INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, MCP/Caring Together was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an annual written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor in one of five personnel records reviewed.
Employee # 5 was hired as a counselor on January 4, 2011. There was no individual training plan documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Annual written individual training plans will be devised during supervision session with staff during the months of May - June. The supervisor will devise the plan with input from the supervisee.
All new employees will have their individual training plan completed with supervisor within 30 days of hire.
Program Director will review all completed individual training plans within 10 days of completion.
Employee# 5 and Program Director completed Individual Training Plan on 5/5/2021. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, the facility failed to ensure that CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills was onsite during the project's hours of operations.
The facility provided documentation that only one employee, who works thirty to thirty-eight hours per week, has current CPR and first aid certification. The facility's hours of operation are Monday, Wednesday, Friday 8:30am-4:30pm and Tuesday, Thursday 8:30am-7:00pm, which totals forty-five hours per week. One employee is not sufficient to provide CPR coverage for the entirety of the project's hours of operation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff are usually CPR certified. However, due to the lack of in-person trainings as a result of COVID-19 this did not occur.
In-person CPR trainings are beginning to become available. In an effort to ensure that there is always trained personnel on duty, all staff will be registered for CPR training. All staff will have completed the training within the next 60 day and will be completely certified.
Certificates of successful completion will be submitted to Program Director for review.
The Program Director's designee has contacted the American Red Cross to schedule CPR First Aid Training for the entire staff. Certifying the entire staff ensures that there is always the appropriate amount of staff on duty that are certified. The trainings are scheduled to be completed by all staff by June 2021.
To ensure that this deficiency does not recur, staff will be registered by the Program Director's designee for virtual CPR/First Aid Training in the future. Successful completion of this training will result in full CPR & First Aid certification. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's previous two training years in one of two applicable personnel record reviewed.
Employee #2 was hired as a counselor on December 7, 2015. The personnel record documented 21 hours of training received during the July 1, 2018 through June 30, 2019 training year and 16 hours of training received during the July 1, 2019 through June 30, 2020 training year.
This is a repeat citation from the April 17, 2019 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors will be provided a monthly training schedule and will assume the responsibility for registering for mandated trainings. The supervisor will mandate trainings for counselor based on licensing regulations, individual certification needs and program/individual needs.
Counselors will submit the certificate to Program Director along with the evaluation. The Program Director will log training hours based on submitted documentation. |
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 a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in two of two applicable personnel records reviewed.
Employee # 4 was hired as a counselor on December 20, 2019. The personnel record documented that the fire extinguisher training was not completed until December 2020.
Employee #5 was hired as a counselor on January 4, 2021. The personnel record documented that the fire extinguisher training was not completed until March 16, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training and documentation of the use of the fire extinguisher occurs within 7 days of hire. Documentation of completion of the training will be placed in the employee's training file after review by the Program Director.
A New Employee Hire Log has been created to note the need for Fire Extinguisher Training. This training will become a part of the new employee orientation. This log is completed and monitored by the Program Director to ensure that training occurs within the first 7 days of hire. |
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 a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies upon employment in two of two applicable personnel records reviewed.
Employee # 4 was hired as a counselor on December 20, 2019. The personnel record documented that the training to perform assigned tasks during emergencies was not completed until December 2020.
Employee #5 was hired as a counselor on January 4, 2021. The personnel record documented that the training to perform assigned tasks during emergencies was not completed until March 16, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff receive Emergency Training within 7 days of the start of their employment. At the completion of the training, the employee will complete a Emergency Training Evaluation form. Successful completion of the Emergency Training Evaluation Form will be reviewed by the Program Director and placed in the employees' Training File.
All new hires will completed the Emergency Training Evaluation Form at the completion of the training, which will occur within 7 days of hire. This training will be incorporated into the orientation phase of employment. The New Employee Training Log will be noted as completed for this task and monitored by the Program Director to ensure compliance. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to verify the individual's identity including name, address and date of birth prior to the administration of an agent in one of three applicable patient records reviewed.
Patient # 5 was admitted on September 12, 2019 and was still active at the time of the inspection. There was no documentation that the verification of the patient's identity was completed in the client record prior to the administration of an agent.
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Plan of Correction
Copies of client's Pennsylvania Identification Card & insurance card are placed in the chart when available. For clients without current photo identification, the following are acceptable for verifying identity:
- Any valid or expired national federal, state or local issued photo identification cards.
- A valid or expired passport.
- A valid or expired student photo ID, which contains the patient's Date of Birth (DOB).
- A photo identification card issued by another licensed NTP.
- A valid or expired check cashing photo identification card.
- A birth certificate and Social Security card.
- A copy of a photo of the patient and a letter directly from another licensed NTP in which the
patient was previously enrolled.
- A copy of a photo from a medical record with verification of date of birth.
- A state or federal correctional facility identification
A copy of the presented form of identification listed above will be placed in the client's chart.
Prior to administering an agent, the physician will verify the clients' identity and document success in the chart.
All clients are instructed to arrive for intake with their insurance card and picture identification to be copied and placed in chart. Staff will document in the Intake Note that verification of client's name, address and date of birth was made as a result of photo identification/insurance card or other presenting documentation.
The physician administering an agent will document in the medication note that they have verified the clients' identity with the identification documents in the chart prior to the administration of agent. The Program Director will verify this documentation during chart reviews that occur at a minimum of every 90 days.
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711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan that was developed with the client in two of six applicable client records reviewed.
Client #5 was admitted on September 16, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was signed by the counselor on November 21, 2019, but it was not signed by the client. There was no additional documentation in the client record that verified the comprehensive treatment plan was developed with the client.
Client #7 was admitted on November 14, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was signed by the counselor on December 16, 2019, but it was not signed by the client. There was no additional documentation in the client record that verified the comprehensive treatment plan was developed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All treatment plans must be devised and reviewed with clients. Appropriate signatures must be obtained upon review of the plan. Inability to obtain the client's signature will be noted on the plan with an explanation of failure to obtain the signature.
All treatment plans are reviewed by the Program Director, who will ensure that there is an explanation documented when signatures are missing. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in one of three applicable client records reviewed.
Client #7 was admitted on November 14, 2019 and was still active at the time of the inspection. There was a treatment plan update completed on April 17, 2020 and the next update was due no later than June 17, 2020; however, the update was not completed until August 19, 2020. Additionally, there was a treatment plan update completed on January 4, 2021 and the next update was due no later than March 4, 2021; however, the update was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All treatment plans will be completed with the client in a timely manner. Treatment plans will be reviewed and updated at a minimum of every 60 days. Failure to provide timely reviews and updates will be documented on the late treatment plan.
The Program Director will review and sign all updated treatment plans to ensure timeliness and documentation of late plans.
The Program Director has developed a Treatment Plan Log for each clinician. This log is shared and reviewed with the therapist during supervision sessions to ensure that all parties are aware of dates that treatment plans are due.
The Treatment Plan for client#7 was completed on 5/5/2021. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information in the client record in three of three applicable client records reviewed.
Client # 1 was admitted on June 20, 2019 and was discharged on September 17, 2019. The client record failed to document follow up information regarding the client as of the date of the inspection.
Client # 2 was admitted on June 11, 2019 and was discharged on July 30, 2019. The client record failed to document follow up information regarding the client as of the date of the inspection.
Client # 3 was admitted on August 7, 2019 and was discharged on November 7, 2019. The client record failed to document follow up information regarding the client as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client's Discharge Summary is to be submitted to the Program Director within 7 business days of discharge. Follow-up telephone calls/letters should be completed within 30 days of discharge from the program.
The completed Follow-up Telephone Form or a copy of the mailed Follow-up Form will be submitted to the Program Director for review and signature. This document will then be placed in the clients' closed chart. |
711.93(c)(2)(i) LICENSURE Name of person/agency/organization
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(i) The name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made to on release of information forms in two of seven client records reviewed.
Client # 3 was admitted on August 7, 2019 and was discharged on November 7, 2019. The client record contained a release of information form to the primary care physician that was signed and dated by the client on August 7, 2019, but the form did not document the name of the person, agency, or organization to whom the disclosure was to be made.
Client # 6 was admitted on November 4, 2020 and was still active at the time of the inspection. The client record contained release of information forms to the primary care physician and a blank release of information form, both were signed and dated by the client on November 4, 2020, but both forms did not document the name of the person, agency, or organization to whom the disclosure was to be made.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Consent forms will be completed to include the name of the person, agency, or organization to whom the disclosure is to be made to on release forms. The release form will also include the contact information for that person, agency or organization.
Upon inspection of the clients' chart, the Program Director will ensure that the counselor has obtained all information listed above.
The Program Director facilitated a training with staff to ensure that Release of Information Forms are completed in entirety and accurately.
Release forms for client#6 have been updated as of 5/4/2021. |
711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(ii) The specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on release of information forms in six of seven client records reviewed. Additionally, the facility failed to keep consent forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (a) for releases of information in four of seven client records reviewed.
Client # 1 was admitted on June 20, 2019 and was discharged on September 17, 2019. The client record contained a release of information form to the emergency contact that was signed and dated by the client on June 20, 2019, but the form did not document the specific information to be disclosed. Additionally, there were two release of information forms to the parole officer, signed and dated by the client on June 20, 2019 and August 21, 2019, that allowed for the release of urine drug screen results, which exceeded the limits established by 4 Pa. Code 255.5.
Client # 2 was admitted on June 11, 2019 and was discharged on July 30, 2019. The client record contained a release of information form to the emergency contact that was signed and dated by the client on June 11, 2019, but the form did not document the specific information to be disclosed. Additionally, there was a release of information form to a government agency, signed and dated by the client on June 11, 2019, that allowed for the release of urine drug screen results, which exceeded the limits established by 4 Pa. Code 255.5.
Client # 3 was admitted on August 7, 2019 and was discharged on November 7, 2019. The client record contained a release of information form to the emergency contact that was signed and dated by the client on August 7, 2019, but the form did not document the specific information to be disclosed.
Client # 5 was admitted on September 12, 2019 and was still active at the time of the inspection. The client record contained a release of information form to the emergency contact that was signed and dated by the client on September 12, 2019, but the form did not document the specific information to be disclosed. Additionally, there was a release of information form to a government agency, signed and dated by the client on September 12, 2019, that allowed for the release of urine drug screen results, which exceeded the limits established by 4 Pa. Code 255.5.
Client # 6 was admitted on November 4, 2020 and was still active at the time of the inspection. The client record contained a release of information form to the emergency contact that was signed and dated by the client on November 4, 2020, but the form did not document the specific information to be disclosed.
Client # 7 was admitted on November 14, 2019 and was still active at the time of the inspection. The client record contained a release of information form to the emergency contact that was signed and dated by the client on November 14, 2019, but the form did not document the specific information to be disclosed. Additionally, there was a release of information form to the parole officer, signed and dated by the client on November 14, 2019, that allowed for the release of urine drug screen results, which exceeded the limits established by 4 Pa. Code 255.5.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors will indicate on Release of Information Forms the specific information being disclosed.
Release of Information Forms are being reviewed by Program and Medical Directors to ensure adherence to PA. Code 255.5.
The Program Director facilitated a training in the correct use of the Release of Information Form to ensure that the appropriate information is being disclosed.
The ROI forms for clients #5,6, & 7 were corrected to meet the standards of PA Code 255.5.The Program Director will monitor the appropriate use of the ROI during chart reviews. |
711.93(c)(2)(iii) LICENSURE Purpose of Disclosure
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(iii) The purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on release of information forms in six of seven client records reviewed.
Client # 1 was admitted on June 20, 2019 and was discharged on September 17, 2019. The client record contained a release of information form to the emergency contact that was signed and dated by the client on June 20, 2019, but the form did not document the purpose of the disclosure.
Client # 2 was admitted on June 11, 2019 and was discharged on July 30, 2019. The client record contained a release of information form to the emergency contact that was signed and dated by the client on June 11, 2019, but the form did not document the purpose of the disclosure.
Client # 3 was admitted on August 7, 2019 and was discharged on November 7, 2019. The client record contained a release of information form to the emergency contact that was signed and dated by the client on August 7, 2019, but the form did not document the purpose of the disclosure.
Client # 5 was admitted on September 12, 2019 and was still active at the time of the inspection. The client record contained a release of information form to the emergency contact that was signed and dated by the client on September 12, 2019, but the form did not document the purpose of the disclosure.
Client # 6 was admitted on November 4, 2020 and was still active at the time of the inspection. The client record contained a release of information form to the emergency contact that was signed and dated by the client on November 4, 2020, but the form did not document the purpose of the disclosure.
Client # 7 was admitted on November 14, 2019 and was still active at the time of the inspection. The client record contained a release of information form to the emergency contact that was signed and dated by the client on November 14, 2019, but the form did not document the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Disclosure form for emergency contact is being revised to note the purpose of the disclosure to the person, agency or organization noted on the form.
The Program Director will review the revised form with the staff to ensure that the form is being completed accurately.
The Program facilitated a Release of Information training on 5/3/2021. Included in the training was the need to include the purpose of the disclosure. The Program Director will monitor the appropriate completion of this form when conducting chart reviews.
ROIs for clients #5,6, and 7 were updated on 5/5/2021 to include purpose of disclosure. |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client on release of information forms in four of seven client records reviewed.
Client # 1 was admitted on June 20, 2019 and was discharged on September 17, 2019. All of the release of information forms in the record were signed by the client and witness on August 21, 2019 and August 27, 2019, but there was no documentation that any of the forms were offered to the client. documentation that a copy of any of the forms were offered to the client.
Client # 3 was admitted on August 7, 2019 and was still discharged on November 7, 2019. All of the release of information forms were signed by the client and witness on August 7, 2019, but there was no documentation that a copy of any of the forms were offered to the client.
Client # 6 was admitted on November 4, 2020 and was still active at the time of the inspection. All of the release of information forms were signed by the client and witness on November 4, 2020, but there was no documentation that a copy of any of the forms were offered to the client.
Client # 7 was admitted on November 14, 1019 and was still active at the time of the inspection. All of the release of information forms were signed by the client and witness on November 14, 2019, but there was no documentation that a copy of any of the forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All consent forms shall be completed in entirety. A copy of the forms shall be offered to the clients. Notation of being offered a copy of the form will be indicated on the form by checking the appropriate box.
Program Director will check to verify that this task is being completed during chart reviews.
The Program Director facilitated an Intake Training. Covered during the training was the need to offer clients a copy of the signed forms and to note acceptance or refusal of copies of the forms.
The Program Director will monitor the accurate completion of consent forms during chart reviews.
The ROI for clients #6 and 7 were updated to meet this standard as of 5/5/2021. |