INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24-25, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cornell Abraxas I 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 personnel records, the facility failed to ensure counselor and counselor assistants received the minimum of at least 6 hours of HIV/AIDS within one year of employment in five of six records.
Staff #7 was hired as a counselor on October 31, 2022 and still employed at time of inspection. Staff #7 was due to have the communicable disease trainings no later than October 31, 2023 but the HIV/AIDS training was not completed until October 18, 2024.
Staff #9 was hired as a counselor assistant on February 20, 2023 and still employed at time of inspection. Staff #9 was due to have the communicable disease trainings no later than February 20, 2024 but the HIV/AIDS training was not completed until May 1, 2024.
Staff #10 was hired as a counselor assistant on July 10, 2023 and still employed at time of inspection. Staff #10 was due to have the communicable disease trainings no later than July 10, 2024 but the HIV/AIDS training was not completed until August 7, 2024.
Staff #11 was hired as a counselor assistant on July 24, 2023 and still employed at time of inspection. Staff #11 was due to have the communicable disease trainings no later than July 24, 2024 but the HIV/AIDS training was not completed until December 18, 2024.
Staff #12 was hired as a counselor assistant on July 24, 2023 and still employed at time of inspection. Staff #12 was due to have the communicable disease trainings no later than July 24, 2024 but the HIV/AIDS training was not completed until December 18, 2024.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Beginning March 21, 2025, the Training Department will monitor completion of employee mandatory training and provide email reminders and/or notifications in the Relias system to supervisors and employees regarding employees who are six months or less away from a mandatory training deadline.
By April 4, 2025, the D/A Program Manager will review the training requirements in 704.11 with all D/A Treatment Supervisors. Supervisors will be instructed to document completion of all mandatory training (e.g., HIV/AIDs) in their employees' professional development plans and track completion during employee supervision.
By April 18, 2025, employees who are out of compliance with HIV/AIDS training will complete the six-hour training. The Training Department will verify compliance and file their training documentation in their training file.
If mandatory training is not completed by 60 days prior to the deadline, a supervisor will meet with the employee to develop a detailed plan to complete the training prior to the due date. This meeting will be documented on a supervisory conference note. If the employee does not complete the training by the due date, corrective action will be pursued.
The Facility Director (Executive Director) is responsible for oversight of this process and will monitor the process for 90 days or until compliance is achieved and sustained. The facility will be in full compliance with the standard by April 18, 2025.
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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 a consent to release information form prior to the disclosure of information in one of seven records.
Client #3 admitted on June 28, 2024 and discharged on November 18, 2024. There was no consent to release information for a government agency, and four separate personal contacts but disclosures were confirmed on July 15, July 30, October 15, October 29, and November 5.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the February 14, 2024 annual licensure inspection and September 4, 2024 follow up inspection.
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Plan of Correction
As of February 10, 2025, documentation of new client intakes is being completed within the facility's Electronic Health Record (EHR). As clinical staff complete intake documentation with new clients, consent to release information forms are completed, signed, and maintained in the EHR.
By April 4, 2025, Treatment Supervisors will complete training with Counselors and Counselor Assistants to review and verify their understanding of the requirements for completing consent to release of information forms, as well as the methodology for documenting the forms in the EHR. Training verification will be filed in the employees' training records.
Beginning April 4, 2025, Treatment Supervisors will complete a review of all new client intake documentation within 72 hours of intake to verify consent to release information forms are fully and accurately completed.
By April 11, 2025, Treatment Supervisors will inspect each client file (paper and/or EHR) to verify all clients have the appropriate consent to release information forms in their files. By April 18, 2025, Treatment Supervisors will notify the Program Manager to verify necessary corrections or additions have been completed.
The Program Manager is responsible for oversight of this process and will monitor the process for 90 days or until compliance is achieved and sustained. The facility will be in full compliance with the standard by April 18, 2025.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered as prescribed in four of seven records reviewed.
Client #1 was admitted June 12, 2024 and discharged November 22, 2024.
A medication was prescribed to be given once daily. The MAR was left blank for the following dates: June 18, June 19, June 20, June 23, August 17, August 18, August 22, August 24, August 30, August 31, September 1, September 7, September 9, September 14, and September 15, 2024.
A second medication was prescribed to be given once daily. The MAR was left blank for the following dates: August 17, August 18, August 22, August 24, August 30, August 31, September 1, September 7, September 9, September 12, September 14, September 15, October 2, October 11, October 16, October 17, and October 22, 2024.
A third medication was prescribed to be given once daily. The MAR was left blank for the following dates: August 17, August 30, and August 31, 2024.
A fourth medication was prescribed to be given once daily. The MAR was left blank for the following dates: September 9 and September 13, 2024.
A fifth medication was prescribed to be given once daily. The MAR was left blank for the following dates: October 7, October 11, October 16, October 17, and October 22, 2024.
Client #2 was admitted July 30, 2024 and discharged November 6, 2024.
A medication was prescribed to be given once daily. The MAR was left blank for the following dates: August 3, August 4, August 16, August 17, August 18, August 20, August 29, August 31, September 1, September 15, September 25, September 26, September 27, September 28, September 29, October 12, October 13, October 25, October 26, October 27, October 30, and October 31, 2024.
A second medication was prescribed to be given once daily for 14 days. The MAR was left blank for the following dates: September 27, September 28, and September 29, 2024.
A third medication was prescribed to be given once daily. The MAR was left blank for the following dates: October 12, October 13, October 25, October 26, October 27, October 30, and October 31, 2024.
Client #3 was admitted June 28, 2024 and discharged November 18, 2024.
A medication was prescribed to be given once daily. The MAR was left blank for the following dates: September 15, September 27, September 28, September 29, October 12, October 13, October 25, October 26, October 27, October 30, and October 31, 2024.
A second medication was prescribed to be given once daily. The MAR was left blank for the following dates: August 3, August 4, August 16, August 18, August 20, August 29, August 31, September 15, September 27, September 28, September 29, October 8, October 12, October 13, October 16, October 17, October 25, October 26, October 27, October 30, and October 31, 2024.
A third medication was prescribed to be given once daily. The MAR was left blank for the following dates: August 18, August 30, August 31, September 9, and September 29, 2024.
Client #7 was admitted June 25, 2024 and still a current client.
A medication was prescribed to be given once daily. The MAR was left blank for the following dates: December 7, December 8, December 14, December 20, December 22, December 25, December 26, 2024, January 4, January 5, January 13, January 18, January 19, January 20, and January 28, 2025.
A second medication was prescribed to be given twice daily. The MAR was left blank for the following dates and times: December 20 at 8 am, December 21 at 8 am, December 22 at 8 am, December 25 at 8 am, December 26 at 8 am, December 27 at 8 am, January 3 at 8 pm, January 4 at 8 am and 8 pm, January 5 at 8 am, January 13 at 8 am and 8 pm, January 18 at 8 am, January 19 at 8 am, January 20 at 8 am, and January 28, 2025 at 8 am.
A third medication was prescribed to be given once daily. The MAR was left blank for the following dates: September 27, September 28, September 29, October 12, October 13, October 25, October 26, October 27, October 30, October 31, November 8, November 9, November 10, November 21, November 23, November 24, November 26, November 27, and November 28, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
By March 31, 2025, the Nurse Manager or Nurse Supervisor will complete refresher training with employees who are trained to supervise the self-administration of medication of drug and alcohol treatment clients. Training will include the medication administration procedures, as well as documentation on the MAR. Employees will be instructed on the appropriate documentation of medication errors on the MAR as well as on an incident report.
Beginning April 1, 2025, the Nurse Manager will complete a weekly review of every Medication Administration Record (MAR) to verify medications are being administered as prescribed. The Nurse Manager will document the review of every MAR on a spreadsheet. When a medication error is identified, the Nurse Manager will verify that an incident report has been completed, and that proper documentation is on the back of the MAR. The Nurse Manager will notify supervisors of employees who have not documented medication administration and/or medication errors correctly. Supervisors will document a supervisory conference with employees and include a corrective action plan to prevent additional documentation errors.
The Nurse Manager will report monthly to the Leadership Team on accuracy of MARs and the process for verifying compliance. The Facility Director (Executive Director) is responsible for oversight of this process and will monitor the process for 90 days or until compliance is achieved and sustained. The facility will be in full compliance with the standard by April 30, 2025.
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident.
The facility had unusual incidents occur on July 11, two incidents on September 14, October 22, November 1, and two incidents on November 17, 2024 which involved physical assault of a client and the facility did not submit an incident report to the Department.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the September 4, 2024 follow up inspection.
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Plan of Correction
Effective March 19, 2025, the Quality & Compliance Specialist will review all incident reports to determine if the information is required to be reported as an unusual incident. By March 28, 2025, the Quality & Compliance Specialist will review with the Abraxas Leadership Team and Supervisory Team the types of incidents that must be reported as unusual incident reports to DDAP. Treatment Supervisors and Program Managers will verify incident reports have been completed in the client record and will notify the Quality & Compliance Specialist of all unusual incidents within their programs. The Quality & Compliance Specialist will be primarily responsible for submitting unusual incident reports via the DDAP portal.
By April 1, 2025, the Quality and Compliance Specialist will review the process for submitting reports with the Executive Director and Drug & Alcohol Program Manager. They will complete unusual incident reports in the DDAP portal if the Quality & Compliance Specialist is not available. By April 1, 2025, the Quality & Compliance Specialist will review and revise, the Reportable Incident Reporting policy to include the requirements and methodology for reporting unusual incidents to the Department within three business days. By April 18, 2025, the Quality & Compliance Specialist will submit the revised policy to the Abraxas Policy Council for approval. By May 2, 2025, the Quality & Compliance Specialist will review the updated policy with the Abraxas Leadership Team and Supervisory Team.
The Facility Director (Executive Director) is responsible for oversight of this process and will monitor the process for 90 days or until compliance is achieved and sustained. The facility will be in full compliance with the standard by May 16, 2025.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident.
The facility had unusual incidents occur on September 15 and October 30, 2024 which involved police or ambulance onsite and the facility did not submit an incident report to the Department.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the February 14, 2024 annual licensure inspection and September 4, 2024 follow up inspection.
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Plan of Correction
Effective March 19, 2025, the Quality & Compliance Specialist will review all incident reports to determine if the information is required to be reported as an unusual incident. By March 28, 2025, the Quality & Compliance Specialist will review with the Abraxas Leadership Team and Supervisory Team the types of incidents that must be reported as unusual incident reports to DDAP. Treatment Supervisors and Program Managers will verify incident reports have been completed in the client record and will notify the Quality & Compliance Specialist of all unusual incidents within their programs. The Quality & Compliance Specialist will be primarily responsible for submitting unusual incident reports via the DDAP portal.
By April 1, 2025, the Quality and Compliance Specialist will review the process for submitting reports with the Executive Director and Drug & Alcohol Program Manager. They will complete unusual incident reports in the DDAP portal if the Quality & Compliance Specialist is not available. By April 1, 2025, the Quality & Compliance Specialist will review and revise, the Reportable Incident Reporting policy to include the requirements and methodology for reporting unusual incidents to the Department within three business days. By April 18, 2025, the Quality & Compliance Specialist will submit the revised policy to the Abraxas Policy Council for approval. By May 2, 2025, the Quality & Compliance Specialist will review the updated policy with the Abraxas Leadership Team and Supervisory Team.
The Facility Director (Executive Director) is responsible for oversight of this process and will monitor the process for 90 days or until compliance is achieved and sustained. The facility will be in full compliance with the standard by May 16, 2025.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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 document an attempted follow up with clients following discharge from the facility in two of four applicable records reviewed.
According to agency policy and procedure manual, follow up with discharged clients is as follows: all discharges will have follow up contact within 30 days and unsuccessful discharge is followed up with in one week.
Client #1 was admitted June 12, 2024 and discharged November 22, 2024. No follow up attempts were documented for this client.
Client #3 was admitted June 28, 2024 and discharged November 18, 2024. No follow up attempts were documented for this client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By April 4, 2025, Treatment Supervisors will review the Follow-up Policy with Counselors and Counselor Assistants, specifically the procedures for following up with clients after their discharge from the program.
By April 11, 2025, Counselors and Counselor Assistants will complete follow up with all clients who have discharged since March 1, 2025. Beginning April 11, 2025, Counselors and Counselor Assistants will follow up with unsuccessfully discharged clients within one week from their discharge date and will complete follow up with successfully discharged clients within 30 days of their discharge date. The follow up information will be documented on the Continuing Care Questionnaire and filed in the client's clinical file.
Beginning April 11, 2025, the Program Manager will review each client's closed file to verify follow up information was documented. The Facility Director (Executive Director) is responsible for oversight of this process and will monitor the process for 90 days or until compliance is achieved and sustained. The facility will be in full compliance with the standard by April 18, 2025.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to obtain an informed and voluntary consent from the client prior to the disclosure of information was submitted and approved by the Department for the February 14, 2024 annual inspection and September 4, 2024 follow up inspections.
Failing to obtain an informed and voluntary consent from the client prior to the disclosure of information was again found to be a deficiency in the February 25, 2025 licensing inspection.
A plan of correction for reporting unusual incidents was submitted and approved by the Department for the February 14, 2024 annual inspection and September 4, 2024 follow up inspections. Reporting of unusual incidents were again found to be a deficiency in the February 25, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By March 24, 2025, the Quality & Compliance Specialist will create a tracking form and begin focused monitoring of all plans of correction. The tracking form will include all plans of correction, action steps, responsible parties, and due dates. By March 26, 2025, the Quality & Compliance Specialist will facilitate training for the Leadership Team which will include all licensing citations, accepted plans of correction, action steps, responsible parties, and due dates. A sign in sheet for the training will be created to verify participation of Leadership Team members.
Beginning April 2, 2025, the Quality & Compliance Specialist will facilitate biweekly monitoring of all corrective action plans and subsequent monitoring activities at the Leadership Team Meeting, to document progress made and ensure any barriers are being addressed with tenacity. The Quality & Compliance Specialist will update the tracking form following the monitoring discussion at each Leadership Team Meeting.
The Facility Director (Executive Director) is responsible for oversight of this process and will monitor the process for 120 days or until compliance is achieved and sustained. The facility will be in full compliance with the standard by May 21, 2025.
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