INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Treatment Trends, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of six personnel records, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.Employee #4 was hired as a counselor on January 12, 2022 and was current in that position at the time of the inspection. At the time of hire, the accreditation status of the university through which the employee obtained their degree, was not verified.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 will be offered an alternate, qualifying role until the accreditation status of the university is verified. If the accreditation status is not able to be verified by 3/31/23, Employee #4 could be offered an extension in that alternate role and given an addition 60-day window to continue to obtain verification. All attempts will be documented and kept in the employee's personnel file.
Qualifications for new employees will be verified at the time of interview and prior to the official onboarding process. If an individual's qualifications are unable to be obtained prior to onboarding, they can be offered an alternate role, if available and applicable, until it is verified.
When an individual applies, and their qualifications are in question, it is the responsibility of the hiring manager to provide the applicant with the website/resource: Evaluation of Foreign Degrees - United States Department of State so that they may obtain verification. An individual whose qualifications are not verified cannot provide services until they are verified and documented with TTI administration. It is the responsibility of the hiring manager to inform TTI administration of the applicant's progress with obtaining the verification.
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to maintain documentation that counselor assistants receive direct observation of the provision of counseling services as part of their close supervision, in two of two applicable records reviewed.Employee # 5 was hired as a Bachelor ' s level counselor assistant on March 3, 2022. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision.Employee # 6 was hired as a Bachelor ' s level counselor assistant on June 7, 2022. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the cases of Employee #5 and Employee #6, their supervision period will be re-instituted and a discussion of the direct observation will be included in the corresponding supervisory note weekly, for the purpose of planning, oversight, monitoring and evaluating their
activities. The supervision notes will be maintained through a log kept in the Clinical Supervisor's office and in the staff record.
For future Counselor Assistants, their supervision will be completed by the Clinical Supervisor and/or other qualifying staff who will keep a log of the hours spent directly observing clinical services and/or closely observing clinical services. This log will be kept in the Clinical Supervisor's office and in the staff record. It will be completed weekly, in accordance with § 704.10 (c), for the purpose of planning, oversight, monitoring and evaluating their activities. This log will be audited by the Program Director or designee.
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705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant inspection on January 5, 2023, the facility failed to ensure that bunk beds were equipped with securely attached railings as bunk beds in Bedrooms #3 and 11 did not have railings. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address this deficiency, a modification was made to all shift checklists including the directive to ensure that all bunk beds are equipped with railings. The Clinical Technicians will be responsible for checking off that they have completed the room checks, ensuring that clients are not removing the railings. The House Manager will review the checklists for each shift. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and a discussion with facility staff, the facility to ensure that two personnel were trained to perform assigned tasks during emergencies prior to being on shift.Employee #5 was hired on March 3, 2022 and is current in that position. Employee #5 began working shifts on March 3, 2022 but was not trained to perform assigned tasks during emergencies until May 10, 2022.Employee #6 was hired on June 7, 2022 and is current in that position. Employee #6 began working shifts on June 7, 2022 but was not trained to perform assigned tasks during emergencies until July 6, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address this deficiency, all new employees will be trained to perform tasks during emergencies, otherwise known as the Emergency Preparedness Plan. This will training occur upon hire. The training will be conducted by the House Manager or designee and monitored by the Program Director. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of seven records, the facility failed to ensure that an informed and voluntary consent from the client for the disclosure of information form contained the specific information to be disclosed in one record reviewed.Client #2 was admitted on April 12, 2022 and was discharged July 29, 2022. The record contained a consent to release information form to a treatment provider signed by the witness on April 20, 2022 that was missing the specific information to be disclosed.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director met with Admissions Coordinator on 01/31/2023 and provided training/supervision to ensure all proper documentation is listed on each release of information, including but not limited to specific information to be disclosed. Once the intake encounter is finalized, it is diverted to the Program Director or designee, who is responsible for ensuring all information contained on those documents are accurate and complete. The Program Director and Clinical Supervisor reviewed all current charts to ensure releases on record are in compliance with the confidentiality standard. The Program Director, Quality Assurance Coordinator, and/or delegate will be conducting randomized audits to ensure confidentiality is being upheld through proper releases of information. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of seven records, the facility failed to ensure that an informed and voluntary consent from the client for the disclosure of information form contained the purpose of disclosure in two records reviewed.Client #2 was admitted on April 12, 2022 and was discharged July 29, 2022. The record contained a consent to release information form to a treatment provider signed by the witness on April 20, 2022 that was missing the purpose of the disclosure.Client #3 was admitted on April 21, 2022 and was discharged July 12, 2022. The record contained a consent to release information form to a pharmacy signed by the client on April 21, 2022 that was missing the purpose of the disclosure.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director met with Admissions Coordinator on 01/31/2023 and provided training/supervision to ensure all proper documentation is listed on each release of information, including but not limited to the purpose of disclosure. The Program Director and Clinical Supervisor reviewed all current charts to ensure releases on record are in compliance with the confidentiality standard. Once the intake encounter is finalized, it is diverted to the Program Director or designee, who is responsible for ensuring all information contained on those documents are accurate and complete. The Program Director, Quality Assurance Coordinator, and/or delegate will be conducting randomized audits to ensure confidentiality is being upheld through proper releases of information. |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of seven records, the facility failed to ensure that an informed and voluntary consent from the client for the disclosure of information form contained the dated signature of the client in two records reviewed.Client #1 was admitted on September 8, 2022 and was discharged on October 16, 2022. The record contained a consent to release information form to the funding source signed by the witness on September 9, 2022, that was missing the signature of the client.Client #2 was admitted on April 12, 2022 and was discharged July 29, 2022. The record contained a consent to release information form to a treatment provider signed by the witness on April 20, 2022, that was missing the date of the client signature.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director met with Admissions Coordinator on 01/31/2023 and provided training/supervision to ensure all proper documentation is listed on each release of information, including but not limited to dated client signature. Once the intake encounter is finalized, it is diverted to the Program Director or designee, who is responsible for ensuring all information contained on those documents are accurate and complete. The Program Director and Clinical Supervisor reviewed all current charts to ensure releases on record are in compliance with the confidentiality standard. The Program Director, Quality Assurance Coordinator, and/or delegate will be conducting randomized audits to ensure confidentiality is being upheld through proper releases of information. |
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.
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Observations
Based on a review of seven client records, the facility failed to document that the client was notified in writing of a decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.Client #1 was admitted on September 8, 2022 and was discharged on October 16, 2022. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address this deficiency, all clients will continue to be offered a 'notification of termination and non-completion' document to be signed upon unsuccessful completion of the program. If the client signs the document, it will be uploaded to the EMR within 7 business days. If the client declines to sign the document, the primary counselor will note this on the document and upload to the EMR within 7 business days. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 ensure a complete client record included information relative to the client's involvement with the project to include follow-up information in two of four applicable records reviewed. Client #1 was admitted on September 8, 2022 and was discharged on October 16, 2022. The client record did not contain documentation of follow-up information.Client #2 was admitted on April 12, 2022 and was discharged July 29, 2022. The client record did not contain documentation of follow-up information.This is a repeat citation from the January 27, 2022 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address this deficiency, the Clinical Associate will continue to conduct follow-up calls for all discharged clients within 7 days of discharge and note the outcome in the EMR. To ensure this occurs, the Program Director or designee will inspect all charts on a monthly basis during supervision with the Clinical Associate. In addition, the Program Director, Clinical Supervisor, Quality Assurance Coordinator, and/or delegate will be conducting randomized audits to ensure that follow-up calls are being conducted and documented. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to document, in the client's complete record, verification that any work done by the client at the project is an integral part of his/her treatment and rehabilitation plan in six records reviewed.Client #1 was admitted on September 8, 2022 and was discharged on October 16, 2022. Client #3 was admitted on April 21, 2022 and discharged on July 12, 2022.Client #4 was admitted on February 17, 2022 and discharged on March 12, 2022.Client #5 was admitted on November 3, 2022 and was active at the time of the inspection. Client #6 was admitted on October 12, 2022 and was active at the time of the inspection.Client #7 was admitted on December 6, 2022 and was active at the time of the inspection.This is a repeat citation from the January 27, 2022 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address this deficiency, the Clinical Supervisor, in conjunction with the Quality Assurance Coordinator, will conduct a follow-up treatment plan training for all clinical staff members. This training will include, but is not limited to, ensuring that the client record contains verification that work done by the client at the project is an integral part of their treatment and rehabilitation plan. The follow-up treatment plan training will be conducted by 3/31/23.
In the interim, all counselors and counselor assistants will meet with their clients to ensure that work done by the client at the project is an integral part of his/her treatment and rehabilitation plan. This will be achieved by entering an updated treatment plan into the record that explains that work being done by the client at the project is an integral part of his/her treatment and rehabilitation plan.
The Program Director, Clinical Supervisor, Quality Assurance Coordinator, and/or delegate will be conducting randomized audits to ensure compliance.
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