INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 11, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Western Pennsylvania Counseling Services, LLC dba Forge Health 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of administrative information, the facility failed to document an overall plan for addressing staff training needs.
Per the policy and procedure, the facility training year is from March to March.
An overall plan for addressing staff training needs was not documented for the March 2024-March 2025 training year.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
704.11 Overall Training Plan
Executive Clinical Director will collaborate with the Compliance Officer and Senior Director of Training and Leadership Development to develop an overall training plan that will address the training needs of the facility for the year ending in March of 2025. The Clinical Director will review individual training plans to ensure they address the overall facility training plan. The Clinical Director will review these with the Executive Clinical Director at the monthly leadership meeting that follows the annual performance evaluations. |
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.
|
Observations
Based on a review of administrative information, the facility failed to document an annual evaluation of the overall training plan.
Per the policy and procedure, the facility training year is from March to March.
An annual evaluation of the overall training plan was not documented for the March 2023-March 2024 training year.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Executive Clinical Director will collaborate with the Compliance Officer and Senior Director of Training and Leadership to evaluate the effectiveness of and compliance with the prior year training plan. This evaluation will take place prior to development of the training plan for the coming year. The Executive Clinical Director will review training plan progress with the Executive Director at monthly leadership meetings. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure the FTE counselor caseload in outpatient programs did not exceed 35 active clients for one of five counselors reviewed.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee #6 was hired as a counselor on August 1, 2023. The employee's ratio calculation was as follows: 11.5/40= 0.2875 (FTE); 11/0.2875 = 38.26, which equals a client/counselor FTE ratio of 38:1.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
704.12 Outpatient Caseload
The CD will complete monthly case load assessments and review these with the ECD. The CD will adjust SUDs hours and case assignments to ensure each clinician does not exceed the recommended ratio. Employee#6 will increase her hours for SUD clients and transfer SUD clients to another therapist to comply with the recommended ratio of 35:1. |
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.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure staff were instructed in the use of fire extinguishers upon employment in one of four records.
Employee #7 was hired as a counselor on April 29, 2024, and was still in the position on the date of the inspection. At the time of the inspection, there was no documentation the training had been completed.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
705.28 Fire Safety
The ECD will implement a new hire checklist to include fire safety training with a deadline within 7 days of the employee's start date. CD will review the new hire checklist weekly to ensure fire safety training is completed within the first 7 days of employment.
Employee#7 completed fire safety training with Relias on 10/11/2024. |
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.
|
Observations
Based on a review of the facility fire drill log for the months of September 2023 through September 2024, the facility failed to provide documentation of a fire drill being conducted the month of November 2023.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the October 11, 2024 licensing inspection.
|
Plan of Correction
The Executive Clinical Director will randomly select a day and time each month to conduct a fire drill. The Executive Clinical Director will record the drill within the facility compliance folder in a monthly log. The Clinical Director will review monthly log during monthly leadership meetings to ensure compliance. |
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure staff signed copies of their individual staff performance evaluations in four of four applicable records.
Staff #1 was hired on August 1, 2023.
Staff #4 was hired on August 1, 2023.
Staff #5 was hired on August 1, 2023.
Staff #6 was hired on August 1, 2023.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
709.26 Personnel Management
The Executive Clinical Director and Clinical Director will collaborate with Human Resources and the Compliance Officer to formalize a signed acknowledgement of each employee's annual performance evaluation. The Clinical Director will ensure the signature is completed during the review of the staff performance evaluation. The Clinical Director will review this with the Executive Clinical Director at the next monthly leadership meeting that follows the review process. |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in two of six applicable records.
Client #3 was admitted on December 1, 2023, and discharged on May 1, 2024. A treatment plan was developed with the client on December 28, 2023, and an update was due no later than February 28, 2024; however, it was completed on March 28, 2024.
Client #7 was admitted on March 28, 2024, and was still active at the time of the inspection. A treatment plan update was completed on July 1, 2024, and the next update was due no later than September 1, 2024; however, it was not completed until September 5, 2024.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the October 11, 2024 licensing inspection.
|
Plan of Correction
709.92 Treatment and Rehabilitation services
The CD will review treatment plan procedures with the clinical team during weekly rounds. The CD will complete audits of randomly selected charts to ensure treatment plans are updated every 60 days. Chart audits will be reviewed with the ECD in monthly leadership meetings. The results of the chart audit will be reviewed monthly with the clinician. SUD clients admitted after 12/1/2024 will be included in audits. |
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.
|
Observations
Based on a review of client records, the facility failed to document case consultations in three of seven records.
The facility's policy and procedure manual states a case consultation must be completed within 7 days of admission and then every 90 days.
Client #3 was admitted on December 1, 2023, and discharged on May 1, 2024. A case consult was due no later than May 8, 2024; however, there was no case consult documented in the record until March 1, 2024.
Client #4 was admitted on February23, 2024, and discharged on July 26, 2024. There were no case consultations documented in client record #4.
Client #7 was admitted on March 28, 2024, and was still active at the time of the inspection. There was a case consult on March 29, 2024, and the next one was due no later than June 29, 2024; however, there were no further case consults documented in in client record #7.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
709.93 Client Records
CD will review case consultation procedures with the clinical team during weekly rounds. The CD will complete chart audits of randomly selected charts to ensure consults are completed within 7 days of admission and then every 90 days thereafter. The CD will review these audits with the ECD at monthly leadership meetings. The CD will review the results of chart audits monthly with the clinicians. SUD clients admitted after 12/1/2024 will be included in audits. |
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.
|
Observations
Based on a review of client records, the facility failed to document follow-up information in two of three applicable discharged records.
The facility's policy and procedure manual states follow up contact is to be completed for all discharges within 90 days.
Client #1 was admitted on January 8, 2024, and was discharged on April 8, 2024. Follow-up was due no later than July 8, 2024; however, it was not completed until July 17, 2024.
Client #2 was admitted on January 26, 2024, and was discharged on April 10, 2024. Follow-up was due no later than July 10, 2024; however, it was not completed until July 17, 2024.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the October 11, 2024 licensing inspection.
|
Plan of Correction
709.93 Client records
The Executive Clinical Director will provide training for the Clinical Director and Office Manager to ensure knowledge of the reports necessary to monitor discharge dates and administrative staff will attempt contact of clients within 90 days of discharge. The Executive Clinical Director will coordinate with the Vice President of Engagement and Experience to formulate best practice to ensure visibility. The Clinical Director will audit charts to include discharge follow up contact and discuss with the Executive Clinical Director in monthly leadership meetings.
|