INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 9-10, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, George Junior Republic in Pennsylvania 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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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor assistant submit documentation to the facility director that they are working towards counselor status in one of one applicable record.
Staff #4 was promoted to a counselor assistant on September 26, 2022, and still employed at time of inspection. Documentation for the 2023 calendar year was not provided as of the date of the inspection.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. After careful consideration, facility has determined that the current Counselor Assistant will be transitioned to a Case Manager position.
2. In the future, individuals promoted to Counselor Assistant will provide written documentation on a quarterly basis to the Facility Director. Such documentation will demonstrate that they are working towards counselor status.
3. The Facility Director will submit the quarterly documentation to the Project Director at the completion of each calendar year.
4. The annual job performance evaluation will include this expectation and, as such, will be reviewed yearly by both the Project Director and the HR Specialist. |
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 personnel records, the facility failed to ensure all employees received the minimum of at least 4 hours of TB/STD and other health related topics within the first year of employment in one of two applicable records.
Staff #4 was promoted to a counselor assistant on September 26, 2022, and still employed at time of inspection. Staff #4 was due to have the communicable disease trainings no later than September 26, 2023. There was documentation provided of the completion of 1 hour of TB/STD training, but the mandatory 4 hours was not completed as of the date of the inspection.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Program Director and Facility Director met with the Director of Staff Development on Friday, January 26, 2024. The Staff Development Director will create a specific training plan for all staff working in the facility that will ensure we are meeting the subject requirements of staff training as well as time frame requirement.
2. Staff #4 to be fully trained in TB/STD criteria by 03/31/2024. This will be monitored and verified by the Facility Director utilizing the Relias Training Platform. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure cold foods were kept at or below 40 degrees Fahrenheit and frozen foods were kept at or below 0 degrees Fahrenheit.
Cottage W refrigerator thermometer read 46 degrees Fahrenheit and the freezer thermometer read 12 degrees Fahrenheit.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1/9/2024 - Project Director notified agency maintenance department of the temperature discrepancy of the refrigerator and freezer in Cottage W.
1/10/2024 - Project Director followed up with Maintenance Supervisor to confirm resolution of the temperature issue.
1/11/2024 - Facility Director performed an on-site check of temperature readings. Refrigerator - 35 degrees and freezer - -10 degrees.
1/26/2024 - Daily temperature log is kept in facility. Temperature reading will be taken twice daily by facility staff. If readings exceed regulatory standards, facility staff will immediately notify agency maintenance personnel. Facility Director will review temperature logs on a weekly basis. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative information, the project director failed to prepare, annually update, and sign a written manual delineating project policies and procedures for the year 2023. There was no policy and procedure manual sign offs provided during the licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. The Project Director will prepare, update, and sign off on a written manual delineating project policies and procedures by the completion of each training year (August 31).
2. The Facility Director will then review the written manual delineating project policies and procedures with the counselor, case manager, and direct care staff by September 30th of each calendar year.
3. Once reviewed, a signature attestation will be completed by the staff and the Facility Director will insure that it is kept on file with the current written manual. |
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 obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in seven of seven records.
Client #1 was admitted on September 08, 2023, and was still an active client at time of inspection. A release of information form to bill insurance for services was not documented in Client #1's record.
Client #2 was admitted on September 14, 2023, and was still an active client at time of inspection. A release of information form to bill insurance for services was not documented in Client #2's record.
Client #3 was admitted on September 20, 2023, and was still an active client at time of inspection. A release of information form to bill insurance for services was not documented in Client #3's record.
Client #4 was admitted on October 02, 2023, and was still an active client at time of inspection. A release of information form to bill insurance for services was not documented in Client #4's record.
Client #5 was admitted on April 26, 2023, and discharged on October 03, 2023. A release of information form to bill insurance for services was not documented in Client #5's record.
Client #6 was admitted on May 10, 2023, and discharged on August 07, 2023. A release of information form to bill insurance for services was not documented in Client #6's record.
Client #7 was admitted on June 07, 2023, and discharged on November 03, 2023. A release of information form to bill insurance for services was not documented in Client #7's record.
Facility staff confirmed billing had occurred.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. A Release of Information Form to bill insurance for services was created by the Facility Director on 2/2/23.
2. It was reviewed with the Counselor Parent, Counselor, and Case Manager on 2/2/23 for training purposes.
3. This release of information is now incorporated into the Orientation/Confidentiality packet created for each new client upon admission.
4. The Case Manager will insure that the release is signed within 24 hours as part of the overall admission process.
5. Within 72 hours, the entire packet is then given to the Facility Director for final review and confirmation of completion.
6. A release of information form to bill insurance for services was added to client #4's record (the only remaining active client reviewed).
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 an individual treatment and rehabilitation plan in seven of seven records.
The individual treatment plan goals and objectives were not individualized and were the same goals and objectives for each client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1.The Facility Director met with the Counselor and Case Manager on 1/12/24 and provided training on the need for treatment and rehabilitation plans to have individualized goals and objectives for each client.
2. The Counselor creates the initial treatment plan with the client's input upon admission and then completes a treatment plan review every 30 days.
3. The treatment plan will include a statement by the client indicating what they wish to work on in treatment.
4. A list of each client and the review date for the next required plan will be provided to the Counselor by the 26th of every month by the Clinical Supervisor.
5. The Counselor will immediately notify the Facility Director upon completion and attestation of review by the client.
6. The Facility Director will monitor the completion of the individualized monthly plans utilizing a monthly spreadsheet. Such spreadsheet will be updated by the 5th of every month.
7. All current clients will have this deficiency corrected, beginning with their February 2024 reports. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to update an individual treatment plan every thirty days in five of seven records.
Client #1 was admitted on September 08, 2023, and was still an active client at time of inspection. An initial treatment plan was developed September 11, 2023, and the first update was due by October 11, 2023. There were no treatment plan updates documented in client #1 ' s record.
Client #2 was admitted on September 14, 2023, and was still an active client at time of inspection. An initial treatment plan was developed September 15, 2023, and the first update was due by October 15, 2023. There were no treatment plan updates documented in client #2 ' s record.
Client #3 was admitted on September 20, 2023, and was still an active client at time of inspection. An initial treatment plan was developed September 21, 2023, and the first update was due by October 21, 2023. There were no treatment plan updates documented in client #3 ' s record.
Client #4 was admitted on October 02, 2023, and was still an active client at time of inspection. An initial treatment plan was developed October 06, 2023, and the first update was due by November 06, 2023. There were no treatment plan updates documented in client #4 ' s record.
Client #7 was admitted on June 07, 2023, and discharged on November 03, 2023. An initial treatment plan was developed on June 9, 2023. There was an update in the record on July 7, 2023, and the next update was due by August 7, 2023. There were no additional updates documented in client #7 ' s record after July 7, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1.The Facility Director met with the Counselor and Case Manager on 1/12/24 and provided training on the need for treatment and rehabilitation plans to be reviewed/updated at least every 30 days.
2.The Counselor creates the initial treatment plan upon admission and then completes a treatment plan review every 30 days for each individual client.
3. A list of each client and the review date for the next required plan will be provided to the Counselor by the 26th of every month by the Clinical Supervisor.
4.The Counselor will immediately notify the Facility Director upon completion and attestation of review by the client.
5. Client # 4's record now contains treatment plan updates for November, December, and January. All other clients reviewed are no longer active. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 provided according to the treatment plan in five of seven records.
Client #1 was admitted on September 08, 2023, and was still an active client at time of inspection. An initial treatment plan was developed September 11, 2023, and indicated client was to have one individual session per week. There was no individual session scheduled or noted cancelation for the week of December 17-23, 2023.
Client #2 was admitted on September 14, 2023, and was still an active client at time of inspection. An initial treatment plan was developed September 15, 2023, and indicated client was to have one individual session per week. There was no individual session scheduled or noted cancelation for the week of October 1-7, 2023, and the week of November 12-18, 2023.
Client #4 was admitted on October 02, 2023, and was still an active client at time of inspection. An initial treatment plan was developed October 06, 2023, and indicated client was to have one individual session per week. There was no individual session scheduled or noted cancelation for the week of October 29-November 4, 2023.
Client #6 was admitted on May 10, 2023, and discharged on August 07, 2023. An initial treatment plan was developed May 11, 2023, and indicated client was to have one individual session per week. There was no individual session scheduled or noted cancelation for the week of May 28-June 3, 2023.
Client #7 was admitted on June 07, 2023, and discharged on November 03, 2023. An initial treatment plan was developed on June 9, 2023, and indicated client was to have one individual session per week. There was no individual session scheduled or noted cancelation for the weeks of July 09-15, 2023, July 23-29, 2023, July 30-August 05, 2023, August 06-08, 2023, and August 13-19, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director met with the Counselor Parent, Counselor, and Case Manager on 1/12/24 and 2/1/24 to provide training in terms of the requirement to provide documentation in client records for any sessions cancelled, refused, or not held for any reason.
The Counselor will provide a notation of cancellation, refusal, or vacation in each client's record which aligns with the client's individual treatment plan prescription of services.
The Facility Director will provide monthly supervisory follow up to the Counselor to insure completion of clinical notation of services.
A record of this supervision will then be provided to the Project Director.
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