INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 27, 2022, 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. Keenan House 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 four personnel records, the facility failed to hire counselors that met the experience requirements for the position.
Employee #4 hired as a counselor on September 30, 2021. Employee #4 did not have one year of clinical experience documented for the position.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To address this deficiency, the Program Director and or Clinical Director will establish an individual training plan for each counselor despite their qualifications that will focus on enhancing their chemical dependency clinical skills. Each counselor will be met for individual and weekly group supervision with the Program Director and have close supervision for approximately 3-9 months, based upon their education, experience and qualifications, with either the Supervisor or Program Director. A 6 month review will be also be established by the Supervisor and will be used to evaluate the counselors performance based on measurable standards and reviewed by the Program Director.
Close supervision of all Counselor Assistants, CA's, will occur for the required amount of time as determined by education and experience. Close supervision will be conducted by qualified staff which includes the Program Director, Clinical Director, and qualified counselors. Close supervision will include observation of sessions, co-facilitation of sessions, and regular review of all unsupervised sessions. Regular review will entail the CA keeping a log of all of their sessions for the determined close supervision time period and a review of the CA's log will be signed off by a qualified staff member who's reviewing the sessions.
A review of all current clinical staff's qualifications to include education and field experience will be conducted by the Program Director and/or Clinical Director. Any staff determined to not meet the qualifications for counselor will be placed in a Counselor Assistant, CA role. The Program Director and/or Clinical Director will develop an appropriate training plan and close supervision measures as outlined above will be implemented.
All future candidates for clinical positions will have their education verified via official transcripts by TTI's human resource representative and
field experience listed on the resume will be verified by the Program Director and/or Clinical Director. Any individual not meeting the qualifications for counselor will be considered for a CA, Counselor Assistant, and will be subjected to the CA guidelines outlined above
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704.12(a)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of the Staffing Facility Summary Report, the facility failed to ensure that projects serving adult clients shall have one FTE counselor for every eight clients.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by 40. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
The FTE counselor ' s caseload calculation is as follows: 116/40= .2.9(FTE); 25/.2.9 = 8.6, which equals to a client/counselor ratio of 9/1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address this deficiency, FTE will be working a 40 hour work week during primary care hours with the facility serving adult clients which calculates to one FTE counselor for every 8 clients. The PTE counselors will serve no more than 4 clients based on 24 hours of primary care hours per week based on the PTE calculations.
The assignment of new clients to counselors will be given by the Admissions Director upon admission and reviewed by the Program Director during the weekly leadership meeting. The number of clients given to FTE or PTE counselors will not exceed the amount of clients from the calculated ratio.
The Program Director has already implemented this allocation and in moving forward.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drills from January 2021 until November 2021, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
To address this deficiency, the Program Director will review the "sleeping hour" drill times with the Operations Manager. The Operations Manager will ensure that a sleeping fire drill occurs in congruence with the fire drill schedule; current practice is that a "sleep hour" drill is scheduled once per quarter. The Operations Manager will bring all completed fire activity logs to the Program Director for review and then submit the report to the Quality Assurance Coordinator for final review/file. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drills from January 2021 to November 2021, the facility failed to document if the fire alarm or smoke detector was set off during the November 2021 fire drill.
These findings were discussed with facility staff during the inspection.
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Plan of Correction
To address this deficiency, the Program Director will review the fire drill schedule with the Operations Manager to make sure that the drills also include setting off a fire alarm or smoke detector. The Operations Manager will bring the logs to the Program Director for review and will be submitted to the Quality Assurance Coordinator to be reviewed and filed. |
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 client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in six client records reviewed.
Client #1 was admitted on October 14, 2021 and was an active client as of the date of the inspection. A consent to release form was signed and dated on October 14, 2021 to the funding source that allowed for the release of discharge summary.
Client #2 was admitted on December 6, 2021 and was an active client as of the date of the inspection. A consent to release form was signed and dated on December 7, 2021 to the funding source that allowed for the release of health physical and medical history.
Client #3 was admitted on December 29, 2021 and was an active client as of the date of the inspection. A consent to release form was signed and dated on December 29, 2021 to the funding source that allowed for the release of clinical evaluations, intake evaluations and medical history.
Client #5 was admitted on July 31, 2021 and was discharged on October 14, 2021. A consent to release form was signed and dated on August 24, 2021 to the funding source that allowed for the release of intake evaluations and progress notes.
Client #6 was admitted on November 1, 2021 and was discharged on January 18, 2022. A consent to release form was signed and dated on November 1, 2021 to the funding source that allowed for the release of health physical, medical history and telephone calls.
Client #7 was admitted October 2, 2021 and was discharged on December 7, 2021. A consent to release form was signed and dated on October 26, 2021 to the funding source that allowed for the release of discharge summary and motivation.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
To address this deficiency, a written policy highlighting the limits established in 4 PA Code 255.5(B) will be developed as to what information can be released.
The policy will be given to the Quality Assurance Coordinator for final review and approved.
An in-house training on Confidentiality, as determined by 4 PA Code 255.5(B), will be facilitated by the Quality Assurance Coordinator during a staff meeting and staff sign off will be required.
Ongoing monitoring of 4 PA Code adherent to 255.5(B) will be as follows:
Counselor will self monitor weekly, Program Director audit bi-weekly, and Quality Assurance Coordinator audit monthly. |
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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in three of the four applicable client records reviewed.
Client #1 was admitted on October 14, 2021 and was still active at the time of the inspection. A treatment plan update was completed on October 15, 2021, and the next update was due no later than November 15, 2021; however, there was no update documented in the record until December 20, 2021.
Client #2 was admitted on December 6, 2021 and was still active at the time of the inspection. A treatment plan update was completed on December 8, 2021, and the next update was due no later than January 8, 2022; however, there was no update documented in the record at the time of the inspection.
Client #6 was admitted on November 1, 2021 and was discharge on January 18, 2022. A treatment plan update was completed on November 5, 2021, and the next update was due no later than December 5, 2021; however, there was no update documented in the record until December 16, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
To address these deficiencies, the counselor will be directed to establish a reminders for treatment plans and treatment plan updates on the outlook calendar for each client on their caseload. The Clinical Director will maintain a spread sheet tracking all treatment plans and treatment plan updates. Regular reviews of due dates will occur during individual supervision and weekly group supervision. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in one of three applicable client records.
Client #5 was admitted on July 31, 2021 and was discharged on October 14, 2021. The client record did not contain documentation that a discharge summary was completed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
To address this deficiency, the counselors will be responsible for implementing a reminder tracking system, (i.e outlook calendar) that highlights when completing a discharge summary. Client charts will be reviewed as follows: Counselor will self audit, Program Director audits bi weekly, and the Quality Assurance Coordinator monthly. |
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 ensure that all work done by the client at the project is an integral part of his treatment and rehabilitation plan in all seven client records reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
To address this deficiency, the Program Director and the Clinical Director will conduct a treatment plan training for all clinical staff members. The training will include, but not limited to: ensuring that the client records contains the verification that work done by the client within the program is an integral part of their treatment and treatment plan. |