INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 22, 2023, 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:
|
Plan of Correction
|
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
|
Observations
The physical plant inspection was conducted on December 20, 2023, as part of the annual licensing inspection process across multiple licenses in the area that took place from December 20, 2023 through December 22, 2023. Based on the physical plant inspection, the facility failed to maintain each outside steps exceeding two steps with a well-secured handrail. Three stairs outside of an emergency exit on the left side of the building did not have a handrail.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Senior Vice President of Support Services will ensure that the handrail is installed by 3/15/23. The Senior Vice President of Support Services will ensure that well-secured handrails are maintained for all outside steps exceeding two steps on a routine basis. |
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 five personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguisher upon employment in one of one applicable record reviewed.
Employee # 1 was hired as the project director on September 29, 2023 and was due to be trained in the use of fire extinguishers upon hire; however, fire safety training was not documented as completed in the personnel record until October 12, 2023.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Currently, all new employees receive training on fire safety emergency procedures, as well as fire extinguisher training with their supervisor on the first day of employment. The new employee signs an attestation indicating they received the training, which is filed in their employee file.
In order to improve upon this process a plan is in place where the Human Resources Business Partners will electronically send new employees training on fire safety emergency procedures, as well as training and instruction on how to use
fire extinguishers prior to their first day of employment. Employees must sign an attestation indicating that they received this training and must return this attestation to the training department by their first day of employment. This attestation will be kept in their training file. The Supervisor of Training and Education will audit new employee files on a monthly basis to ensure compliance with this regulation. The new process is expected to be implemented by 3/1/24
|
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of five personnel records, the facility failed to ensure that one of one applicable staff member was trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 1 was hired as the project director on September 29, 2023 and is current in that position. Employee # 1 began working shifts on September 29, 2023, but was not trained to perform assigned tasks during emergencies until October 12, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Currently, all new employees receive training on fire safety emergency procedures, as well as fire extinguisher training with their supervisor on the first day of employment. The new employee signs an attestation indicating they received the training, which is filed in their employee file.
In order to improve upon this process a plan is in place where the Human Resources Business Partners will electronically send new employees training on fire safety emergency procedures, as well as training and instruction on how to use
fire extinguishers prior to their first day of employment. Employees must sign an attestation indicating that they received this training and must return this attestation to the training department by their first day of employment. This attestation will be kept in their training file. The Supervisor of Training and Education will audit new employee files on a monthly basis to ensure compliance with this regulation. The new process is expected to be implemented by 3/1/24.
|
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 five personnel records, the facility failed to ensure that personnel records contained a reviewed and signed annual written staff performance evaluations in two of four applicable records reviewed.
Employee # 4 has been a counselor since May 17, 2021 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by September 3, 2023, but was not signed by the employee until November 1, 2023.
Employee # 5 has been a counselor since March 12, 2003 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by May 13, 2023, but was not signed by the employee until November 27, 2023.
This is a repeat citation from the January 23, 2023 annual licensing inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Supervisor received corrective counseling and education regarding the importance of completing employee performance evaluations in a timely manner. The Human Resources Business Partner sends email and calendar reminders for both the employee and the supervisor when performance evaluations are coming due. The Human Resources Business Partner monitors the completion of performance evaluations on a weekly basis via an automated Weekly Status Report to ensure that evaluations are completed as required. The Human Resources Business Partner submits a monthly report of performance evaluation completion progress to the Executive Leadership Team. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of seven client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.
Client # 2 was admitted to the Outpatient level of care on August 24, 2023 and was discharged for non-compliance on October 30, 2023. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor has added the Notification of Termination process to the Documentation Checklist, which will help remind clinicians that they need to send a Notification of Termination Letter to patients if they are being involuntarily terminated from treatment. After the Notification of Termination Letter is sent, this will be documented in the Contact Log within the patient's electronic health record. The Clinical Supervisor will educate staff on this process during clinical supervision on 1/22/24. The Clinical Supervisor will run a report of non-routine discharges each month and will audit each chart (that is applicable) to ensure the Notification of Termination process is being followed. The Quality Analyst will do quarterly chart reviews and will report progress to leadership.
|
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a preliminary treatment plan on the day of admission, per policy, in four of seven records reviewed.
Client # 1 was admitted on January 30, 2023 and was discharged on October 12, 2023. The record did not contain a preliminary treatment plan.
Client # 2 was admitted on August 24, 2023 and was discharged on October 30, 2023. The record did not contain a preliminary treatment plan.
Client # 3 was admitted on February 6, 2023 and was discharged on July 3, 2023. The record did not contain a preliminary treatment plan.
Client # 5 was admitted on August 8, 2023 and was active at the time of the inspection. The record did not contain a preliminary treatment plan.
These finding were discussed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor will update the Documentation Checklist to include the Preliminary Treatment and Rehabilitation Plan. The Documentation Checklist is an internal document that helps clinicians keep track of documentation due dates. The Clinical Supervisor re-educated staff on the process for the completion of the Preliminary Treatment and Rehabilitation Plan during Clinical Supervision on 1/15/24. The Clinical Supervisor will do monthly chart audits to ensure that Preliminary Treatment and Rehabilitation Plans are being completed on time. The Quality Analyst will do quarterly chart reviews and will report progress to leadership.
|
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of seven client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within two weeks of admission, per the facility policy, in five of seven applicable records reviewed.
Client # 1 was admitted on January 30, 2023 and was discharged on October 12, 2023. The individual treatment and rehabilitation plan was due to be completed by February 13, 2023; however, the record did not contain an individual treatment and rehabilitation plan.
Client # 2 was admitted on August 24, 2023 and was discharged on October 30, 2023. The individual treatment and rehabilitation plan was due to be completed by September 7, 2023; however, it was not completed until October 25, 2023.
Client # 3 was admitted on February 6, 2023 and was discharged on July 3, 2023. The individual treatment and rehabilitation plan was due to be completed by February 20, 2023; however, it was not completed until March 7, 2023.
Client # 5 was admitted on August 8, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by August 22, 2023; however, it was not completed until October 18, 2023.
Client # 6 was admitted on June 16, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by June 30, 2023; however, it was not completed until July 19, 2023.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor will add the completion of Individual Treatment and Rehabilitation plans within the timeframes specified to the Documentation Checklist, which is an internal document that helps clinicians keep track of documentation due dates. The Clinical Supervisor re-educated staff on the treatment planning process during Clinical Supervision on 1/15/24. The Clinical Supervisor will do monthly chart audits to ensure that Individual Treatment and Rehabilitation Plans are being completed on time. The Quality Analyst will do quarterly chart reviews and will report progress to leadership. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in two of six applicable records reviewed.
Client # 5 was admitted on August 8, 2023 and was active at the time of the inspection. The treatment plan completed on October 18, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session the weeks of October 16, 2023 or October 30, 2023, or between November 10, 2023 and December 13, 2023.
Client # 7 was admitted on July 20, 2023 and was active at the time of the inspection. The treatment plan completed on July 24, 2023, indicated that the client was to receive one individual session per month; however, the record contained no documentation of an individual session during the month of August.
This is a repeat citation from the January 23, 2023 and November 4, 2021 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor re-educated staff on the Individual Treatment and Rehabilitation planning process, including ensuring that documentation in the record reflects that services are provided according to the treatment plan. The Clinical Supervisor also educated staff on the importance of documenting when a patient is a "no show" for a treatment service and to ensure they document when there is a change in frequency of the treatment service. This education occurred during Clinical Supervision on 1/15/24. The Clinical Supervisor will do monthly chart audits to ensure that services are being provided and documented according to the Individual Treatment and Rehabilitation Plan. The Quality Analyst will do quarterly chart reviews and will report progress to leadership. |
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 have a complete client record on an individual which includes information relative to the client ' s involvement with the project including case consultation notes every 90 days, per policy, in four of seven client records reviewed.
Client # 1 was admitted on January 30, 2023 and was discharged on October 12, 2023. There was no documentation of a case consultation in the record.
Client # 2 was admitted on August 24, 2023 and was discharged on October 30, 2023. There was no documentation of a case consultation in the record.
Client # 4 was admitted on May 18, 2023 and was discharged on August 30, 2023. There was no documentation of a case consultation in the record.
Client # 6 was admitted on June 16, 2023 and was active at the time of the inspection. The first case consultation note was due to be completed by September 16, 2023; however, it was not documented as completed until November 15, 2023.
These findings were reviewed with the project staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor added Case Consultation notes to the Documentation Checklist, which is an internal document that helps clinicians keep track of documentation due dates. The Clinical Supervisor will re-educate staff on the Case Consultation Process, including timeframes and the requirement that every patient record needs to contain documentation of a Case Consultation during Clinical Supervision on 1/22/24. The Clinical Supervisor will do chart audits monthly to ensure that Case Consultations are completed on time. The Quality Analyst will do quarterly chart reviews and will report progress to leadership. |
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.
|
Observations
Based on a review of client and personnel records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for providing counseling services according to the treatment plan was submitted and approved by the Department for the January 23, 2023 and November 4, 2021 annual licensing inspections. Providing counseling services according to the treatment plan was again found to be a deficiency in the December 20, 2023 through December 21, 2023 licensing inspection.
A plan of correction for ensuring a complete client record included case consultation notes according to policy was submitted and approved by the Department for the January 23, 2023 annual licensing inspection. Completing case consultation notes according to policy was again found to be a deficiency in the December 20, 2023 through December 21, 2023 licensing inspection.
A plan of correction for ensuring employee performance evaluations were completed annually was submitted and approved by the Department for the January 23, 2023 annual licensing inspection. Completing employee performance evaluations annually was again found to be a deficiency in the December 20, 2023 through December 21, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Senior Executive Director of Regional Outpatient Services is responsible for the implementation of Plans of Correction. The Plans of Correction are reviewed with staff during supervision meetings. All of the Plans of Correction for this audit, will be reviewed with staff by 1/22/24. The Senior Executive Director of Regional Outpatient Services will monitor progress of the Plans of Correction on a quarterly basis, during quarterly meetings with the Quality Department. The Compliance Department will also monitor the progress of each Plan of Correction on a quarterly basis to ensure compliance. |