INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 5, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Horizons Recovery Centers, 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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704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
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Observations
Based on a review of the facility policy manual, the project failed to develop a written policy to address relapse of recovering clinical personnel. The project ' s policy shall It is further intended that employees avail themselves of this benefit before such problems as family disruptions, substance abuse, health conditions, or similar difficulties begin to detract from their approach toward their work. also address the discipline of nonrecovering employees who abuse alcohol and other drugs.The facility ' s policy provides all employees the benefit of an Employee Assistance Program. It indicates " It is further intended that employees avail themselves of this benefit before such problems as family disruptions, substance abuse, health conditions, or similar difficulties begin to detract from their approach toward their work. " The policy does not speak to relapse of recovering personnel.These findings have been reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Chief Compliance Officer will meet and work to create a policy and procedure to address the Relapse of recovering clinical personnel. This policy and procedure will also involve and include the already in place Employee Assistance Program policy and procedure. After completion of the Relapse of recovering clinical personnel by 6/20/2023 the Chief Compliance Officer will send a policy and procedure addendum to all staff with this policy and procedure ensure proper communication to all staff. To sustain compliance with all policies and procedures the leadership team will meet to review annually to ensure compliance with all licensure and accreditation. |
704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
Based on a review of the facility policy manual, the project failed to develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Chief Compliance Officer will meet to review the current policy and procedure regarding the hiring of staff and update the policy and procedure to include how the potential new staff will be reviewed and evaluated to ensure they are appropriate to the population served no later than 6/20/2023. Upon completion of the updated policy and procedure communication will be sent to all staff as an addendum to the policy and procedures of the organization. To sustain compliance with all policies and procedures the leadership team will meet to review annually to ensure compliance with all licensure and accreditation. |
704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) 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 and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of personnel files, the facility failed to provide documentation that one clinical supervisor met at least one of the qualifications for the position.Employee #5 was hired on August 1, 2022 as a clinical supervisor and was still in that position at the time of the inspection. The personnel record did not include written verification of qualifying professional credentials or an application or resume to evaluate the educational and experience required for the position.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Chief Compliance Officer and Executive Clinical Director will meet and review the human resources employee file for the Pennsylvania clinical supervisor to ensure all qualifications for the position are met and documented in the employee's human resources file by 6/20/2023. The clinical supervisor employee file will also be reviewed for written and or electronic verification of qualifying professional credentials to an application or resume to evaluate the educational and experience required for the position by 6/20/2023. To ensure ongoing compliance the clinical supervisor will have an annual training plan in their employee file to ensure all required training are completed and documented as required with all licensure and accreditation requirements. The Director of Human Resources will review all training plans annually and update the plans as required. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel files, the facility failed to provide documentation that one lead counselor who had not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision. Employee #2 was hired October 7, 2022 as a lead counselor and was still in that position at the time of the inspection. There was no documentation that the employee had completed a core curriculum in clinical supervision.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Chief Compliance Officer and Executive Clinical Director met to review the employee training plan for the clinical supervisor to ensure it included all required core curriculum in clinical supervision and the documentation of completion was in the employee file by 6/20/2023. To ensure compliance the Director of Human Resources will review all employee trainings plans annually to update and ensure completion of all required licensure and accreditation requirements. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel files, the facility failed to provide documentation that one clinical supervisor participated in monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Employee #5 was hired on August 1, 2022 as a clinical supervisor and was still in that position at the time of the inspection. The personnel record did not include documentation of monthly meetings with their supervisor.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Executive Clinical Director and Chief Compliance Officer will meet to update the current Supervision policy and procedure in place to include requirement 704.6(e) by 6/20/2023. Completion of this policy and procedure update will be sent out as an addendum to all staff for communication by 7/1/2023. All meetings will continue to be documented by "meeting logs" to ensure the compliance and that clinical supervisor(s) participate in monthly meetings with their supervisors to discuss their duties and performance for the first six months of employment in that position. Frequency of meetings may change based upon the clinical supervisor's skill level. Meeting logs will be checked monthly by the Executive Clinical Director to ensure ongoing compliance. |
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy manual, the project director failed to 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 an assessment of staff training needs.The staff development program in the policy manual spoke to the orientation of new employees, the annual training requirements for each position, and specific annual trainings for employees. There was no documentation of how training needs would be assessed or who is required to conduct the assessment of staff training needs. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Executive Director, Executive Director and Chief Compliance Officer met to update the current policies and procedures involving staff trainings to include the comprehensive staff development program for agency personnel with specific indication of who is responsible and the time frames for completion of an assessment of staff training needs and documentation will be indicated on the employee trainings plans by 7/1/2023. Completion of this policy and procedure update and updated training plans will be sent out for communication to all staff by 7/3/2023. To ensure ongoing compliance The Executive Director will review and update all training plans annually to ensure all licensure and accreditation requirements are met. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy manual, the project director failed to 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 an overall plan for addressing these needs.The staff development program in the policy manual spoke to the orientation of new employees, the annual training requirements for each position, and specific annual trainings for employees. There was no documentation of how an overall training plan would be created or who would be responsible for the creation. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Executive Director, Executive Director and Chief Compliance Officer met to update the current policies and procedures involving staff training to include how overall training plans will be created and who is responsible for the creation by 7/1/2023. The updated policy and procedure will be sent out to all staff for communication by 7/3/2023. The Executive Director will check all training plans annually to ensure is it documented who is responsible for the training plan. |
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 the policy manual, the project director failed to 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 a mechanism to collect feedback on completed training.The staff development program in the policy manual spoke to the orientation of new employees, the annual training requirements for each position, and specific annual trainings for employees. There was no documentation related to a mechanism to collect feedback on completed training or who would be responsible for it.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Chief Compliance Officer met to update the current policies and procedures involving the comprehensive staff development program to include how collection of feedback on completed trainings and who would be responsible for the collection would be done by 7/1/2023. The updated policy and procedure will be sent out to all staff for communication by 7/3/2023. To ensure ongoing compliance the Executive Director will check all training plans and documents monthly to ensure the completed trainings and related documents are collected and documented properly in the training plans and employee file(s) by the proper staff personnel. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the policy manual, the project director failed to 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 an annual evaluation of the overall training plan.The staff development program in the policy manual spoke to the orientation of new employees, the annual training requirements for each position, and specific annual trainings for employees. There was no documentation related to an annual evaluation over the overall training plan or who would be responsible for it. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Chief Compliance Officer met to review and update the comprehensive staff development program to include when the annual review of the training plans would take place and who is responsible for the review of the training plans by 7/3/2023. The updated policy and procedure will be sent out to all staff for communication by 7/3/2023. All training plans will be updated by the Chief Compliance Officer to include a section of when the annual review of the training plan is and who is responsible for the review by 7/3/2023. To ensure ongoing compliance the Director of Human Resources will review the employee training plans annually to ensure they are reviewed and updated by designated personnel as required. |
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 written individual training plan for each employee, appropriate to that employee ' s skill level, that was developed annually with input from both the employee and the supervisor in six out of six records reviewed. The individual training plans provided by the facility failed to document they were developed with the employee and the supervisor. There were no signatures or dates on the plans, nor were there supervisory notes documenting the creation of the individual treatment plans.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director, Executive Clinical Director and Chief Compliance Officer met to review and update the employee training plans to include a section for supervisory notes documenting the creation of the training plans and a section for the employee and supervisor to provide a signature and date once created and reviewed together by 7/1/2023. To ensure compliance the Chief Compliance Officer will review all training plans annually to ensure they are updated with notes, signatures and dates by the employee and supervisor. |
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 of personnel records, the facility failed to document 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 in three applicable records reviewed.The communicable disease training documented through the online provider was only a total of twenty five minutes long and was not a Department approved curriculum. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Executive Director, Executive Director and Chief Compliance Officer met to review and update the current communicable disease trainings to meet a minimum of 6 hours of HIV/AIDS and as least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a department approved curriculum, counselors and counselor assistants will complete the trainings within the first year of employment and all other staff shall complete the training within the first two years of employment by 7/7/2023. All employee training plans will be updated to reflect these requirements by the assigned training plan employee and supervisor by 7/14/2023. To ensure ongoing compliance the training plans will be reviewed annually by the assigned employee and supervisor and updated with all licensure and accreditation requirements. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in four of six personnel records.Employee # 2 was hired on October 7, 2022 as a counselor and was current in that position at the time of the inspection. Employee #7 was not instructed in the use of the fire extinguisher upon hire, the training was conducted January 30, 2023.Employee #4 was hired on February 6, 2023 as a counselor and was still current in that position at the time of the inspection. There was no documentation in the personnel record that Employee #4 was instructed in the use of the fire extinguisher upon hire.Employee #5 was hired on August 1, 2022 as a clinical supervisor and was still in that position at the time of the inspection. There was no documentation in the personnel record that Employee #5 was instructed in the use of the fire extinguisher upon hire.Employee #6 was on July 29, 2022 as the project director and was current in that position at the time of the inspection. There was no documentation in the personnel record that Employee #6 was instructed in the use of the fire extinguisher upon hire.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Compliance Officer will add a "how to use a fire extinguisher" presentation training and test provided from The Occupational Safety and Health Administration (OSHA) to all new employees to complete during their new hire orientation. This training and test will be completed within the orientation timeline of the employees first 7 days of hire. Current employees have until 6/20/2023 to complete the training and test for compliance. The Director of Human Resources will complete the "HR Audit tool" to ensure all employee files have this training and test completed and documented in the employee file. |
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
Based on a review of fire drill logs submitted, the facility failed to conduct unannounced fire drills at least once a month.The facility opened in August 2022 and there were only two documented fire drills conducted from that time until April 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met on 6/9/2023 to review and update the current fire drill policy and procedure to include that a fire drill must take place unannounced monthly and the fire drill form will continue to be filled out by the Executive Director and submitted to the Chief Compliance Officer. To ensure ongoing compliance the Chief Compliance Officer will collect and review all completed fire drill forms monthly by the Executive Director. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in four of six personnel records.Employee # 2 was hired on October 7, 2022 as a counselor and was current in that position at the time of the inspection. Employee #7 was not trained to perform assigned tasks during emergencies prior to working a shift, the training was conducted January 30, 2023.Employee #4 was hired on February 6, 2023 as a counselor and was still current in that position at the time of the inspection. There was no documentation in the personnel record that Employee #4 was trained to perform assigned tasks during emergencies.Employee #5 was hired on August 1, 2022 as a clinical supervisor and was still in that position at the time of the inspection. There was no documentation in the personnel record that Employee #5 was trained to perform assigned tasks during emergencies.Employee #6 was on July 29, 2022 as the project director and was current in that position at the time of the inspection. There was no documentation in the personnel record that Employee #6 was trained to perform assigned tasks during emergencies. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met to review the emergency codes procedures to ensure they included instructions on what each shift and staffs responsibilities are during an emergency codes on 6/13/2023 . Emergency code trainings will continue to be given and reviewed during new hire orientation and the completed document for the review of the emergency code training will be placed in the employees file before the employees first onsite shift. To ensure on going compliance the Chief Compliance Officer will check all employee files monthly for proper completion and documentation of emergency codes procedures and training. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of written fire drill logs submitted, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.The fire drill log for February 28, 2023 did not document the time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.The fire drill log for March 28, 2023 did not document the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met to review and update the current fire drill form to include sections to document the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. The updated fire drill form will be completed by 6/20/2023 and utilized monthly starting 7/1/2023. To ensure ongoing compliance the Chief Executive Director will receive all completed fire drill forms from the Executive Director monthly and review for proper completion. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs submitted for February and March 2023, the facility failed to prepare alternative exit routes to be used during fire drills.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met to review the fire drill form to ensure the form includes a section that is opened ended on which exit route was used during the fire drill so all and any exit routes can be utilized during not only fire drills but all emergency codes. This update was completed on 6/9/2023 by the Chief Compliance Officer. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of fire drill logs submitted for February and March 2023, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.Both fire drills that were conducted occurred on Tuesdays.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met on 6/9/2023 to discuss the requirements for fire drills to include and happen unannounced on different days of the week, at different time of the day and on different staffing shifts. Fire drill forms will be completed monthly by the Executive Director and submitted to the Chief Compliance Officer. The Chief Compliance Officer will check fire drill forms monthly for compliance to ensure the fire drills are occurring on different days of the week, at different times of the day and on different staffing shifts. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs submitted for February and March 2023, the facility failed to document whether they set off a fire alarm or smoke detector during each fire drill.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met on 6/9/2023 to review the requirements for proper completion of fire drill forms to include documenting which fire alarm or smoke detector was used during the fire drill. The Executive Director will complete and submit the fire drill forms to the Chief Compliance Officer monthly. The Chief Compliance Officer will review the submitted fire drill form to ensure documentation of which fire alarm or smoke detector was used during the fire drill is properly documented. |
709.24 (a) (2) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(2) Identification of the treatment models and practices utilized by the project.
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Observations
Based on a review of the facility ' s policy manual, the governing body failed to adopt a written plan for the coordination of client treatment and rehabilitation services that included the identification of the treatment models and practices utilized by the project.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Executive Clinical Director and Chief Compliance Officer met to review and update the current policy's and procedures to include the identification of the treatment models and practices utilized by the project. The updated policy and procedure will be sent out to all staff for communication by 7/1/2023. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
Based on a review of the facility ' s policy manual, the governing body failed to adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws that specifically included the utilization of volunteers.The facility reports volunteers are not utilized, however there is no documentation related to volunteers in the policy manual.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Executive Director, Executive Director and Chief Compliance Officer met to review and update the current policies and procedures to include that the project does not utilize volunteers. The updated policy and procedure will be sent out to all staff for communication by 7/1/2023. |
709.26 (b) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(1) Application or resume for employment.
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Observations
Based on a review of personnel records, the facility failed to include an application or resume for employment in one of six records reviewed. Employee #5 was hired on August 1, 2022 as a clinical supervisor and was still in that position at the time of the inspection. The personnel record did not include an application or resume for employment. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met on 6/9/2023 to review all employee files to ensure they included an application or resume for employment. To ensure ongoing compliance the Chief Compliance Officer will check employee files monthly for proper submission of an application or resume. |
709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
Based on a review of personnel records, the facility failed to include written verification of qualifying professional credentials in one of six records reviewed. Employee #5 was hired on August 1, 2022 as a clinical supervisor and was still in that position at the time of the inspection. The personnel record did not include written verification of qualifying professional credentials.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met on 6/9/2023 to review employee files to ensure they included documentation of written or electronic verification of qualifying professional credentials. To ensure on going compliance the Chief Compliance Officer will review employee files monthly for verification of qualifying professional credentials and that they are documented. |
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 client records, the facility failed to obtain an informed and voluntary consent from clients for the disclosure of information to their funder in nine out of ten records reviewed. The facility confirmed billing had occurred. Client #1 was admitted to the outpatient level of care on October 28, 2022 and discharged on November28, 2022.Client #2 was admitted to the outpatient level of care on February 8, 2023 and discharged on April 11, 2023. Client #3 was admitted to the outpatient level of care on January 23, 2023 and was discharged on April 4, 2023.Client #5 was admitted to the outpatient level of care on September 21, 2022 and was current at the time of the inspection.Client #6 was admitted to the outpatient level of care on January 18, 2023 and was current at the time of the inspection.Client #7 was admitted to the outpatient level of care on February 20, 2023 and was current at the time of the inspection. Client #8 was admitted to the partial hospitalization level of care on April 4, 2023 and discharged on May 4, 2023.Client #9 was admitted to the partial hospitalization level of care on August 25, 2022 and transferred to the outpatient level of care on October 28, 2022. Client # 10 was admitted to the partial hospitalization level of care on November 2, 2022 and transferred to the outpatient level of care on February 8, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will contact the electronic medical records company and submit a request to update the current insurance consent form for release of information to include a fillable box to type the clients insurance provider into. The updated form will also include the name of the person, agency or organization to whom the disclosure is made, the specific information disclosed, purpose of the disclosure and the date, event or condition when the consent will expire. The form will be completed and have a dated signature of the client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15.
Chief Compliance Officer will send out communication via company email of this policy and procedure update.
Executive Director will complete weekly chart audits until 7/31/2023 for proper completion and compliance with this standard.
To ensure current clients are compliant the updated consent form will be reviewed with client and clinical staff and then signed and kept in the clients record. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document whether a copy of a client consent was offered to one client and a copy maintained in the client record in one of eight records reviewed.Client #1 was admitted on October 28, 2022 and discharged on November28, 2022. An informed and voluntary consent for the disclosure of information for a family member was signed on August 25, 2022, but there was no documentation that a copy was offered. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Executive Clinical Director and Chief Compliance Officer met to review and update the client consent forms in the electronic medical records to include a check box that the client was offered a copy of the form. The new form will be sent out and communicated with the updated process to all staff by 7/1/2023. |
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, the facility failed to document written acknowledgement that the project may not discriminate in the provision of services on the basis of marital status in ten out of ten records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Executive Clinical Director and Chief Compliance Officer met to review and update the client orientation form in the electronic medical record to include that the project may not discriminate the provision of services on the basis of marital status. This updated form will be reviewed with all staff by 7/1/2023. For current clients to make sure they are aware of the update clinical staff will meet with each client and have them review and sign the updated form in their client record. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to notify the client they had an opportunity to request reconsideration of a decision terminating treatment in one applicable record reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Executive Clinical Director and Chief Compliance Officer met to review and update the terminating treatment form to include a section stating the client has a opportunity to request reconsideration of a decision to terminate their treatment. This updated form will be sent out and reviewed to all staff by 7/1/2023. |
709.81(a)(3) LICENSURE Intake and admission
709.81. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(3) Requirements for completion of treatment.
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Observations
Based on a review of the facilities policy manual and client handbook, the project director failed to develop a written plan providing for intake and admission which includes the requirements for completion of treatment.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Executive Clinical Director met to review and update the client handbook to include the requirements for the completion of treatment. The updated client handbook was sent out to all staff with this addition and reviewed on 6/8/2023. |
709.81(b)(1) LICENSURE Intake and admission
709.81. 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 client records, the facility failed to have intake procedures that included documentation of the disclosure to the client the criteria for admission, treatment, completion and discharge in three out of three records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Executive Clinical Director met to review and update the client intake form in the electronic medical record to include the criteria for admission, treatment, completion and discharge information. The Executive Director will send this updated form and review to all staff by 7/1/2023. |
709.81(b)(2)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to have intake procedures that included a client orientation to the project that included a familiarization with project policies in three out of three records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Executive Clinical Director met to review and update the client orientation form in the electronic medical record to include a section on the review and familiarization with the projects policies. This updated form will be sent out by the Executive Director and reviewed with all staff by 7/1/2023. |
709.81(b)(2)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to have intake procedures that included a client orientation to the project that included a familiarization with the facility ' s hours of operation in seven out of seven records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Executive Clinical Director and Chief Compliance Officer met to review and update the the client handbook to include the facilities hours of operation. The updated client handbook was sent out by the Chief Compliance Officer to all staff and reviewed on 6/8/2023. |
709.81(b)(2)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to have intake procedures that included a client orientation to the project that included a familiarization with the facility ' s fee schedule in three out of three records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Executive Clinical Director and Chief Compliance Officer met to review and update the client handbook that is given at the client orientation to include the facilities fee schedule. The Chief Compliance Officer sent out the updated client handbook to all staff for review on 6/8/2023. |
709.81(b)(2)(iv) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to have intake procedures that included a client orientation to the project that included a familiarization with the services provided in three out of three records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Executive Clinical Director and Chief Compliance Officer met to review and update the client handbook given and reviewed with the client during orientation to include the services provided by the facility. The updated client handbook was sent out by the Chief Compliance Officer to all staff and reviewed on 6/8/2023. |
709.81(b)(6) LICENSURE Intake and admission
709.81. 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, the facility failed to document a psychosocial evaluation during the intake procedures. The information provided did not provide an evaluation of the historical information leading to the client ' s current situation in three of three records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Executive Clinical Director met to review the current psychosocial evaluation to ensure it includes a section to document the evaluation of the historical information leading to the clients current situation. It was confirmed by the Executive Clinical Director on 6/8/2023 this section is in the psychosocial evaluation. The Executive Clinical Director will complete weekly chart audits to ensure all client psychosocial evaluations are completed fully and properly. These completed chart audits will be submitted to the Chief Compliance Officer weekly for 30 days and then monthly for ongoing compliance. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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, the facility failed to follow their procedures to develop the master treatment plan within three days of admission in one of three records reviewed. Client #10 was admitted to the partial hospitalization level of care on November 2, 2022 and discharged on February 8, 2023. The master treatment plan was due to be developed by November 5, 2022, however it was not documented until November 10, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Executive Clinical Director met to review all client records to ensure the master treatment plans were completed within 3 days of admission. The Executive Clinical Director will complete chart audits weekly for 30 days and then monthly there after to ensure compliance. These completed chart audits will be submitted to the Chief Compliance Officer. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 develop treatment plans that included written documentation of the type and frequency of treatment and rehabilitation services in one of three records reviewed.Client #10 was admitted to the partial hospitalization level of care on November 2, 2022 and discharged on February 8, 2023. Treatment and rehabilitation plans documented on November 10, 2022, December 13, 2022, January 18, 2022, did not include the type of treatment and rehabilitation services. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Executive Clinical Director met to review all client records to ensure they included documentation of the type of frequency of treatment and rehabilitation services. The Executive Clinical Director will complete a clinical training on the documentation requirements in the client record with the clinical team and weekly chart audits for 30 days and then monthly thereafter to ensure compliance. These completed chart audits and clinical training meeting will be submitted to the Chief Compliance Officer. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to review and update a treatment and rehabilitation plan at least every 30 days in one of three records reviewed.Client #10 was admitted to the partial hospitalization level of care on November 2, 2022 and discharged on February 8, 2023. A treatment and rehabilitation plan was developed on November 10, 2022 and was due to be updated by December 10, 2022 but was not documented until December 13, 2022. The next treatment and rehabilitation plan was due to be updated on January 18, 2023 but was not documented until January 18, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Executive Clinical Director met to review all client records to ensure the treatment and rehabilitation plans are updated every 30 days. The Executive Clinical Director will have a training meeting with the clinical team reviewing the client record and treatment documentation timelines by 6/20/2023. The Executive Clinical Director will complete weekly chart audits for 30 days and then monthly thereafter the ensure ongoing compliance. The completed training meeting and chart audits will be submitted to the Chief Compliance Officer. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure that counseling was provided to a client on a regular and scheduled basis that included and documented individual counseling, at least twice weekly in one of three records reviewed.Client #8 was admitted to the partial hospitalization level of care on April 4, 2023 and discharged in May 4, 2023. The individual treatment and rehabilitation plan dated April 11, 2023 indicated individual counseling only once a week.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Executive Clinical Director met to review client records to ensure that counseling is being provided on a regular and scheduled basis that includes documented individual counseling, at least twice a week or as required. The Executive Clinical Director will provide a training meeting with the clinical team reviewing the documentation and timeline requirements for clients and their records. The Executive Clinical Director will complete weekly chart audits for 30 days and then monthly thereafter to ensure on going compliance. The completed meeting training and chart audits will be submitted to the Chief Compliance Officer. |
709.91(a)(3) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(3) Requirements for completion of treatment.
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Observations
Based on a review of the facilities policy manual and client handbook, the project director failed to develop a written plan providing for intake and admission which includes the requirements for completion of treatment.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Executive Clinical Director and Chief Compliance Officer met to to review and update the client handbook to include the requirements for completing treatment. The Chief Compliance Officer sent out the updated client handbook to all staff and reviewed on 6/8/2023. |
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 client records, the facility failed to have intake procedures that included documentation of the disclosure to the client the criteria for admission, treatment, completion and discharge in seven out of seven records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Executive Clinical Director met to review and update the orientation forms in the client electronic medical records to include the disclosure to the client the criteria for admission, treatment, completion and discharge information. This updated form will be sent out by the Executive Director to all staff and reviewed by 7/1/2023. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to have intake procedures that included a client orientation to the project that included a familiarization with project policies in seven out of seven records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Executive Clinical Director met to review and update the client orientation form in the electronic medical records to include familiarizing the client with the projects policies. This updated form will be sent out by the Executive Director to all staff and reviewed by 7/1/2023. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to have intake procedures that included a client orientation to the project that included a familiarization with the facility ' s hours of operation in three out of three records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Executive Clinical Director and Chief Compliance Officer met to review and update the client handbook that is reviewed at the client orientation to include the facilities hours of operation. This updated client handbook was sent out by the Chief Compliance Officer to all staff and reviewed with on 6/8/2023. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to have intake procedures that included a client orientation to the project that included a familiarization with the facility ' s fee schedule in seven out of seven records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Executive Clinical Director and Chief Compliance Officer met to review and update the client handbook that is reviewed with the client at orientation to include the facilities fee schedule. The Chief Compliance Officer sent and reviewed the updated client handbook to all staff on 6/8/2023. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to have intake procedures that included a client orientation to the project that included a familiarization with the services provided in seven out of seven records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Executive Clinical Director and Chief Compliance Officer met to review and update the client handbook that is reviewed with the client during orientation to include the services provided by the project. The Chief Compliance Officer sent out and reviewed the updated client handbook with all staff on 6/8/2023. |
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, the facility failed to document a psychosocial evaluation during the intake procedures. The information provided did not provide an evaluation of the historical information leading to the client ' s current situation in five out of seven records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Executive Clinical Director met to review the current psychosocial evaluation to ensure it includes a section to document the evaluation of the historical information leading to the clients current situation. It was confirmed by the Executive Clinical Director on 6/8/2023 this section is in the psychosocial evaluation. The Executive Clinical Director will complete weekly chart audits to ensure all client psychosocial evaluations are completed fully and properly. These completed chart audits will be submitted to the Chief Compliance Officer weekly for 30 days and then monthly for ongoing compliance. |
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 develop treatment plans that included written documentation of the type and frequency of treatment and rehabilitation services in two of six records reviewed.Client #2 was admitted to the outpatient level of care on February 8, 2023 and discharged on April 11, 2023. Client #2 had a treatment and rehabilitation plan documented on February 24, 2023 that did not include the type of treatment and rehabilitation services. Client #4 was admitted to the outpatient level of care on January 3, 2023 and was a current client at the time of the inspection. Client #4 had a treatment and rehabilitation plan documented on March 10, 2023 that did not include the type or frequency of treatment and rehabilitation services. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Executive Clinical Director met to review all client records to ensure they included documentation of the type of frequency of treatment and rehabilitation services. The Executive Clinical Director will complete a clinical training on the documentation requirements in the client record with the clinical team and weekly chart audits for 30 days and then monthly thereafter to ensure compliance. These completed chart audits and clinical training meeting will be submitted to the Chief Compliance Officer. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to complete a discharge summary in one of three applicable records reviewed.Client #1 was admitted to the outpatient level of care on October 28, 2022 and discharged on November28, 2022. There was no documentation of a discharge summary documented in the record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Executive Clinical Director and Chief Compliance Officer met to review client records to ensure discharge summaries were completed for appropriate client records. The Executive Clinical Director will have a training on documentation requirements for discharge summaries with the clinical team. The Executive Clinical Director will complete weekly chart audits for 30 days and then monthly thereafter to ensure ongoing compliance. The completed training meeting and chart audits will be submitted to the Chief Compliance Officer. |
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 conduct a follow-up within seven days of discharge, per facility policy in three of three applicable records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Executive Clinical Director met to review documentation of follow-up within seven days of discharge if applicable to the client records. The Executive Clinical Director with provide a training with the clinical team on the requirements for follow-up timeliness and documentation for client records by 6/20/2023. The Executive Clinical Director will complete weekly chart audits for 30 days and then monthly thereafter to ensure ongoing compliance. The completed training meeting and chart audits will be submitted to the Chief Compliance Officer. |