INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 22, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Monroe County Counseling Services, 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:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to ensure that Employee #1, the project director/counselor, had an individual training plan documented in the employee's personnel/training record for the current training year.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
On November 1st, 2018 The Project Director/Counselor developed an Individual Training Plan Form and included it in the Project Director's Personnel folder. The form will be monitored effective immediately by the Project Director to ensure that DDAP training requirements are met in the next year. The Project Director will monitor the DDAP training schedule and reach out to other Service Providers and the Carbon, Monroe Pike SCA seeking collaboration and appropriate training. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to maintain a fire drill log for the time period reviewed-December 2017 through September 2018. Therefore, verification that unannounced fire drills were conducted on a monthly basis was unable to be determined at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new Fire Drill Log was developed and completed retroactively for the period December 2017 through October 22nd, 2018 for all drills conducted but not properly documented. The new Log includes all of the required data elements under 705.28. The Project Director will ensure that timely Fire Drills consistent with DDAP regulations, especially regarding the date, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The Project Director will be responsible for ensuring that Fire drill logs are adequately documented and readily available in the future.
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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
The facility failed to maintain valid, informed and voluntary consent to release information forms within the limits established by 4 Pa. Code 255.5 (b) in five of seven client records reviewed. Additionally, the facility failed to document valid witness signatures and dates, as well as valid client signatures and dates in two of seven client records reviewed. Client #1 was admitted on Septmber 3, 2018 and was still active at the time of the inspection. A consent to release information form to the probation officer, signed by the client, allowed for the release of the results of the D&A assessment, which exceeded 255.5. Additionally, that same consent to release information form to the probation officer failed to document the dates of when the client and the witness signed the form.Client #2 was admitted on September 11, 2018 and was still active at the time of the inspection. A consent to release information form to the probation officer, signed on September 11, 2018 by the client, allowed for the release of the results of the D&A assessment, which exceeded 255.5. Additionally, that same consent to release information form to the probation officer failed to document a dated witness signature.Client #5 was admitted on April 10, 2018 and was discharged on May 6, 2018. A consent to release information form to the probation officer, signed on April 3, 2018, allowed for the release of the results of the D&A assessment, which exceeded 255.5.Client #6 was admitted on December 29, 2017 and was discharged on February 28, 2018. A consent to release information form to the probation officer, signed on December 29, 2018, allowed for the release of the results of the D&A assessment, which exceeded 255.5.Client #7 was admitted on March 16, 2018 and was discharged on May 30, 2018. A consent to release information form to the probation officer, signed on March 16, 2018, allowed for the release of the results of the D&A assessment, which exceeded 255.5.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On October 22nd, 2018 a new informed and voluntary consent form from the client that excluded all references that exceeded PA Code 255.5 limits was developed at the DDAP Licensing Specialist's request and immediately implemented. The Projected director provided the missing dates and witness signatures immediately to Client #1 and Client #2.
Additionally, annotations and redactions to all Release Forms deleting the language exceeding 255.5 were made to all clients listed here and, by extension, to all active Clients. As noted above a new Release Form was developed and will be used for all new clients.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to provide documentation of the written acknowledgement by the clients verifying that they had been informed of their client rights in four of seven client records reviewed.Client #1 was admitted on September 3, 2018 and was still active at the time of the inspection.Client #2 was admitted on September 11, 2018 and was still as active at the time of the inspection.Client #3 was admitted on September 6, 2018 and was still active at the time of the inspection.Client #5 was admitted on April 10, 2018 and was discharged on May 6, 2018. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An MCCS Client Handbook was immediately printed and made available to all active Clients. Effective immediately the Project Director is responsible for ensuring that all Clients sign an Acknowledgement Form during the intake and admission session that includes receipt of the MCCS Handbook that includes information on MCCS policies, client rights (civil rights and liberties consistent with 709.30) program rules and requirements related to treatment, hours of operation, fee schedule and services provided.
The Projected director provided the Handbook to Client #1, #2 and #3 on October 23rd, 2018.
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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.
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Observations
The facility failed to provide intake documentation verifying that the criteria for admission, treatment, completion, and discharge was disclosed to the client in four of seven client records reviewed.Client #1 was admitted on September 3, 2018 and was still active at the time of the inspection.Client #2 was admitted on September 11, 2018 and was still as active at the time of the inspection.Client #3 was admitted on September 6, 2018 and was still active at the time of the inspection.Client #5 was admitted on April 10, 2018 and was discharged on May 6, 2018. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When a person completes a full drug and alcohol assessment at intake, the MCCS staff is responsible for disclosing to the client the agency's and the client's responsibility regarding admission, treatment modality, goals of treatment and discharge criteria. Effective immediately the Project Director will ensure that this session is fully documented and that the client signs an Acknowledgement Form that he has been informed of the criteria for admission, treatment, completion and discharge.
This was done for Clients #1 #2 and #3 on October 24th, 2018. Client #5 was discharged for non-attendance.
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709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
The facility failed to provide intake documentation verifying that the client was oriented to the program in four of seven client records reviewed.Client #1 was admitted on September 3, 2018 and was still active at the time of the inspection.Client #2 was admitted on September 11, 2018 and was still as active at the time of the inspection.Client #3 was admitted on September 6, 2018 and was still active at the time of the inspection.Client #5 was admitted on April 10, 2018 and was discharged on May 6, 2018. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure client familiarization with the Project Policies, The Acknowledgement Form and all prior Intake and orientation issues such as Project rules and requirements related to treatment hours of operation, fee schedule, client responsibilities and all support services as it relates to achieving a successful discharge in 60-90 days will be reviewed, again if necessary, with all clients and documented.
This was done for Clients #1. #2 and #3 on October 29th, 2018. Client #5 was discharged for non-attendance.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
The facility failed to provide intake documentation that the client gave their consent to be treated at the facility in all seven client records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients were signing a Release Form that covered treatment consent but it was not clear and/or specific enough. Therefore, a new Consent for Treatment Form and disclosure of information was developed that includes information on the client's treatment, diagnosis, prognosis, attendance and/or lack of attendance at treatment sessions and other pertinent treatment information regarding client participation at the Project. As of November 12th, 2018, this new Consent Form was executed for all seven clients cited here and for all active cases. In the future, the Project director shall be responsible for ensuring that this consent is executed at the Intake session before client begins treatment.
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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
The facility failed to provide a treatment plan update within the regulatory timeframe in one of one applicable client records reviewed.Client #4 was admitted on November 7, 2017 and was discharged on January 16, 2018. The comprehensive treatment plan was completed on November 7, 2017 and the first update was due no later than January 7, 2018. However, the update was not completed prior to the client's discharge from treatment These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The inspection results indicated that one one of the charts ( Client # 4) failed to provide a treatment plan update. This was a rare occasion where the Client completion timeframe of 60 days was extended solely because the client had transportation issues and could not make it to his last session to sign his aftercare plan or discharge papers. Nevertheless, the Project Director established a new Treatment Plan Tracking System that will ensure that all future client cases/discharges exceeding the 60 day time periods will have an updated treatment plan processed regardless of treatment extension reason and or short time period. |
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
The facility failed to provide a complete client record documenting the client's involvement with the project in six of seven client records reviewed.Client #1 was admitted on September 3, 2018 and was still active at the time of the inspection. There were no documented progress notes and the record of service was not completed for any of the client's sessions.Client #2 was admitted on September 11, 2018 and was still active at the time of the inspection. There were no documented progress notes and the record of service was not completed for any of the client's sessions.Client #3 was admitted on September 6 2018 and was still active at the time of the inspection. There were no documented progress notes and the record of service was not completed for any of the client's sessions.Client #4 was admitted on November 11, 2017 and was discharged on January 16, 2018. There was no aftercare plan documented in the client record.Client #5 was admitted on April 10, 2018 and was discharged on May 6, 2018. There was no follow-up information documented in the client record as of the date of the inspection.Client #6 was admitted on December 29, 2017 and was discharged on February 28, 2018. There was no aftercare plan documented in a the client record. Additionally, there was no follow-up information documented in the client record as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of the inspection date, the Project Director reviewed and began to ensure that all active Clients had timely Records of Service and Progress notes completed, especially for clients scheduled to be satisfactorily discharged.
As of November 3rd, all Progress notes and the Record of Service were completed for Client #1, who was satisfactorily discharged and signed an Aftercare Plan.
As of November 10th, all Progress notes and the Record of Service were completed for Client #2, who was satisfactorily discharged and signed an Aftercare Plan.
As of November 6th, all Progress notes and the Record of Service were completed for Client #3, who was satisfactorily discharged and signed an Aftercare Plan.
It is MCCS policy that prior to discharge a written aftercare plan shall be developed between all clients satisfactorily discharged and the primary counselor that includes the required DDAP standards such as referral to appropriate agencies in the client's community for additional individual, family, educational or vocational counseling or medical services as necessary and encouraged to continue involvement with A.A., N.A. and/or any other provider if necessary, etc. While Client #4 did sign an Aftercare Plan, a copy of it was not in the Chart. In the future, The Project Director will be responsible for reviewing all satisfactory discharges to ensure that copies of Aftercare plans are properly executed and documented in Chart.
It is the policy of MCCS to conduct follow-up services with clients who have been discharged or referred from the program to other service providers regarding the Client's progress since discharge, Problem areas with which the client may need help and the development of strategies for resolving these problems and assurance to the client that the program stands ready to render services at any time they may be needed.
On November 10th, 2018 MCCS established a system where Follow-up letters to clients will be maintained in a in a tickler file and will be mailed out at the appropriate times. Returned forms will be forwarded to the primary counselor and then filed in the client's file. In the future, It will be the sole responsibility of the Project Director or his designee to document on the appropriate form follow-up contacts and make them part of the client's record. Regarding Client #5, phone contact was made but not documented in chart. The Project Director updated the Chart on November 10th, 2018.
Regarding Client #6, who is well known to the Project Director, the Client had signed an Aftercare Plan that had not been copied and filed in Chart. Two follow-up calls were made to client who is doing well. The Project Director made the appropriate annotations to Client Chart indicating same on November 7th, 2018.
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