INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 23, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Caron Counseling Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(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 seven personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one applicable employee received the minimum of 4 hours of TB/STD training within the regulatory timeframe.Employee #6 has been employed as a counselor at the facility since May 17, 2021 and was due to have the communicable disease trainings no later than May 17, 2022. However, the facility provided no documentation of the completion of the TB/STD trainings as of the date of the inspection.This is a repeat citation from the November 4, 2021 annual licensing inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #6 is scheduled to attend TB/STD training on 4/21/2023. If an earlier training date becomes available prior to April, Employee #6 will register for the earlier date.
The Director of Training will monitor the completion of the mandatory DDAP trainings for new hires on a quarterly basis to ensure staff receive the required trainings within their first year of employment. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director.Employee # 1 was promoted to the position of Project Director on July 1, 2021 and has remained in that position. The facility's training year that was reviewed was from July 1, 2021 through June 30, 2022. Employee # 1's employee record only documented 1 hour of training for the period reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 has completed 8 hours of training in the current training year which ends on June 30, 2023. Employee #1 is also scheduled to attend DDAP TB/STD for 4 hours in February which will bring his total training hours to 12 hours for the training year.
In addition, the Director of Training will monitor the completion of employee #1 training hours on a quarterly basis to ensure 12 hours are obtained this training year.
To ensure training hours are completed as required for future training years, the Training Administrator will distribute a training hours report on a quarterly basis to the Facility Director, Project Director and Compliance Officer.
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709.24 (a) (3) 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:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility ' s policy manual and discussion with facility staff, the facility failed to follow their written procedures for the management of treatment and rehabilitation services, pertaining to case consultations occurring every 90 days in three of three appliable records reviewed.Client #4 was admitted to the Outpatient level of care on March 4, 2022 and discharged on September 15, 2022. There was no documentation of a case consultation by June 4, 2022.Client #5 was admitted to the Outpatient level of care on May 24, 2022 and was active at the time of the inspection. There was no documentation of a case consultation by August 24, 2022. Client #6 was admitted to the Outpatient level of care on July 26, 2022 and was active at the time of the inspection. There was no documentation of a case consultation by October 26, 2022. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the requirements for completion of case consultations every 90 days. The Clinical Supervisor will provide the re-education and it will be documented.
The Clinical Supervisor will monitor the completion of case consultations through monthly chart reviews to ensure they are being completed every 90 days. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of seven personnel records, the facility failed to ensure that personnel records contained a reviewed and signed annual written staff performance evaluations in three of four applicable records reviewed. Employee # 2 has been the Facility Director since June 30, 2014 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by October 1, 2022 but was not signed by the employee until November 15, 2022.Employee # 6 has been a counselor since May 17, 2021 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by July 30, 2022 but was not signed by the employee until October 19, 2022.Employee # 7 has been a counselor since June 21, 2021 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by August 27, 2022 but was not signed by the employee until January 11, 2023.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisors will be re-educated on the requirement to complete and sign performance evaluations on an annual basis per the timeframe outlined in Caron's policy.
The Corporate Director of Human Resources will monitor the completion of performance evaluations on a monthly basis to ensure evaluations are completed as required. |
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 seven client records, the facility failed to document the frequency of treatment and rehabilitation services in their treatment plan in three records reviewed. Client #1 was admitted on October 18, 2022 and discharged on December 12, 2022. The individual treatment and rehabilitation plan completed on November 18, 2022 did not document the recommended frequency of services. Client #6 was admitted on July 26, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on August 2, 2022 did not document the recommended frequency of services. Client #7 was admitted on November 4, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on December 12, 2022 did not document the recommended frequency of services. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the elements that are to be included on a treatment plan including "frequency of services". The Clinical Supervisor will provide this education by 2/24/2023.
The Clinical Supervisor will complete monthly chart reviews to ensure treatment plans include frequency of services. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of seven client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of six applicable records reviewed.Client #4 was admitted on March 4, 2022 and discharged on September 15, 2022. The individual treatment and rehabilitation plan was completed on March 11, 2022 and the treatment plan update was due to be completed by May 11, 2022; however, no treatment plan updates were completed prior to discharge.Client #5 was admitted on May 24, 2022 and was active at the time of the inspection. A treatment plan update was completed on October 24, 2022 and the next treatment plan update was due to be completed by December 24, 2022; however, the next treatment plan update was not completed until January 12, 2023.Client #6 was admitted on July 26, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 2, 2022 and the treatment plan update was due to be completed by October 2, 2022; however, the next treatment plan update was not completed until November 14, 2022.These finding were discussed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the requirement to complete treatment plan updates every 60 days. The Clinical Supervisor will provide this education by 2/24/2023.
The Clinical Supervisor will complete monthly chart reviews to ensure treatment plan updates are completed every 60 days. |
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, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in three of five applicable records reviewed.Client #2 was admitted on August 2, 2022 and was discharged on October 11, 2022. The treatment plan completed on September 15, 2022, indicated that the client was to receive three group sessions per week; however, the record only contained documentation of two group sessions during the week of September 19, 2022 and one group session the week of September 26, 2022.Client #4 was admitted on March 4, 2022 and discharged on September 15, 2022. The treatment plan completed on March 11, 2022, indicated that the client was to receive one group session per week; however, the record contained no documentation of a group session the weeks of March 14, 2022, April 11, 2022, May 9, 2022, May 30, 2022, June 6, 2022, June 27, 2022, and July 4, 2022.Client #5 was admitted on May 24, 2022 and was active at the time of the inspection. The treatment plan completed on July 31, 2022, indicated that the client was to receive one individual session per week; however, the record did not contain documentation of an individual session between September 29, 2022 and October 20, 2022.This is a repeat citation from the November 4, 2021 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the completion of treatment plans and treatment plan updates to ensure the services and treatment being delivered is reflected accurately in the treatment plan. The Clinical Supervisor will provide the re-education by 2/24/23.
The Quality Department will update the monthly chart review form to include monitoring of treatment plans and treatment plan updates to ensure they are reflective of the services delivered.
The Clinical Supervisor will complete the monthly chart reviews to ensure the treatment plans accurately reflect services being delivered. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client ' s involvement with the project including case consultation notes in two of two applicable client records reviewed. Client #1 was admitted to the Outpatient level of care on October 18, 2022 and discharged on December 12, 2022. There was no documentation of a case consultation in the record. Client #2 was admitted to the Outpatient level of care on August 2, 2022 and discharged October 11, 2022. There was no documentation of a case consultation in the record.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
taff will be re-educated on the requirements for completion of case consultations every 90 days. The Clinical Supervisor will provide the re-education and it will be documented.
The Clinical Supervisor will monitor the completion of case consultations through monthly chart reviews to ensure they are being completed every 90 days. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information in two of four applicable records reviewed. Client #1 was admitted on October 18, 2022 and discharged on December 12, 2022. There was no documentation of follow up information in the client record. Client #3 was admitted on March 9, 2022 and discharged on May 25, 2022. There was no documentation of follow up information in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical staff will be re-educated on the requirement to complete patient follow-up within 10 days per Caron policy. The Clinical Supervisor will provide this re-education by 2/24/2023.
The Clinical Supervisor will monitor the completion of patient follow-up by running a report from the electronic medical records system on a weekly basis. |