INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 4, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Caron Counseling Services 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 nine personnel records, the facility failed to ensure that each employee had a training plan completed in one record reviewed.
Employee # 9 was hired as a counselor on June 21, 2021 and was still in that position at the time of the inspection. The training plan was due to be completed by July 21, 2021 but was not completed until October 15, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new process for completion of initial training plans for new employees has been developed and will be implemented with all new hires as of December 14th.
The Director of Training will monitor the completion of training plans for new employees on a monthly basis for the next 3 months to ensure compliance.
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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 nine personnel records, the facility failed to ensure that staff received TB/STD training in one record reviewed.
Employee # 8 has been in the position of counselor since August 3, 2020 and was due to complete at least four hours of TB/STD training by August 3, 2021. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #8 will attend the required 4 hour DDAP TB/STD training by 1/31/22. The Director of Training will monitor the completion of TB/STD training for new employees on a quarterly basis to ensure compliance. |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on a physical plant inspection on November 4, 2021, the facility failed to clearly indicate exits by the use of signs. A door labeled " Emergency Exit Only " on the second floor, was not actually an emergency exit and instead led down two flights of stairs to two locked doors.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was discovered that the emergency exit cited was not locked, the door was "stuck" and needed to be sanded on one part of the door. The door was sanded and tested on December 8, 2021.
To monitor this does not occur again, Director of Facilities will conduct a physical plant inspection including testing of all emergency exits on a quarterly basis. The Compliance Department will review these quarterly inspection logs to ensure inspections are completed. |
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 nine personnel files, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in two records reviewed.
Employee #6 was hired as a counselor on December 30, 2020 and was due to be trained in the use of fire extinguishers by January 5, 2021; however, fire safety training was not documented as complete until October 18, 2021.
Employee #7 was hired as a counselor on May 17, 2021 and was due to be trained in the use of fire extinguishers by May 27, 2021; however, fire safety training was not documented as complete until June 2, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new onboarding and training process has been developed for new employees including fire extinguisher training. This new process will be implemented by 1/4/22. The Director of Employment/Recruiting will monitor the completion of fire extinguisher training for new employees for 3 months to ensure compliance. |
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 from December 2019 through October 2021, the facility failed to conduct unannounced fire drills for the 2020 months of March, May, September, October, and December and the 2021 months of February and May.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new process and schedule for completion of fire drills has been developed and implemented as of December 1, 2021. The VP of Facilities will monitor the completion of fire drills on a monthly basis to ensure all drills are completed as required. The Compliance Department will monitor the completion of fire drills on a quarterly basis to ensure compliance |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of fire drill logs from December 2019 through October 2021, the facility failed to conduct fire drills during normal staffing conditions. The drill on March 30, 2021 occurred at 06:15 A.M. and the facility does not open until 08:00 A.M.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new process and schedule for completion of fire drills has been developed and implemented as of December 1, 2021. The new schedule ensures fire drills are only conducted within the facilities hours of operation. The VP of Facilities will monitor the completion of fire drills on a monthly basis to ensure all drills are completed as required. The Compliance Department will monitor the completion of fire drills on a quarterly basis to ensure compliance |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from December 2019 through October 2021, the failed to maintain a complete fire drill log in records for eight months.
The fire drill log for December 2019 was missing the exit route use and the number of persons in the facility at the time of the drill.
The fire drill log for January 2020 was missing the date, exit route used, and the number of persons in the facility at the time of the drill.
The fire drill log for February 2020 was missing the exit route used and the number of persons in the facility at the time of the drill.
The fire drill log for June 2020 was missing the date, exit route used, and the number of persons in the facility at the time of the drill.
The fire drill log for July 2020 was missing the date and exit route used.
The fire drill log for August 2020 was missing the exit route used and number of persons in the facility at the time of the drill.
The fire drill log for November 2020 was missing the number of persons in the facility at the time of the drill.
The fire drill log for June 2021 was missing the exit route used.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new fire drill form was developed and maintenance staff were trained in the use of the new form for conducting fire drills.
The new form ensures compliance with state regulations and was implemented as of December 1, 2021. The VP of Facilities will monitor the completion of fire drills on a monthly basis to ensure all drills are completed and documented per state requirements. The Compliance Department will monitor the completion of fire drills on a quarterly basis to ensure compliance |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in three records.
Client #4 was admitted on July 30, 2021 and was an active client at the time of the inspection. The transfer note indicating a change to the treatment plan recommendations indicated individual counseling to be completed weekly; however, no individual sessions were held between October 7, 2021 and October 29, 2021.
Client #5 was admitted on February 24, 2021 and was an active client at the time of the inspection. The treatment and rehabilitation plan update from April 8, 2021 specifies the frequency of counseling to include three groups per week. However, documentation of group attendance is weekly after May 6, 2021 with no corresponding change in a treatment plan update.
Client #6 was admitted on May 1, 2021 and was an active client at the time of the inspection. The counseling services listed on the treatment and rehabilitation plan updates were not consistent in matching the individual and group counseling progress notes or the levels of care identified in case consultation notes. The October 8, 2020 treatment and rehabilitation plan indicated one individual session a week. One individual session was documented on October 8, 2020 and the next was not documented until November 17, 2020. The treatment and rehabilitation plan dated November 17, 2020 indicated one individual session a week. There was no documentation of an individual session for the week of November 23, 2020 - November 29, 2020. An individual session occurred on December 3, 2020 but no others were documented until May 12, 2021. The last documented treatment and rehabilitation plan updated is dated February 22, 2021. The last documented individual session is dated July 15, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counseling staff will be re-educated on the process for updating treatment plans when patient's counseling services have changed.
The Clinical Supervisor will monitor patient's treatment plans and service delivery via open chart reviews on a monthly basis. |