INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, treatment Trends Inc.-Confront was found to be not 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
A review of the facility's Staffing Requirements Facility Summary Report was conducted as part of the licensing inspection. The facility's training year reviewed was 7/1/2015 through 6/30/2016. Employee #7 was hired as a counselor on 5/21/2013; only 20 hours of training was documented as completed as of the date of the licensing inspection.Employee #8 was hired as a counselor on 12/2/2014; only 24.5 hours of training was documented as completed as of the date of the licensing inspection.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
This information was discussed with Program Director and Office Manager after the licensing inspection on Monday February 13, 2017.
Program Director and Lead Counselor will review staff training hours on a biannual basis and schedule trainings with staff in accordance to hours needed.
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on February 7, 2017, it was observed that the wall in the front basement group room had peeling paint from water intrusion.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The wall in the front basement group room was sanded and repainted by facility maintenance workers on February 7, 2017.
Staff will notify Program Director when they notice maintenance concerns, which will then be submitted to maintenance department. Building checklist will be completed on a monthly basis by Office Manager and Program Director. |
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.
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Observations
Based on a physical plant inspection conducted on February 7, 2017, the facility failed to ensure privacy by allowing unobstructed visual access from the hallway during counseling sessions in two groups rooms. Group room #6 located on the second floor and the back group room located in the basementThese findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility will be applying for an exception to the regulation, however Program Director assured that visual access to Group room #6 and the back group room located in the basement was covered on February 7, 2017.
Program director and Lead counselor will review this regulation with the staff and the need for compliance.
Program director will periodically check to ensure the window coverings are in good shape and are being utilized during counseling sessions. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted on February 7, 2017, it was observed that the 2nd floor restroom water temperature measured at 128F and the basement restroom water temperature measured at 128.4F. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Water Temperature will be checked on a monthly basis by Office Manager during completion of Building Checklist. Water temperature will also be checked by the facility maintenance team during the quarterly inspections.
Maintenance adjusted the water temperature throughout the facility to 116.2 degrees on February 24, 2017. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of client #1's record on February 7, 2017, the facility failed to ensure clients confidentiality by putting the clients full name who participated in group on a group progress note dated 2/1/17. This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
Reviewed with staff member responsible for this note on February 8, 2017 and the note was corrected by this staff member on the same date.
Notes will be checked weekly by Program Director or Lead Counselor for any confidentiality concerns which will then be addressed with the staff responsible. |
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
Client records were reviewed on February 7, 2017. The facility failed to obtain a valid consent to release information in client record #1.Additionally, the facility exceeded what is permissible in 4 PA code 255.5 in the following records.Client #1 was admitted on 11/2/16 and was an active client at the time of the inspection. A consent to release information form, dated 9/28/16, to a government agency did not indicate what information was to be released or the purpose of the release. A consent to release information form, dated 9/28/16, to a funding source allowed for the release of "Attendance, discharge summary and recommendations". Additionally a fax transmission dated 1/3/17 to another treatment provider was found in the record, however no consent to release information to this provider was documented at the time of the inspection.Client #4 was admitted on 3/22/16 and discharged on 8/2/2016. A consent to release information form, dated 3/22/16, to a government agency allowed for the release of "recommendations".Client #5 was admitted on 1/28/16 and discharged on 8/9/2016. A consent to release information form, dated 1/28/16, to a government agency allowed for the release of "recommendations".Client #6 was admitted on 3/23/16 and discharged on 9/13/2016. A consent to release information form, dated 3/22/16, to a government agency allowed for the release of "evaluation/assessment".Client #7 was admitted on 2/8/16 and discharged on 8/6/2016. A consent to release information form, dated 4/8/16, to a government agency allowed for the release of "recommendations".This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Client 1, 4, 5, 6, 7: Program Director and Lead Counselor will review confidentiality law, 4 PA 255.5 and create a new release of information form by March 1, which will be reviewed with staff in individual supervision sessions. Staff will then complete new releases with clients at their next scheduled appointments to be completed by March 15, 2017.
Client 1: Client record was reviewed with counselor on February 8, 2017. A release will be obtained by March 15, 2017.
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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
A review of client records were conducted on February 7, 2017.Client #2 was admitted on 9/8/16 and was an active client at the time of the inspection. A comprehensive treatment plan was documented on 9/26/16; a treatment plan update was due by 11/26/16 but was not documented until 12/9/16.Client #4 was admitted on 3/22/16 and discharged on 8/2/2016. A comprehensive treatment plan was documented on 4/27/16; a treatment plan update was due by 6/27/16 but was not documented until 6/30/16. Client #5 was admitted on 1/28/16 and discharged on 8/9/2016. A treatment plan update was documented on 5/5/16; a treatment plan update was due by 7/5/16 but was not documented until 7/27/16.Client #7 was admitted on 2/8/16 and discharged on 8/16/2016. A treatment plan update was documented on 5/2/16; a treatment plan update was due by 7/2/16 but was not documented until 7/5/16.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Client 2, 4, 5, 7: Program Director and Lead Counselor will review treatment plan update due dates with counselors on a monthly basis in supervision to start by March 1, 2017. |
709.93(a) 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:
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Observations
A review of client records was conducted on February 7, 2017. Client #5 was admitted on 1/28/16 and was discharged on 8/9/16. An individual progress note dated 7/28/16 was not documented on the Record of Service. Additionally, no discharge summary or aftercare plan was documented in the record at the time of the inspection.Client #6 was admitted on 3/23/16 and was discharged on 9/13/16. No Record of Service entries were documented after 6/26/16, however the following services were delivered according to the following progress notes that were documented:Individual sessions: 7/11, 7/25, 8/1, 8/8, 8/15, 8/29 and 9/12/16Group Sessions: 6/27, 7/7, 7/11, 7/27, 7/28, 8/4, 8/11, 8/18, 8/25, 9/1 and 9/8/16.Additionally, no aftercare plan was documented in the record at the time of the inspection.Client #7 was admitted on 2/8/16 and was discharged on 8/16/16. No Record of Service entries were documented after 6/23/16, however the following services were delivered according to the following progress notes that were documented:Individual sessions: 7/5, 7/18, 8/1, and 8/15/16.Group Sessions: 6/30, 7/5, 7/7, 7/12, 7/14, 7/21, 7/26, 7/28 and 8/4/16.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Client 5, 6, 7: At the onset of every new month, Billing Clerk will print Record of Service for all clients, which will then be given to the counselors to be checked for the previous month.
Aftercare plans are to be completed on the last date of service with the client. Staff will review all aftercare plans and discharge paperwork on a monthly basis in supervision with Lead Counselor and/or Program Director.
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