INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 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, Catholic Charities Counseling and Adoption Services, 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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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 records, the facility failed to document unannounced fire drills at least once a month from March 2021 through April 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility: Catholic Charities Counseling & Adoption Services (CCCAS).
The previous CEO/Project Director resigned as on 11/1/2021 and the current Interim CEO & Interim Project Director were unaware of this requirement.
The practice of unannounced monthly fire drills has been restored as of 5/9/2022 for CCCAS and is being documented in a fire drill log by the Interim CEO.
The Interim D&A Project Director will audit this process to ensure this Policy is being carried out.
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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 a review of personnel records, the facility failed to document annual written staff performance evaluations in two of two records.
No annual performance evaluations were documented since March 1, 2021 in the following records:
Employee # 1 was hired June 1, 2000.
Employee # 2 was hired July 10, 2007.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility: Catholic Charities Counseling & Adoption Services (CCCAS).
The previous CEO/Project Director resigned as on 11/1/2021 and the current Interim CEO & Interim Project Director were unaware of this requirement.
The practice of annual evaluations has been restored by the Interim CEO as of 6/1/2022 for each D&A counselor.
The current Interim CEO is responsible for the immediate correction and reimplementation of this Policy and the Interim D&A Project Director will assist as needed.
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709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in two of seven records.
The facility obtained prior authorization for drug and alcohol treatment without written consent from the client in the following records:
Client # 5 was admitted December 9, 2021.
Client # 6 was admitted October 7, 2021 and discharged December 16, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility: Catholic Charities Counseling & Adoption Services (CCCAS).
The Interim D&A Project Director has reviewed this process with the other D&A counselor and both have corrected these issues.
Each client signs an informed consent form at the time of admission. We only communicate with whoever is approved by the client. Each informed consent is approved for one year, if the client is seen for more than a year a new informed consent form is necessary. this policy has been reviewed by the D&A counselors and its use reinforced.
The Project Director will ensure that all current and future client will have the client sign a consent to release information for the funding entity prior to the release of information. The project director will conduct a random chart audit of open records to ensure releases are documented.
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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 consultation notes every three months, per facility policy, in two of four records.
No case consultation notes were documented in the following records:
Client # 4 was admitted January 20, 2022.
Client # 5 was admitted December 9, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility: Catholic Charities Counseling & Adoption Services (CCCAS).
Due to illnesses the case consultation documents were not completed within the required three-month time frame.
The Policy of documenting case consultations notes has been reviewed by the Interim Project Director. This deviation has been addressed and the Policy has been discussed by the D&A Project Director and the other D&A counselor and it's use reinforced.
The Project Director has trained the staff on the policy for completion of case consultations and will conduct random open chart audits to ensure compliance with this regulation.
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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 a complete client record including follow-up information within three months of discharge, per facility policy, in two of four records.
Client # 6 was admitted October 7, 2021 and discharged December 16, 2021.
Client # 7 was admitted August 18, 2021 and discharged November 18, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility: Catholic Charities Counseling & Adoption Services (CCCAS).
The Policy of sending follow-up letters to D&A clients within 3 months of discharge has been reviewed and modified by the Interim CEO.
The Interim D&A Project Director will audit this process to ensure this Policy is being carried out.
The D&A counselor will provide the discharged client information to the office manager, who will then keep a calendar of when the follow-up will be due. The office manager will send a follow-up letter to each discharged client within three months of discharge and maintain a copy of the letter in the record. The project director will randomly check closed records to ensure the follow-up is being conducted.
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