INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Renewal Treatment, Inc. 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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704.12(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.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that staff caseloads remained at or below 35:1.The facility reported to be operating with a 40 hour workweek.Employee #3 was reported to work 40 hours per week with all 40 hours being devoted to client treatment. Employee #3 has a caseload of 40 clients. The caseload calculation is as follows: 40/40 = 1 FTE 40 clients/1 FTE = 40:1 caseloadEmployee #5 was reported to work 40 hours per week with all 40 hours being devoted to client treatment. Employee #5 has a caseload of 37 clients. The caseload calculation is as follows: 40/40 = 1 FTE 37 clients/1 FTE = 37:1 caseloadThese findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall ensure that staff caseloads remain at 35:1 or below. Renewal Treatment, Inc. has stopped taking referrals until we fill an open Counselor position. Renewal Treatment, Inc. is actively interviewing internal and external candidates and shall fill the open Counselor position by the most expedited means. Once the new Counselor is hired, Renewal Treatment, Inc. will begin accepting referrals again ensuring that the caseloads do not exceed the 35:1 ration. The Clinical Supervisor received instruction on this deficiency and is aware of this requirement and shall ensure we meet staffing rations. The Clinical Supervisor shall be responsible for new intake caseload assignments and shall have overall oversight responsibility for this corrective action. This plan of correction is in place. |
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, the facility failed to document unannounced fire drills at least once per month.The fire drill logs were reviewed for September 2021 - August 2022. There was no documentation of fire drills conducted for the months of January, February, March, April, May, June and July 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall document fire drills at least monthly. The Director of Security shall ensure that the fire drills are scheduled every month and that they are completed. The Director of Security shall maintain a logbook of all fire drills and shall audit this logbook at least monthly to ensure compliance. The VP HR and Compliance provided instruction to the Director of Security on this deficiency and the requirements for fire drills. The Director of HR and Compliance and VP of HR and Compliance shall be copied via email when all fire drills are completed and shall ensure they meet all regulatory requirements. The Director HR and Compliance and VP HR and Compliance shall have overall oversight responsibility for this plan of action. This plan of action is in place. |
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 client records, the facility failed to document treatment plan updates at least every 60 days in four of seven client records.Client # 4 was admitted on March 16, 2022 and discharged on August 1, 2022. A treatment plan was documented on March 22, 2022. There were no treatment plan updates documented in client record #4.Client #5 was admitted on March 9, 2022 and is currently an active client. A treatment plan was documented on May 3, 2022. There were no treatment plan updates documented in client record #5.Client #6 was admitted on April 8, 2022 and is currently an active client. A treatment plan was documented on April 11, 2022. There were no treatment plan updates documented in client record #6.Client #7 was admitted on May 12, 2022 and is currently an active client. A treatment plan was documented on June 9, 2022. There were no treatment plan updates documented in client record #7.This is a repeat deficiency from the September 8, 2021, January 7, 2021 and October 17, 2019 annual licensing inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall document treatment plan updates at least every sixty (60) days. The Clinical Supervisor shall provide training and instruction to the Counselors on this deficiency and this regularity requirement. The Clinical Supervisor shall audit the case records at least monthly to verify compliance. In addition, the Compliance Specialist shall audit the case records, at least monthly, and report their compliance finding to the VP HR and Compliance. The VP HR and Compliance, Director of HR and Compliance and Clinical Director shall have overall oversight responsibility for this plan of action. This plan of correction is in place. |
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 document case consultations at least every 90 days in five of seven client records.Client #1 was admitted on October 21, 2021 and discharged on February 8, 2022. There were no case consultations documented in client record #1.Client #2 was admitted on February 25, 2022 and discharged on June 20, 2022. There were no case consultations documented in client record #2.Client #3 was admitted on November 5, 2021 and discharged on June 27, 2022. There were no case consultations documented in client record #3.Client #4 was admitted on March 16, 2022 and discharged on August 1, 2022. There were no case consultations documented in client record #4.Client #7 was admitted on May 12, 2022 and is currently active. There were no case consultations documented in client record #7.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. treatment staff shall perform case consultations at least every 90 days. The Clinical Director provided instruction to the Clinical Supervisors on this requirement. The Clinical Director and Clinical Supervisors shall provide instruction to the Counselors on this deficiency and requirement. The Clinical Supervisor shall ensure compliance by auditing the case records on a monthly basis. In addition, the Compliance Specialist shall audit the case records on a monthly basis and report the compliance findings to the VP HR and Compliance. The Clinical Director and VP HR and Compliance shall have overall oversight responsibility for this plan of correction. This plan of correction is in place. |
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 document follow up contact within 30 days of discharge, as per agency policy, in four of four client records.Client #1 was admitted on October 21, 2021 and discharged on February 8, 2022. There was no follow up documented in client record #1.Client #2 was admitted on February 25, 2022 and discharged on June 20, 2022. There was no follow up documented in client record #2.Client #3 was admitted on November 5, 2021 and discharged on June 27, 2022. There was no follow up documented in client record #3.Client #4 was admitted on March 16, 2022 and discharged on August 1, 2022. There was no follow up documented in client record #4.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. treatment staff shall complete, and document follow up contacts within thirty (30) days of discharge, per agency policy. The Clinical Director shall provide instruction for the Clinical Supervisors on this deficiency and requirement. The Clinical Director and Clinical Supervisors shall provide instruction/training for the Counselor/Cnslr. Asst. staff on this deficiency and requirements for follow up per agency policy. The Clinical Supervisor shall ensure compliance by auditing the close out case records to ensure compliance. In addition, the Compliance Specialist shall audit the close out records and report the compliance finding to the VP HR and compliance. The Clinical Director and VP HR and Compliance shall have oversight responsibility for this plan of corrections. This plan of correction is in place. |
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 treatment plan updates was submitted and approved by the Department for the September 8, 2021, January 7, 2021, and October 17, 2019, annual licensing inspections. Treatment plan updates were again found to be a deficiency in the September 12, 2022, annual licensing inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall comply with plans of correction that are approved by the Department. The Project Director and Clinical Director shall meet with the Executive Management team (CEO, VP HR and Compliance, VP Administration) on a bi-weekly basis to review the status of Department approved plans of correction. Reporting on plans of correction status will be a standing agenda item. At that time any barriers to compliance will be resolved ensuring that all plans of correction are completed within the corrective action date. Meeting minutes will be taken to document discussions, elimination of barriers and expectations for compliance. Oversight staff that fail to follow through with plans of correction will receive disciplinary personnel actions. The executive management team has met with the Project Director and Clinical Director to establish these expectations and set the meeting time frames for corrective action plan review. The VP HR and Compliance shall have oversight responsibility for this plan of correction. This plan of correction is in place and shall ensure compliance with all plans of correction including the treatment plan update regulatory requirements. |