 10-11, 2020, the facility failed to identify what specific information to be disclosed on informed and voluntary consent to release information forms in client record # ' s 2 and 5.
Client #2 was admitted on January 14, 2020 and was still active at the time of the inspection. A consent to release information form to a family member, dated January 14, 2020, did not list what specific information could be released.
Client #5 was admitted on January 2, 2020 and discharged on January 21, 2020. A consent to release information form to a family member, dated January 2, 2020, did not list what specific information could be released.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 5, 2019 annual licensing inspection.
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Plan of Correction
This citation was addressed with the counselor and following all staff. A new release was filled out with the appropriate information for clients #2 and 5. It was revealed during the Audit of 9/8/19 that the chart audits were not being performed in a timely manner. The new Facilities director has implemented a new policy in which the Director will oversee all chart audits on a monthly basis. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit. This Policy was implemented on 3/15/2020. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete Releases and the specific information to be released per the type of release signed. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records on March 10-11, 2020, the facility failed to obtain a dated signature from the client on an informed and voluntary consent to release information form in client record # ' s 1 and 2.
Client #1 was admitted on January 30, 2020 and was still active at the time of the inspection. A consent to release information form, dated January 30, 2020 by the counselor, to a government agency did not have a dated signature by the client.
Client #2 was admitted on January 14, 2020 and was still active at the time of the inspection. A consent to release information form, dated January 14, 2020 by the counselor, to the funding source did not have a dated signature by the client.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 5, 2019 annual licensing inspection.
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Plan of Correction
This citation was addressed with the counselor and following to all staff. Afterword's a new release was filled out with the appropriate information for clients #1 and 2. It was revealed during the Audit of 9/8/19 that the chart audits were not being performed in a timely manner. The new Facilities director has implemented a new policy in which the Director will oversee all chart audits on a monthly basis. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit. This Policy was implemented on 3/15/2020. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete Releases and the specific information to be released per the type of release signed. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records on March 10-11, 2020, the facility failed to properly document an expiration date on the informed and voluntary consent to release information forms in client record # ' s 2 and 5.
Client #2 was admitted on January 14, 2020 and was still active at the time of the inspection. There were two consent to release information forms in the client ' s record that were missing the expiration information. Both dated January 14, 2020, one was to a family member and the other was to a laboratory.
Client #5 was admitted on January 2, 2020 and discharged on January 21, 2020. There were two consent to release information forms in the client ' s record that were missing the expiration information. Both dated January 2, 2020, one was to a family member and the other was to a laboratory.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 5, 2019 annual licensing inspection.
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Plan of Correction
This citation was addressed with the counselor and all staff about proper filling out of the date of expiration or what terms of expiration. and a new release was filled out with the appropriate information for clients #2. Client #5 could not have their information updated due to discharge. It was revealed during the Audit of 9/8/19 that the chart audits were not being performed in a timely manner. The new Facilities director has implemented a new policy in which the Director will oversee all chart audits on a monthly basis. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit. This Policy was implemented on 3/15/2020. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete Releases and the specific information to be released per the type of release signed. |
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 a review of client records and the policy and procedures manual on March 10-11, 2020, the facility failed to ensure that the client had been made aware of their client rights in client record # ' s 1, 2, 3, 4, 5, 6 and 7. In addition, the facility ' s client rights policy failed to include all parts of the client rights regulation. In both the client record documentation and the policy and procedures manual, the project failed to include that a client may not be discriminated against based on color, marital status and handicap.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 5, 2019 annual licensing inspection.
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Plan of Correction
This citation has been corrected in that corrections to both the policies and procedures manual and the Clients rights documentation in the active client charts have been updated as of May 1 2020, to state " " 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." This was the responsibility of the Facilities director. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on March 10-11, 2020 the facility failed to document a completed psychosocial evaluation in client record # ' s 1 and 3.
Client #1 was admitted on January 30, 2020 and was still active at the time of the inspection. A psychosocial document in the client ' s record was not fully completed by the counselor.
Client #3 was admitted on December 19, 2019 and discharged on February 18, 2020. There was no psychosocial evaluation documented in the client ' s record.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 5, 2019 annual licensing inspection.
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Plan of Correction
This citation was addressed with the counselor and all staff about proper filling out of all admit paperwork including the Bio Social. Client #1 chart was corrected on 4/1/20 Client #3 was discharged and therefore could not be corrected. It was revealed during the Audit of 9/8/19 that the chart audits were not being performed in a timely manner. The new Facilities director has implemented a new policy in which the Director will oversee all chart audits on a monthly basis. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit. This Policy was implemented on 3/15/2020. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete all admit file paperwork to comply with DDAP regulations. |
709.92(a) 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:
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Observations
Based on a review of client records on March 10-11, 2020, the facility failed to provide documentation of a comprehensive treatment plan or an accurately dated signature on the comprehensive treatment plan in client record # ' s 1, 3 and 7.
Client #1 was admitted on January 30, 2020 and was still active at the time of the inspection. There was no documentation of a comprehensive treatment plan in the client ' s record.
Client #3 was admitted on December 19, 2019 and discharged on February 18, 2020. There was no documentation of a comprehensive treatment plan in the client ' s record.
Client #7 was admitted on December 10, 2019 and was still active at the time of the inspection. A comprehensive treatment plan was dated by the client and counselor for December 25, 2019, which is Christmas Day. The facility was not open for business in observation of the holiday.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 5, 2019 annual licensing inspection.
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Plan of Correction
This citation was addressed with the counselor and all staff about proper filling out of all admit paperwork including the Master Treatment Plan.
Client #1 chart was corrected on 4/1/20 Client
#3 was discharged and therefore could not be corrected.
Client # 7, this chart had a program generated date that landed on a holiday. The clinician had completed the Treatment plan paperwork on December 26, 2019 and wrote in the date for the program generated date. This was an oversite of both the Clinician and the supervisor who did not fully confirm the program generated date was correct. The POK is to confirm before signature the actual date is generated on all forms, and the appropriate signature is reflective of the actual date.
It was revealed during the Audit of 9/8/19 that the chart audits were not being performed in a timely manner. The new Facilities director has implemented a new policy in which the Director will oversee all chart audits on a monthly basis. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit. This Policy was implemented on 3/15/2020. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete all admit file paperwork to comply with DDAP regulations.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) 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 on March 10-11, 2020, there was no documentation that the clients records counseling services according to their individual treatment plan in client record # ' s 1, 2, 4 and 7.
Client #1 was admitted on January 30, 2020 and was still active at the time of the inspection. The preliminary treatment plan, dated January 30, 2020, indicated weekly or bi-weekly individual counseling sessions. There were no documented individual counseling sessions in the client ' s record.
Client #2 was admitted on January 14, 2020 and was still active at the time of the inspection. The comprehensive treatment plan, dated January 29, 2020, indicated individual sessions " 1-2X wkly " and group sessions once per week. The record of service and progress notes indicated that the client did not receive individual sessions between January 23 - February 2 and February 11 - 23, 2020. In addition, the client did not receive group sessions from admission on January 14 until February 2, and February 11-March 1, 2020.
Client #4 was admitted on October 16, 2019 and discharged on January 13, 2020. The comprehensive treatment plan, dated October 30, 2019 indicated individual sessions " 1-2x wkly " and group sessions " weekly or biweekly " . The record of service and progress notes indicated that the client did not receive individual counseling sessions between October 17 - December 18, 2019 and December 20, 2019 - January 12, 2020. In addition, the client did not receive group sessions between October 31- November 26, 2019 and November 28 until discharge on January 13, 2020.
Client #7 was admitted on December 10, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated December 25, 2019 indicated individual sessions " 1-2x wkly " and group sessions two times per week. The record of service and progress notes indicated that the client did not receive individual counseling sessions between December 27, 2019 - January 26, 2020 and February 18 - March 8, 2020. In addition, the client only received one group session, on December 26, 2019 for the week of December 22-28, 2019.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 5, 2019 annual licensing inspection.
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Plan of Correction
This citation was addressed with the counselor and all staff about proper filling out of all admit paperwork including the Master Treatment Plan. All clients Master treatment plan are to reflect the actual rate of service. This is to be documented on their MTP clearly and with no range of service. If a change of service is required or the client has completed that level of service, it is the clinician's duty to update that by documenting the change in the Treatment plan review.
Client #1 chart was corrected on 4/1/20 Client
Client #2 documentation supporting the gaps of service were not present in the chart. The Facilities director has retrained all staff of the importance of documenting all Cancelations and No shows for all clients.
#4 was discharged and therefore could not be corrected.
Client # 7, documentation supporting the gaps of service were not present in the chart. The Facilities director has retrained all staff of the importance of documenting all Cancelations and No shows for all
It was revealed during the Audit of 9/8/19 that the chart audits were not being performed in a timely manner. The new Facilities director has implemented a new policy in which the Director will oversee all chart audits on a monthly basis. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit. This Policy was implemented on 3/15/2020. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete all admit file paperwork to comply with DDAP regulations.
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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
Based on a review of client records on March 10-11, 2020, the facility failed to provide a complete client record, which is to include progress notes, aftercare plans, discharge summaries and documentation of follow-up information, in client record # ' s 3, 4, 5, and 6.
Client #3 was admitted on December 19, 2019 and discharged on February 18, 2020. The client record did not contain an aftercare plan, discharge summary and documentation of follow-up information.
Client #4 was admitted on October 16, 2019 and discharged on January 13, 2020. The client record did not contain a discharge summary and documentation of follow-up information.
Client #5 was admitted on January 2, 2020 and discharged on January 21, 2020. The client record was missing progress notes from attended sessions.
Client #6 was admitted on August 6, 2018 and discharged on January 7, 2020. The client record did not contain a discharge summary.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 5, 2019 annual licensing inspection.
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Plan of Correction
It was revealed during the Audit of 9/8/19 that the chart audits were not being performed in a timely manner. The new Facilities director has implemented a new policy in which the Director will oversee all chart audits on a monthly basis. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit and continuing through to discharge of a client. This Policy was implemented on 3/15/2020. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete all admit and discharge file paperwork to comply with DDAP regulations. The new Client File paperwork will go into effect on May 1, 2020. |