INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 22, 2021 through July 23, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD / New Start II 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(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 ensure that the project director completed at least 12 clock hours of training during the facility's July 1, 2019 through June 30, 2020 training year.
Employee #1 was hired as the Project Director on February 28, 2018. The personnel record documented 0 hours of training during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of New Start II will schedule quarterly meeting with the Project Director to ensure 12 training hours are completed and meets the Annual Training Requirements for licensure.
The Director or Clinical Director of New Start II will meet with the Project Director in the months of January, April, July, and October to review and ensure the required training have been scheduled or taken meets the requirements for 12 training hours and meet the requirements. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that each clinical supervisor completed at least 12 clock hours of training annually during the facility's July 1, 2019 through June 30, 2020 training year in one of one applicable personnel records reviewed.
Employee # 3 was hired as a clinical supervisor on October 12, 2018. The personnel record documented 11 hours of training received during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of New Start II will review the Clinical Supervisors training hours quarterly to ensure 12 training hours are completed and meets the Annual Training Requirements for licensure.
The Director of New Start II will meet with the Clinical Supervisor in the months of January, April, July, and October to review and ensure the required training have been scheduled or taken meets the requirements for 12 training hours and meet the licensure expectations. |
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 the review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee, in one of four applicable personnel records reviewed.
Employee # 2 was hired as the facility director on July 22, 2015. There were employee self-evaluations documented on June 3, 2020 and June 3, 2021; however, there was no documentation of annual evaluations completed by the supervisor and signed by the employee.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that timely submission of staff Annual Performance Evaluations are reviewed and signed in a timely manner. Evaluations will be submitted for signatures to Supervisors within two weeks of completion date so that performance reviews can by scheduled and signatures are obtained.
Evaluation are due by the end of the fiscal year June 30th. The Director will provide employee's with their evaluations the first week of June, and provide one week for completion.
The Director will submit all evaluations to assigned Supervisors for review and signatures the second week of the June. The Director will follow up with Supervisors one week before their due date June 30th of the years of submission. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) 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 four of fourteen client records reviewed.
Client # 2 was admitted on October 8, 2019 and was discharged on October 16, 2019. There was a release of information form to an emergency contact that was signed by the client and witness; however, the form did not document the name of the person, agency, or organization to whom the disclosure was to be made.
Client # 5 was admitted on January 27, 2020 and was discharged on February 11, 2020. There was a release of information form to an emergency contact that was signed by the client and witness; however, the form did not document the name of the person, agency, or organization to whom the disclosure was to be made.
Client # 11 was admitted on October 16, 2019 and was discharged on February 12, 2020. There was a release of information form to an emergency contact that was signed by the client and witness; however, the form did not document the name of the person, agency, or organization to whom the disclosure was to be made.
Client # 14 was admitted on February 11, 2020 and was discharged on May 8, 2020. There was a release of information form to an emergency contact that was signed by the client and witness; however, the form did not document the name of the person, agency, or organization to whom the disclosure was to be made to.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By August 16th, 2021 the Program Director will train all staff on the proper procedures when completing consent forms with a high concentration on documenting the name of the person, agency, or organization to whom the disclosure was to be made on. The Program Director will train all staff on Informed & Voluntary consent forms. The Director will al so review the Intake Packet and insure tilted form are added stating Voluntary and Informed consents making it two separate documents for easy identification.
The Director will train staff to cover all sections in detail of the Intake Packet/Consents including writing out the person, agency or organization to disclose information.
Both the Program Director and Clinical Supervisor will ensure charts will be reviewed monthly and consents are being completed correctly and in their entirety.
Clients #2,#5,#11, and# 14 are discharged
In the event any consent is not completed correctly, Program Director will meet with the respective client to complete consent and then meet with the staff member to go over consents and discuss reason(s) consent was not correct.
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709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) 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 consent to release information forms in four of fourteen client records reviewed.
Client # 2 was admitted on October 8, 2019 and was discharged on October 16, 2019. The release of information form to an external individual was signed by the witness and the release of information form for an emergency contact was signed by the client and witness, but both of the release forms failed to document the specific information to be disclosed.
Client # 6 was admitted on March 12, 2021 and was discharged on March 17, 2021. The release of information forms to another treatment provider and an emergency contact were signed by the client and witness, but both of the release forms failed to document the specific information to be disclosed.
Client # 8 was admitted on July 28, 2020 and was still active at the time of the inspection. The release of information forms to an external individual and a mobile therapist were signed by the client and witness, but both of the release forms failed to document the specific information to be disclosed.
Client # 11 was admitted on October 16, 2019 and was discharged on February 12, 2020. The release of information form to an external individual was signed by the witness and the release of information form to an emergency contact was signed by the client and witness, but both of the release forms failed to document the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By August 16, 2021 the Program Director will train all staff on the proper procedures when completing consent forms with a high concentration on documenting specific information to be disclosed on consent to release information. Once consents are completed by staff, the Director and/or Clinical Supervisor will review each consent to ensure that the specific information to be disclosed is documented correctly on each respective consent.
The Director will train staff to cover all sections in detail of the Intake Packet/Consents including writing out specific information on person, agency or organization to disclose information.
Both the Program Director and Clinical Supervisor will ensure charts are reviewed monthly and consents are being completed correctly in their entirety.
Program Director will also review all open charts to ensure that each consents disclosures are completed correctly and in their entirety.
Clients #2, #6, and #11, are discharged
On August 16, 2021 the Director will meet with client #8 to complete consent in their entirety. Program Director will document and identify specific information to be disclosed on the consent to release information forms. The Director will check off the appropriate boxes on the release of information form.
Director will monitor for on-going compliance at the end of each one.
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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) 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 consent to release information forms in four of fourteen client records reviewed.
Client # 2 was admitted on October 8, 2019 and was discharged on October 16, 2019. The release of information form to an external individual was signed by the witness and the release of information form to an emergency contact was signed by the client and witness, but both of the release forms failed to document the purpose of the disclosure.
Client # 6 was admitted on March 12, 2021 and was discharged on March 17, 2021. The release of information forms to another treatment provider and an emergency contact were signed by the client and witness, but both of the release forms failed to document the purpose of the disclosure.
Client # 8 was admitted on July 28, 2020 and was still active at the time of the inspection. The release of information forms to an external individual and a mobile therapist were signed by the client and witness, but both of the release forms failed to document the purpose of the disclosure.
Client # 11 was admitted on October 16, 2019 and was discharged on February 12, 2020. The release of information form to an external individual was signed by the witness and the release of information form to an emergency contact was signed by the client and witness, but both of the release forms failed to document the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By August 16, 2021 the Program Director will train all staff on the proper procedures when completing consent forms with a high concentration on documenting the purpose of the disclosure with the correct written dates and signature of the clients on consent to release information document. The Director will ensure the dates, signature, and purpose of the disclosure is clearly documented on the consents.
The Director will train staff to cover all sections in detail of the Intake Packet/Consents including writing out the date, signature, and purpose of the disclose information.
Both the Program Director and Clinical Supervisor will ensure charts are reviewed monthly and consents are being completed correctly in their entirety.
Program Director will also review all open charts to ensure that each consents disclosures are completed correctly and in their entirety.
Clients #2, #6, and #11, are discharged
On August 16, 2021 the Director will meet with client #8 to complete consent in their entirety. Program Director will document and identify information that requires correction and have the correct dates and signature recorded on the consent to release information. The Director will check off or write the appropriate information in the boxes on the release of information form to indicate its purpose.
In the event any consent is not completed correctly, Program Director will meet with the respective client to complete consent and then meet with the staff member to go over consents and discuss reason(s) consent was not correct.
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709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in seven of fourteen client records reviewed.
Client # 2 was admitted on October 8, 2019 and was discharged on October 16, 2019. The release of information form to an external individual was signed by the witness, the form did not document the dated signature of the client. Additionally, the release of information forms to a pharmacy, social service agencies, the funding source, a government agency, an emergency contact and a urinalysis laboratory were all signed by the client and witness, but all of the release forms failed to document the date of the client signatures.
Client # 5 was admitted on January 27, 2020 and was discharged on February 11, 2020. The release of information forms to a pharmacy, social service agencies, the funding source, a government agency, an emergency contact and the urinalysis laboratory were signed by the client and witness, but all of the release forms failed to document the date of the client signatures.
Client # 6 was admitted on March 12, 2021 and was discharged on March 17, 2021. The release of information forms to another treatment provider and to the emergency contact were signed by the client and witness, but both of the release forms failed to document the date of the client signatures.
Client # 8 was admitted on July 28, 2020 and was still active at the time of the inspection. The release of information forms to an external individual, another treatment provider, a pharmacy, social service agencies, the funding source, an emergency contact and the urinalysis laboratory were signed by the client and witness, but all of the release forms failed to document the date of the client signatures.
Client # 9 was admitted on December 16, 2020 and was still active at the time of the inspection. The release of information forms to another treatment provider, a pharmacy, social service agencies, the funding source, an emergency contact and the urinalysis laboratory were signed by the client and witness, but all of the release forms failed to document the date of the client signatures.
Client # 11 was admitted on October 16, 2019 and was discharged on February 12, 2020. The release of information form to an external individual was signed by the witness, but the form failed to document the dated signature of the client. Additionally, the release of information forms to another treatment provider, a pharmacy, social service agencies, the funding source, a government agency, an emergency contact and the urinalysis laboratory were signed by the client and witness, but all of the release forms failed to document the date of the client signatures.
Client # 14 was admitted on February 11, 2020 and was discharged on May 8, 2020. The release of information forms to another treatment provider, a pharmacy, social service agencies, the funding source, a government agency, an emergency contact and the urinalysis laboratory were signed by the client and witness, but all of the release forms failed to document the date of the client signatures.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By August 16, 2021, the Program Director will train all staff on the proper procedures when completing consent forms with a high concentration on documenting the dates and signature of the clients on consent to release information documents. The Director will ensure the dated signature of the client is documented on the consents.
The Director will train staff to cover all sections in detail of the Intake Packet/Consents including writing out the dated signature of the client for the purpose of disclose of information.
The Program Director and Clinical Supervisor will review Intake Packets upon submission and review for corrections. In addition, both Director and Clinical Supervisor will ensure charts are reviewed monthly and consents are being completed correctly in their entirety.
Program Director will also review all open charts to ensure that each consents disclosures are completed correctly and in their entirety.
Clients #2, #5, #6, #11, and #14, are discharged
On August 9, 2021 the Director will meet with client #8 and #9 to complete consent in their entirety. Program Director will document and identify information that requires correction and have the correct dated signature recorded on the consent to release information. The Director will check off or write the appropriate information in the boxes on the release of information form to indicate its purpose.
In the event any consent is not completed correctly, Program Director will meet with the respective client to complete consent and then meet with the staff member to go over consents and discuss reason(s) consent was not correct.
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709.28 (c) (5) 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. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the witness on release of information forms in seven of fourteen client records reviewed.
Client # 2 was admitted on October 8, 2019 and was discharged on October 16, 2019. The release of information form to an external individual was signed by the witness, but the form did not document the date of the witness signature. Additionally, the release of information forms to a pharmacy, social service agencies, the funding source, a government agency, an emergency contact and the urinalysis laboratory were signed by the client and witness, but all of the release forms failed to document the date of the witness signatures.
Client # 5 was admitted on January 27, 2020 and was discharged on February 11, 2020. The release of information forms to a pharmacy, social service agencies, the funding source, a government agency, an emergency contact and the urinalysis laboratory were signed by the client and witness, but all of the release forms failed to document the date of the witness signatures.
Client # 6 was admitted on March 12, 2021 and was discharged on March 17, 2021. The release of information form to another treatment provider and an emergency contact were signed by the client and witness, but both of the release forms failed to document the date of the witness signatures.
Client # 8 was admitted on July 28, 2020 and was still active at the time of the inspection. The release of information forms to an individual, another treatment provider, a pharmacy, social service agencies, the funding source, an emergency contact and the urinalysis laboratory were signed by the client and witness, but all of the release forms did not document the date of the witness signatures. Additionally, the release of information form to a government agency was signed by the client on July 28, 2020, but the release form was not signed by the witness until August 10, 2020.
Client # 9 was admitted on December 16, 2020 and was still active at the time of the inspection. The release of information forms to another treatment provider, a pharmacy, social service agencies, the funding source, an emergency contact and the urinalysis laboratory were signed by the client and witness, but all of the release forms failed to document the date of the witness signatures.
Client # 11 was admitted on October 16, 2019 and was discharged on February 12, 2020. The release of information forms to another treatment provider, a pharmacy, social service agencies, the funding source, a government agency, an emergency contact and the urinalysis laboratory were signed by the client and witness, but all of the release forms failed to document the date of the witness signatures.
Client # 14 was admitted on February 11, 2020 and was discharged on May 8, 2020. The release of information forms to another treatment provider, a pharmacy, social service agencies, the funding source, a government agency, an emergency contact and the urinalysis laboratory were signed by the client and witness, but all of the release forms failed to document the date of the witness signatures.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By August 16, 2021, the Program Director will train all staff on the proper procedures when completing consent forms with a high concentration on documenting the dated signature of the witness is on consent to release information documents. The Director will ensure the dated signature of the witness is documented on the consents.
The Director will train staff to cover all sections in detail of the Intake Packet/Consents including writing out the dated signature of the witness for the purpose of completing the disclose agreement.
The Program Director and Clinical Supervisor will review Intake Packets upon submission and review for corrections. In addition, both Director and Clinical Supervisor will ensure charts are reviewed monthly and consents are being completed correctly in their entirety.
Program Director will also review all open charts to ensure that each consents disclosure are completed correctly and in their entirety.
Clients #2,#5, #6,#11,and #14, are discharged
On August 9, 2021 the Director will meet with client #8 and #9 to complete consent in their entirety. Program Director will document and identify information that requires correction and have the correct dated signature of the witness recorded on the consent to release document. The Director will check off or write the appropriate information in the boxes on the release of information form to indicate its purpose.
In the event any consent is not completed correctly, Program Director will meet with the respective client to complete consent and then meet with the staff member to go over consents and discuss reason(s) consent was not correct.
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709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event or condition upon which the consent will expire on a consent to release information form in one of fourteen client records reviewed.
Client # 9 was admitted on December 16, 2020 and was still active at the time of the inspection. The release of information form to the funding source was signed and dated by the client and witness; however, the form failed to document the date, event or condition upon which the consent will expire.
This findings was reviewed with facility staff during the licensing process.
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Plan of Correction
By August 16, 2021, the Program Director will train all staff on the proper procedures when completing consent forms with a high concentration on documenting the dated, event and condition upon which the consent will expire. The Director will ensure the dated; event and condition upon which the consent will expire are documented.
The Director will train staff to cover all sections in detail of the Intake Packet/Consents including writing out the exploration date disclose agreement is to end.
The Program Director and Clinical Supervisor will review Intake Packets upon submission and review for corrections. In addition, both Director and Clinical Supervisor will ensure charts are reviewed monthly and consents are being completed correctly in their entirety.
Program Director will also review all open charts to ensure that each consents disclosure are completed correctly and in their entirety.
On August 9, 2021 the Director will meet with client #9 to complete consent in their entirety. Program Director will document and identify information that requires correction and have the exploration date recorded on the consent to release document. The Director will check off or write the appropriate information in the boxes on the release of information form to indicate its purpose.
In the event any consent is not completed correctly, Program Director will meet with the respective client to complete consent and then meet with the staff member to go over consents and discuss reason(s) consent was not correct.
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