INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28-29, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Treatment & Healing 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
The drug and alcohol treatment project failed to provide documentation of a full-time clinical supervisor for every eight full-time counselors based on a review of the Staffing Requirements Facility Summary Reports for the four facilities within the project. The Staffing Requirements Facilities Summary Reports for the facilities were dated July 24, 2023 (Milton,) July 25, 2023 (E. Stroudsburg,) July 6, 2023 (Honesdale) and July 5, 2023 (Altoona) documented a total of 8.25 full-time counselors employed by the project. This number of
full-time counselors would require a minimum of one full-time clinical supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The position of clinical supervisor has been posted both internally and externally by the company. The clinical supervisor will be mobile and will conduct group supervisor and 1-1 supervision with all clinical staff. They will also be responsible for the oversight and training of all counselor assistants. |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to supervise its counselor assistant by a full-time clinical supervisor or counselor who meets the qualifications. The facility employs one counselor assistant and a Facility Director.
Employee #3 was hired July 25, 2022 as a Counselor Assistant and was still employed in this position at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The position of clinical supervisor has been posted both internally and externally by the company. The clinical supervisor will be mobile and will conduct group supervisor and 1-1 supervision with all clinical staff. They will also be responsible for the oversight and training of all counselor assistants. Until a clinical supervisor is hired, the lead counselor from a sister facility will do weekly supervision with the counselor assistant and document such. This lead counselor will observe groups and 1-1 session in person 1x/wk and will do case consults weekly via telehealth. This process of supervision was begun on 9/25/23. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, it was determined that, in two out of three personnel records reviewed, the facility failed to ensure that staff members completed a feedback form on all attended trainings.
Employee #2 was hired as a Facility Director on April 27, 2022. A review of this personnel record revealed no documented training feedback forms for the July 1, 2022-June 30, 2023 facility training year.
Employee #3 was hired as a Counselor Assistant on July 25, 2022. A review of this personnel record revealed no documented training feedback forms for the period between July 25, 2022-July 25, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The training feedback form has been supplied to all staff members by the Project Director. Beginning on 9/1/23, the Facility Director has implemented a system in which all completed staff trainings must be submitted to her and HR. At that time, they will be given training feedback forms and they will complete them and return to the director and HR. The facility Director will monitor the training plans and completions/feedback forms on a monthly basis. |
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 and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a counselor assistant on July 25, 2022, and was due to complete the communicable disease trainings no later than July 25, 2023. There was no documentation in this personnel record of the completion of the four-hour TB/STD training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The missing training has been placed on the employee's annual training plan, and she has been actively seeking the training. She is currently on all available waitlists for the training, both virtual and live, within a reasonable traveling distance. The Facility Director will follow up with the staff, monthly, to monitor the progress of enrollment and attendance. All attempts to enroll will be documented. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ventilate bathrooms by exhaust fan or window, in the staff bathroom. It was observed by DDAP staff that this lavatory does not have a window and that the exhaust fan was not functioning.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/22/23, The Facility Director contacted building maintenance to report the issue and request repairs. The Facility Director will continue to contact the maintenance department weekly until the issue is resolved. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of the facility's administrative actions, the governing body failed to make the annual report available to the public.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will contact the website developer to address the noted issues. The annual report link will be updated with a section to include the names of board members, directors, and any other invested shareholders. This will be monitored monthly by the Project Director and updated as needed by the website developer. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent, in two out of eight client records, 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 the date, event, or condition upon which the consent will expire.
Client #1 was admitted on November 1, 2022, and was still an active client at the time of the inspection. A consent to release form dated November 1, 2022, for a funding source did not include documentation of an expiration date or condition.
Client #5 was admitted on October 24, 2022, and was discharged on May 8, 2023. A consent to release form dated October 24, 2022, for a family member did not include documentation of an expiration date or condition.
This is a repeat citation from the August 3, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will hold a staff training on proper completion of consents on 9/28/23. This will include a step by step walk through of the completion of the consent. This will then be monitored with monthly chart audits by the Facility Director. These will consist of 2 charts/clinician being pulled randomly each month for the check. These audits will begin following the training on 9/28/23. To address the issue with the current chart, the clinician will have the client sign a new consent, and the Facility Director will review for completion. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on the comprehensive treatment plans in three out of seven applicable records reviewed.
Client #2 was admitted on November 7, 2022, and was still active at the time of the inspection. The treatment plan was dated December 2, 2022.
Client #3 was admitted on May 5, 2023, and was still active at the time of the inspection. The treatment plan was dated May 19, 2023.
Client #4 was admitted on September 15, 2022, and was still active at the time of the inspection. The treatment plan was dated October 3, 2022.
This is a repeat citation from the August 3, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will hold a training with staff on 9/29/23. This training will guide the staff in how to notate on the treatment plan the LOC, the supports to be utilized, and the frequency of group and individual services for the duration of the treatment stay. This will be monitored with monthly chart audits of 2 charts randomly selected from each clinician's caseload. If the Director finds continued issues, additional 1-1 training will be provided to that clinician. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of eight applicable client records reviewed.
Client #1 was admitted on November 1, 2022, and was still active at the time of the inspection. A treatment plan update was completed on June 13, 2023, and the next update was due no later than August 13, 2023; however, there was no treatment plan update documented in the record at the time of the renewal inspection.
Client #2 was admitted on November 7, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on December 2, 2022, and the next update was due no later than February 2, 2023; however, there was no treatment plan update documented in the record until May 22, 2023.
Client #5 was admitted on October 24, 2022 and was discharged on May 8, 2023. A comprehensive treatment plan update was completed on November 11, 2022 and an update was due no later than January 11, 2023; however, there was no treatment plan update documented in the record until January 23, 2023.
This is a repeat citation from the September 29, 2021 and the August 3, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will provide in house training to all clinicians on timelines and how to manage/address them due to missed appointments and/or ASA discharges on 9/28/23. Successful intervention will be measured by chart audits completed monthly by the facility director. These audits will consist of 2 charts, randomly selected, off of each caseload. These audits will begin following the training on 9/28/23. If the treatment plans are found to not meet the said parameters, the Facility Director will meet with the clinician 1-1 for further guidance. |
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 outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in three out of seven charts reviewed.
Client #2 was admitted on November 7, 2022, and was still active at the time of the inspection. A treatment plan update dated May 22, 2023, indicated one individual outpatient sessions per month; additionally, it also indicated one group session per month. The record of service and progress notes indicated that the client received no individual sessions from May 22, 2023 through July 18, 2023.
Client #4 was admitted September 15, 2022, and was still active at the time of the inspection. The comprehensive treatment plan, dated October 3, 2022, indicated one individual outpatient session per week. The record of service and progress notes indicated that the client received no individual sessions during the weeks of September 25, 2022, October 9, 2022, October 16, 2022 and October 23, 2022.
Client #5 was admitted on October 24, 2022, and was discharged on May 8, 2023. The comprehensive treatment plan, dated November 11, 2022 , indicated one individual outpatient sessions per week; additionally, it also indicated a group session one time weekly. The record of service and progress notes indicated that the client received no individual sessions during the weeks of March 12, 2023, March 19, 2023 and March 26, 2023.
This is a repeat citation from the August 3, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/22/23 the Facility Director will hold an in house training on the need to document all missed appointments, cancelled, rescheduled, and no shows with a special note. The completion of such will be monitored with monthly chart audits. These audits will involve the Facility Director randomly pulling 2 charts from each clinician. Should the issue present in any chart, that Facility Director will follow up with that clinician and offer further guidance and training. The audits will begin following an additional training on 9/29/23. |
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 a case consultation within guidelines established by the facility's policy and procedures manual in eight out of eight applicable records reviewed. The facility's policy states that case consultations must be completed within thirty days of the intake session.
Client #1 was admitted on November 1, 2022, and was still active at the time of the inspection. The initial case consultation dated November 1, 2022, was signed only by the clinician. There was no secondary review or sign-off.
Client #2 was admitted on November 7, 2022, and was still active at the time of the inspection. The initial case consultation dated November 7, 2022 was signed only by the clinician. There was no secondary review or sign-off.
Client #3 was admitted on May 5, 2023, and was still active at the time of the inspection. The initial case consultation dated May 5, 2023, was signed only by the clinician. There was no secondary review or sign-off.
Client #4 was admitted on admitted on September 15, 2022, and was still active at the time of the inspection. The initial case consultation dated September 15, 2022, was signed only by the clinician. There was no secondary review or sign-off.
Client #5 was admitted on admitted on October 24, 2022, and was discharged on May 8, 2023. The initial case consultation dated October 24, 2022, was signed only by the clinician. There was no secondary review or sign-off.
Client #6 was admitted on admitted on March 23, 2023, and was discharged on April 24, 2023. The initial case consultation dated March 23, 2023, was signed only by the clinician. There was no secondary review or sign-off.
Client #7 was admitted on admitted on January 13, 2023, and was discharged on April 26, 2023. The initial case consultation dated January 13, 2023, was signed only by the clinician. There was no secondary review or sign-off.
Client #8 was admitted on admitted on April 10, 2023, and was still active at the time of the inspection. The initial case consultation dated April 10, 2023 was signed only by the clinician. There was no secondary review or sign-off.
This is a repeat citation from the August 3, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will provide an in house training to all clinicians on timelines and how to address them due to missed appointments on 10/19/23. They will also be trained on the importance of consults being presented and signed by all present for the consultation and not just the clinician or the supervisor. Successful intervention will be measured by chart audits completed monthly by the facility director. This will consist of 2 randomly pulled charts selected of each caseload, with the audits beginning following the training on 10/19/23. If the case consult does not meet the said parameters, the Facility Director will meet with that clinician for further 1-1 guidance. |
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 provide a complete client record, which is to include follow-up information in three out of three applicable discharged record reviews.
Client #5 was admitted on October 24, 2022 and was discharged on May 8, 2023.
Client #6 was admitted on March 23, 2023 and was discharged on April 24, 2023.
Client #7 was admitted on January 13, 2023 and was discharged on April 26, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When a client has successfully completed formal treatment and no longer has the need for treatment, follow up will occur by the 30 day mark.
When a client has not successfully completed treatment, (discharge statuses of disciplinary, therapeutic, and against staff advice)follow up will occur within 7 days of discharge.
No follow up will be done on those clients who were discharged with the status of incarceration or on those individuals who only received a drug and alcohol evaluation in which the individual was found to be inappropriate for treatment and/or no recommendation was made for further treatment.
The policy will be reviewed with staff on 10/19/23. It will then be monitored by the facility director who will audit every closed chart within 30 days of discharge. Charts found to be noncompliant will be redirected back to the clinician and further training given. These audits will begin following the training on 10/19/23.
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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 the review of patient records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction was submitted to the Department for inspections occurring on September 29, 2021, and August 3, 2022 addressing the requirement to document treatment plan updates within the regulatory timeframe.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
When a client has successfully completed formal treatment and no longer has the need for treatment, follow up will occur by the 30 day mark.
When a client has not successfully completed treatment, (discharge statuses of disciplinary, therapeutic, and against staff advice)follow up will occur within 7 days of discharge.
No follow up will be done on those clients who were discharged with the status of incarceration or on those individuals who only received a drug and alcohol evaluation in which the individual was found to be inappropriate for treatment and/or no recommendation was made for further treatment.
The policy will be reviewed with staff on 10/19/23. It will then be monitored by the facility director who will audit every closed chart within 30 days of discharge. Charts found to be noncompliant will be redirected back to the clinician and further training given. These audits will begin following the training on 10/19/23. |