INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 5, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, American Treatment Network LLC 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:
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
Based on a review of personnel files, the facility failed to ensure that one applicable clinical supervisor had completed a core curriculum in clinical supervision which is a requirement for the position.
Employee # 2 was promoted to the position of clinical supervisor on May 1, 2023 and is current in that position. Employee # 2 did not function for 2 years as a supervisor and has not completed a core curriculum as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will conduct Supervision once per month with all newly hired Clinical Supervisors to review Staff Development plans to ensure that The Clinical Supervisor has completed the applicable Clinical Supervision core curriculum or has registered for the training by the required time according to hire date.
Employee #2 who was promoted in the role as clinical supervisor on May 1, 2023. On the date of inspection employee # 2 had completed 70% of the clinical supervisor training and will complete the rest of the core curriculum supervisor training by November 1, 2024.
The Quality Assurance Manager will monitor to ensure 100% of the clinical supervisor training has been completed by the required time frame by reviewing the Clinical Supervisor Training plan. Documentation will provide feedback on the completed training. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
|
Observations
Based on a discussion with facility staff and submitted documents, the facility failed to complete an overall plan for addressing staff training needs based on the assessment of staff training needs for the current training year.
These findings were reviewed with facility staff during the inspection process.
|
Plan of Correction
The Facility Director will develop a comprehensive program for each personnel which will be included in the policies and procedures for all staff.
The Clinical Supervisor will provide an assessment of all training needs for each staff member.
The Clinical Supervisor will identify and address all training needs and develop and overall training plan. Within the overall training plan documentation will be provided as well on the completed training development plan.
The clinical Supervisor will meet annually with staff to review and evaluate the year's overall training plan.
The Facility Director will monitor to ensure all training plans meet the standards and policies have been included. |
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure that two of seven applicable employees received 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 within the regulatory timeframe.
Employee # 4 has been in the position of counselor since March 13, 2023 and was due to have the communicable disease trainings no later than March 13, 2024. However, the personnel record contained no documentation of the completion of the HIV/AIDS or TB/STD trainings as of the date of the inspection.
Employee # 7 has been in the position of counselor since March 20, 2023 and was due to have the communicable disease trainings no later than March 20, 2024. However, the personnel record contained no documentation of the completion of the HIV/AIDS or TB/STD trainings as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor Will provide list of all training needs for each staff member.
The Clinical Supervisor will identify required trainings in the overall training plan and monitor progress for staff once per month with each staff member.
The Facility Director will review and monitor staff development plans for 100% of the staff once per month to identify when required trainings are completed so that all required trainings are completed at the regulatory timeframe.
Employee #4 will complete HIV/AID and STD/TB the DDAP required six hours of HIV/AIDS, and 4 hours of TB by December 22, 2024
Employee #7 resigned and left American Treatment Network on August 16th, 2024, and will not be able to complete the required trainings.
|
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of seven personnel records, the facility failed to demonstrate that a sufficient number of staff persons had CPR certification, as only one of the full-time staff members was certified in CPR between the last inspection and August 20, 2024.
This is a repeat citation from the September 25, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor will monitor all staff development plans to ensure that CPR is part of the required trainings and completed at the required date to keep all required staff certified in CPR.
The Facility Director will monitor and review the staff development plans to ensure all staff is certified in CPR and meeting the requirement.
The Clinical Supervisor has scheduled a CPR training on 10/9/2024 to meet the requirement that a sufficient number of staff have completed CPR with certifications.
The Facility Director will review certifications when the CPR training has been completed. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
The facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room, as a group session in office 2 could be heard clearly in office 1, the room next door, at 11:50 a.m. on September 5, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor has since the date of the inspection on 9/6/2024 implemented sound machines in all counseling group and individual sessions so no one can be heard in any other rooms.
The Clinical Supervisor will ensure sound machines are being implemented by completing daily routine rounds. All results from the daily routine rounds will be reviewed in supervision.
The Facility Director will review with Clinical Supervisor that all sound machines are working and being used appropriately, once per week in the daily update meeting. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
|
Observations
Based on a review of eight client records, the facility failed to document disclosure to the client of criteria for admission, treatment, or completion in three records reviewed.
Client # 3 was admitted on January 19, 2024 and was discharged on June 7, 2024.
Client # 5 was admitted on March 11, 2024 and was active at the time of the inspection.
Client # 6 was admitted on December 27, 2023 and was active at the time of the inspection.
This is a repeat citation from the September 25, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director has implemented a new intake and admission form to disclose to the client needed criteria for admission, treatment, and completion.
The Clinical Supervisor will ensure by reviewing that all staff is completing the newly implemented intake and admission form.
Client # 3 was discharged on June 7th, 2024, and cannot update new form.
Client # 5 is currently active and complete4d a new intake and admission form on 9/26/2024.
Client # 6 is currently active and completed a new intake and admission form on 9/26/2024. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of five applicable records reviewed.
Client # 2 was admitted on November 29, 2023 and was discharged on May 22, 2024. A treatment plan update was completed on February 14, 2024 and a treatment plan update was due to be completed by April 14, 2024; however, no treatment plan updates were completed prior to the date of discharge.
Client # 5 was admitted on March 11, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 11, 2024, and a treatment plan update was due to be completed by May 11, 2024; however, the next treatment plan update was not completed until July 9, 2024.
Client # 6 was admitted on December 27, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 27, 2023, and a treatment plan update was due to be completed by February 27, 2024; however, the next treatment plan update was not completed until March 8, 2024. The next treatment plan update was due to be completed by May 8, 2024; however, it was not completed until June 25, 2024.
Client # 7 was admitted on December 4, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 7, 2023, and a treatment plan update was due to be completed by February 7, 2024; however, the next treatment plan update was not completed until April 25, 2024. The next treatment plan update was due to be completed by June 25, 2024; however, it was not completed until July 3, 2024.
This is a repeat citation from the September 25, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor has implemented a tracking spread sheet to monitor all treatment plan reviews and updates required at least every 60 days.
The tracking tool and results will be discussed at the group and individual clinical supervision meetings.
Each staff member will be responsible tracking and updating his/her case load for documentation dates and due dates, including treatment plans.
The Clinical Supervisor will review upcoming treatment plans during each individual supervision with staff to stay current with documentation due dates.
The Clinical Supervisor will inform staff that for any potential lapse in treatment plans that she will be notified immediately, and a case management note is documented to reflect gap and next steps.
The Facility Director will monitor 10 charts per month to ensure treatment plan updates are current at the 60 days timeframe.
Quality Assurance officer will audit 25% of all treatments.
Client #2 was discharged on May 23, 2024, no updates could be made.
Client #5 is currently active, and client's treatment plan has been updated.
Client #6 is currently active, and his treatment plan has been updated and is current.
Client #7 is currently active, and her treatment plan is current and active.
|
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.
|
Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in three of seven records reviewed.
Client # 2 was admitted on November 29, 2023 and was discharged on May 22, 2024. The treatment plan completed on November 29, 2023, indicated that the client was to receive three group sessions per week; however, the record did not document any group sessions offered between December 27, 2023 and January 24, 2024. The treatment plan completed on February 14, 2024, indicated that the client was to receive one group session per week; however, the record did not document any group sessions offered between March 20, 2024 and April 17, 2024.
Client # 3 was admitted on January 19, 2024 and was discharged on June 7, 2024. The treatment plan completed on April 10, 2024, indicated that the client was to receive one individual session and one group session per week; however, the record did not contain documentation of any group or individual sessions between April 17, 2024 and May 15, 2024.
Client # 5 was admitted on March 11, 2024 and was active at the time of the inspection. The treatment plan completed on July 9, 2024, indicated that the client was to receive one group session per week; however, the record only documented two group sessions offered during the weeks of July 29, 2024 and August 5, 2024, and only one group offered the week of August 12, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor will monitor with a treatment plan tracking tool to ensure all counseling services match the treatment plan recommendation.
The clinical Supervisor will review all case management documentation to ensure if any gaps are present in any services that those gaps in treatment are documented in case management section of the client's chart.
The Facility Director will audit 10 client charts per month to ensure treatment plan matches counseling services as well as gaps in treatment are clearly documented in case management.
Client #2 has discharged and completed treatment.
Client #3 is currently discharged due to noncompliance with outpatient treatment.
Client #5 is currently active and primary therapist made outreach and documented that outreach. Primary Therapist will document any gap in services or noncompliance to ensure treatment and services match and to show all gaps in treatment are documented.
|
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.
|
Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information within thirty days of admission, in three of seven applicable records reviewed.
Client # 3 was admitted on January 19, 2024 and was discharged on June 7, 2024. There was no documentation of case consultation information in the record.
Client # 6 was admitted on December 27, 2023 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
Client # 7 was admitted on December 4, 2023 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
This is a repeat citation from the September 25, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor has developed and implemented an admission tracking system in the EMR system for all new admissions to ensure all new clients are receiving case consultations within the specified period identified in the policy manual.
The Quality Assurance Manager will audit monthly all new admissions to ensure case consultations are being completed in the 30-day time period.
Client #3 has been discharged from American Treatment Network
Client #6 is currently active, and a case consultation note has been completed by The Clinical Supervisor and the primary therapist.
Client #7 is currently active with treatment and The Clinical Supervisor, and the Primary Therapist have completed a case consultation note. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in one of one applicable record reviewed.
Client # 2 was admitted on November 29, 2023 and was discharged on May 22, 2024. The client record did not contain documentation of a completed aftercare plan.
This is a repeat citation from the September 25, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor has communicated and implemented to all clinical staff the requirement of documenting a joint after-care plan that includes the client's involvement for all successful discharges.
The Clinical Supervisor will monitor and document all discharges to confirm after-care plans are being carried out with the client's involvement.
The Facility Director will audit 10 charts per month to ensure all after-care plans have been completed by all clients who have been discharged.
Client #2 is currently discharged.
Client #2 was called by called by The Clinical Supervisor on October 4, 2024, to complete an aftercare plan with the client and do a follow up. This interaction will be documented in the EMR system.
|
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.
|
Observations
Based on a review of client records and the facility policy and procedure manual, 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 within 30 days of discharge, in three of four applicable records reviewed.
Client # 1 was admitted on October 18, 2023 and was discharged on January 15, 2024. The follow-up information was not documented until February 21, 2024.
Client # 2 was admitted on November 29, 2023 and was discharged on May 22, 2024. The client record did not contain documentation of follow-up information.
Client # 3 was admitted on January 19, 2024 and was discharged on June 7, 2024. The client record did not contain documentation of follow-up information.
This is a repeat citation from the September 25, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor has communicated and implemented for all clinical staff with client's involvement to conduct and document within 30 days a follow-up engagement for all clients being discharged per policy.
The joint follow-up information will be documented in a case management note in EMR.
The Clinical Supervisor will monitor all discharges on a monthly basis to ensure joint follow-ups are carried out and follow documented in the case management section of the EMR chart.
The Quality Assurance Manager will audit at least 20% of all discharges to verify the requirement of within 30 days to have a follow up case management note completed by primary therapist and client.
Client # 1 was outreached on 9/27/2024 by the Clinical Supervisor and documentation has been completed in the client's chart in the case management section to reflect that.
Client #2 was outreached on 9/27/2024 by the Clinical Supervisor and documentation has been completed in the client's chart in the case management section to reflect that.
Client #3 was outreached on 9/27/2024 by the Clinical Supervisor and documentation has been completed in the client's chart in the case management section to reflect that.
|