INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Casa de Consejeria y Salud Integral, 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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704.11(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 the review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics, within the regulatory timeframe, in one of six applicable personnel records reviewed. Employee #6 was hired as a counselor on June 2, 2021 and was due to receive at least four hours of TB/STD training no later than June 2, 2022; however, the TB/STD training was completed in March 2023.This finding was discussed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor under the supervision of the facility director will ensure the all staff completes 6 hours HIV/AIDS and 4 hours of Tuberculosis, sexually transmitted diseases, and other health related topic within 12 months of all employees hired in the organization. This training may be provided as an in-service or outside training as long as the training curriculum focuses on reviewing general information on transmission, prevention, causes, symptoms, and treatments. In order to prevent this in the future, the facility director along with the clinical supervisor will conduct monthly reviews of staff training files to ensure compliance of training plans and schedule upcoming trainings needed for each new hire. |
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 Requirement Facility Summary Report, the facility failed to ensure that the Full Time Equivalent (FTE) counselor caseload in outpatient programs did not exceed 35 active clients in two of seven counselors employed. The FTE counselor caseload is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.Employee #6 was hired as a counselor on June 2, 2021. The employee's FTE ratio calculation was as follows: 35/40= .875(FTE); 34/.875= 38.85, which equals a client/counselor ratio of 38:1.Employee #10 was hired as a counselor on October 31, 2022. The employee's ratio calculation was as follows: 40/40= 1(FTE); 36/1= 36, which equals a client/counselor ratio of 36:1.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has adjusted employee 6 and 10 caseloads to reflect the correct amount of clients based on the correct ratios. The facility director will ensure that all client caseloads follow the same protocol by following the formula provided in order to prevent incorrect assignment. The facility director will check weekly on admissions, discharges and assignments to keep correct carloads at all times. |
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 review of the May 82022 through April 2023 fire drill logs, the facility failed to identify, on their fire drill logs, the amount of time it took for evacuation during the drills conducted in March 2023 and April 2023.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will review and retrain the facility director on the correct way to conduct a fire drill and complete the fire drill logs. This includes, but not limited to exit route used, the amount of time it took for evacuation or whether the fire alarm/smoke detector was operative, and alternating days and times covering our operating hours. The facility director will set monthly reminders to conduct fire drills and complete the fire drill log correctly by filling in and checking off the necessary information required after conducting the fire drill. The facility director will also set monthly check-ins and review of documents to ensure its appropriate completion. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year (2021), based on an administrative review. This is a repeat citation from the May 9, 2022 and the May 17, 2021 annual licensing renewal inspections. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has contacted an independent public accountant who will have our 2021 financial audit completed by the date indicated above. The Executive Director will make sure to secure the commencement of future audits no later than May 31 through an engagement letter and completed by June 30 |
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:
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Observations
Based on a review of client records, the facility failed to document that an individual treatment and rehabilitation plan was developed with the client in four of seven client records reviewed.Client #1 was admitted on July 14, 2022 and was active at the time of inspection. There was no documentation of an individual treatment and rehabilitation plan, in the record, at the time of inspection.Client #5 was admitted on September 20, 2022 and was discharged on December 2, 2022. There was no documentation of an individual treatment and rehabilitation plan, in the record, at the time of inspection.Client #6 was admitted on September 22, 2022 and was discharged on November 30, 2022. There was no documentation of an individual treatment and rehabilitation plan, in the record, at the time of inspection.Client #7 was admitted on September 27, 2022 and was discharged on December 6, 2022. There was documentation of an individual treatment and rehabilitation plan in the record that was dated October 26, 2022; however, there was no written documentation that the treatment plan was developed with the client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor along with the facility director will hold an in-service training with all clinical staff to review treatment/recovery plans timeframes including PTP within 15 days of admission, CTP within 30 days of admission, and updates every 60 days after. The in-service training will also review the importance of completing and documenting each plan with the client.
The facility director will also complete weekly reviews of documentation that must be filed along with compliance reports to ensure clinical documents completions and that documents are available for reviews timely. |
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 client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in four of five applicable client records reviewed. Client #1 was admitted on July 14, 2022 and was active at the time of inspection. The preliminary treatment plan, dated July 14, 2022, indicated group sessions one time per week. There was no documentation, in the record, of any group sessions being provided throughout the treatment episode.Client #2 was admitted on July 20, 2022 and was active at the time of inspection. A treatment plan update, dated January 23, 2023, indicated weekly individual sessions. There was no documentation, in the record, of individual counseling sessions being provided during the weeks of February 12, 2023 - February 25, 2023 and March 26, 2023 - April 22, 2023. Client #3 was admitted on July 27, 2022 and was active at the time of inspection. A treatment plan update, dated December 14, 2022, indicated weekly individual sessions. There was no documentation, in the record, of individual counseling sessions being provided during the weeks of January 1, 2023 - January 7, 2023 and January 15, 2023 - January 28, 2023.Client #7 was admitted on September 27, 2022 and was discharged on December 6, 2022. The individual treatment plan, dated October 26, 2022, indicated group sessions three times per week. There was no documentation, in the record, of group sessions being provided during the weeks of October 30, 2022 - November 26, 2022. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor along with the facility director will hold an in-service training with all clinical staff to review treatment/recovery plans action steps including but not limited to frequency of treatment sessions and the alignment of the treatment plans through the rest of the clinical documentation like the progress notes. The training will emphasize the importance of the treatment plan and how it drives a client's treatment.
The facility director will also complete weekly reviews of documentation that must be filed along with the development and implementation of compliance reports to ensure the completion of clinical documents and that the documents are available for reviews timely. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include a record of services provided, in seven of seven client records reviewed.In each client record reviewed, there was no documentation of a record of services provided.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In service training will be provided by the Program Evaluator on compliance documentation submission policy and documentation timeline for all client records to the entire clinical department by June 30, 2023 reviewing and emphasizing on case consultation, service logs, discharge follow-ups.
The Executive Director will review this again with a Program Director and Clinical Supervisor to fully address all compliance issues. An internal audit will be conducted by selected team members to ensure clinical files and its documentation is completed timely. The internal audit committee will also provide a separate internal audit for active and discharged files every three months.
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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 maintain a complete client record, which is to include case consultation notes, in two of three applicable client records reviewed.Client #1 was admitted on July 14, 2022 and was active at the time of inspection. There was no documentation of case consults, in the record, at the time of the inspection. Client #2 was admitted on July 20, 2022 and was active at time of inspection. There was no documentation of case consults, in the record, at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In service training will be provided by the Program Evaluator on compliance documentation submission policy and documentation timeline for all client records to the entire clinical department by June 30, 2023 reviewing and emphasizing on case consultation, service logs, discharge follow-ups.
The Executive Director will review this again with a Program Director and Clinical Supervisor to fully address all compliance issues. An internal audit will be conducted by selected team members to ensure clinical files and its documentation is completed timely. The internal audit committee will also provide a separate internal audit for active and discharged files every three months.
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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 maintain a complete client record, which is to include follow-up information, in four of four applicable client records reviewed.Client #4 was admitted August 16, 2022 and was discharged on November 28, 2022. There was no documentation of follow-up, in the record, at the time of inspection.Client #5 was admitted September 20, 2022 and was discharged on December 2, 2022. There was no documentation of follow-up, in the record, at the time of inspection.Client #6 was admitted September 22, 2022 and was discharged on November 30, 2022. There was no documentation of follow-up, in the record, at the time of inspection.Client #7 was admitted September 27, 2022 and was discharged on December 6, 2022. There was no documentation of follow-up, in the record, at the time of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In service training will be provided by the Program Evaluator on compliance documentation submission policy and documentation timeline for all client records to the entire clinical department by June 30, 2023 reviewing and emphasizing on case consultation, service logs, discharge follow-ups.
The Executive Director will review this again with a Program Director and Clinical Supervisor to fully address all compliance issues. An internal audit will be conducted by selected team members to ensure clinical files and its documentation is completed timely. The internal audit committee will also provide a separate internal audit for active and discharged files every three months.
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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 an administrative review, the facility failed to comply with plans of correction that were previously approved by the Department. A plan of correction for failing to complete an annual financial audit was submitted and approved by the Department for the May 9, 2022 and May 17, 2021 annual licensing inspections. Failing to complete an annual financial audit was again found to be a deficiency in the April 27, 2023 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive director will ensure that the plan of corrections is followed until the next review. The Executive Director along with facility directors will ensure that all corrective steps are implemented and executed. The Executive Director will review the Plan of Corrections monthly and document what is reviewed to ensure that the program stays on track with the changes stated during supervisions with the facility directors. This will include the completion of the financial audit. |