INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on February 17-18, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Coatesville Treatment Center, 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
Based on the administrative review of the staffing requirements facility summary report, the facility failed to have one clinical supervisor for every eight full-time equivalent (FTE)counselors or counselor assistants, or both.The findings include:The staffing requirements facility summary report was reviewed on February 17-18, 2016. A final review took place on February 22, 2016. The facility failed to employ a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both. There are currently 13 full and part time counselors employed. Employee #3 is a clinical supervisor with a current caseload of 6 patients. Because employee is serving in the capacity of a clinician employee #3 will not be considered a full-time clinical supervisor. Employee #7 is a clinical supervisor with a current caseload of 6 patients. Because employee is serving in the capacity of a clinician employee #7 will not be considered a full-time clinical supervisor. These findings were reviewed with facility staff after the licensing process.
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Plan of Correction
The Clinical Supervisors (Employee 3 and 7) caseloads will be reduced to five patients and placed on the caseload of other Counselors that have the capacity to increase their caseload based on the new regulation. The patients that will be removed from both caseloads have been in treatment for over 3 years and are in a higher phase of recovery. These patients are only required to meet for individual Counseling 6x per year based on the regulation. Clinical Supervisor will reduce the caseload to five patients each in the system on 3/26/2016.
If our census continues to increase, Clinic Director will follow the new hiring process and submit for approval to the Regional Director to hire another Counselor and reduce the number of patients being carried by the Clinical Supervisors and Counselors as needed. Once approved, The Recruiting team will advertise for the position. Clinical Supervisors will continue to be responsible for monitoring caseloads to ensure it meets the new regulation requirement. Clinical Supervisor will continue to assign patients to caseloads.
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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 and training records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in one of eleven applicable records reviewedThe findings include:Eleven personnel records which required documentation of mandatory communicable disease training were reviewed on February 17-18, 2016. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee #11. Employee #11 was hired on February 22, 2011 as a part-time Front Office Assistant. This employee was required to obtain six hours of HIV/AIDS and 4 hours of TB/STD training by February 22, 2013. Employee #11 failed to obtain the training as of the date of the inspection. These findings were reviewed with facility staff during the licensing process.This is a repeat citation.The facility was previously cited for noncompliance of this standard during the March 11-12, 2015 licensing inspection. The facility's plan of correction approved on April 22, 2015 stated that the Clinic Director would ensure that this employee would be registered for training by 7/31/2015.
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Plan of Correction
Employee #11 will be registered to attend the HIV/AIDS Training in Bucks County on April 29th. Employee #11 will be registered for TB/STD Training in Philadelphia on Friday, May 20th.
Clinic Director, going forward, will ensure that all employees, part-time and full-time will be scheduled for HIV/AIDS and TB/STD within the first year of employment. Clinic Director will locate HIV/AIDS training through the approved training list provided by the County and State. Clinic Director will ensure that all new staff are register for the training as apart of their oerientation process. Direct supervisors will be responsible for tracking the trainings for their direct reports on a monthly basis to ensure all required trainings are meet by end of their first year of employment. |
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
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of eleven personnel records reviewed.The findings included:Eleven personnel records were reviewed on February 17-18, 2016. Six counselor records were reviewed for 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in one of six counselor personnel records.Employee # 8 was hired on March 31, 2014. The facility training year is from January through December. The training year for January to December 2015 was reviewed. Employee # 8 only completed 22.0 clock hours of annual training for 2015.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #8 completed 21 hours based on a miscalculation of her hours. Going forward to ensure all 25 hours are completed on time by all members of the Clinical Staff, Clinical Supervisors will do a month audit to track all training hours for their direct reports. There will be an additional audit on 12/15 to ensure all hours have been met. If the hours have not been met, staff will be required to complete online approved trainings by DDAP including those offered by the PCB Board (Pennsylvania Certification Board). |
715.9(b)(2) LICENSURE Intake
(b) Exceptions to the requirements in subsection (a) are:
(2) Upon readmitting a patient who has been out of a narcotic treatment program for 6 months or less after a voluntary termination, the narcotic treatment program shall update the information in and review the patient 's file to show current opiate narcotic dependency, but need not conduct a physical examination and applicable laboratory tests. Privileges earned during the previous treatment may be reinstated at the discretion of the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to verify the individual's identity, including name, address, and date of birth, and other identifying data in one of six records reviewed.The findings include:Six narcotic treatment patient records were reviewed on February 17-18, 2016, to ensure the facility screened individuals prior to administration of an agent. The facility failed to verify the individual's identity, including name, address, date of birth, and other identifying data prior to administration of an agent in record #5.Patient #5 was admitted to the program on July 4, 2008 and was an active patient at the time of the inspection. The facility failed to provide documentation that patient #5 had been screened prior to administration of an agent.The findings were reviewed with facility staff during the monitoring inspection.This is a repeat citation.The facility was previously cited for noncompliance of this standard during the March 17-18, 2015 licensing inspection. The facility's plan of correction was submitted on April 13, 2015 and approved on April 30, 2015
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Plan of Correction
Due to some technical issues with our patient system, some patient pictures were deleted. The Front Office has went through each patient in the Tower system and documented which photos were missing. New photos were taken and uploaded to the system. Each six months, the Front Office staff will be responsible for taking new photos and uploading them to the system as well as taking a copy of the picture ID and place them in the patient file. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on the review of patient records and discussion with staff, the facility failed to demonstrate that patient photographs are updated every three years. The findings include:Dosing was observed on February 18, 2016 at approximately 9:00 am. The dosing system, Tower, includes a photograph of each active patient. There was no date of when the photo was taken or an expiration date. Patient #5 was admitted August 7, 2008 and the patient record did not contain an identification photo. When asked, staff confirmed that the narcotic treatment program does not maintain onsite an updated photograph taken every 3 years of each patient in treatment.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to some technical issues with our patient system, some patient pictures were deleted. The Front Office has went through each patient in the Tower system and documented which photos were missing. New photos were taken and uploaded to the system. Each six months, the Front Office staff will be responsible for taking new photos and uploading them to the system as well as taking a copy of the picture ID and place them in the patient file. There is not a place on the system to specific track when the photo was taken. Front Office will add to the note section of the Identification Page of when the photo was taken starting 3/31/2016. |
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 a timely treatment plan update in two of eight client records. The findings include: Twelve client records were reviewed on February 17-18, 2016. Eight client records were required to have a treatment plan update. The facility failed to document a treatment plan update in client records #2 and 11.Client #2 was admitted on July 13, 2014. A treatment plan update was due by May 24, 2015 and was completed June 11, 2015. The next treatment plan update was due August 11, 2015 and was completed November 17, 2015. A treatment plan updated was not documented for January 2016.Client #11 was admitted on October 1, 2015. The comprehensive treatment plan was completed on October 22, 2015. The treatment plan update was due December 22, 2015 and was completed on January 18, 2016. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There were four staff that were terminated/resigned between April - August of 2015. New staff were hired between August and November.
Starting 3/28/2016, when staff resign/terminate, Clinical Supervisors will audit each record to access paperwork that is needed, place a note to explain the gaps, then assign the patient to another Counselor to meet with the client within 30 days of the resignation/termination and complete all needed paperwork.
Clinical Supervisors will also doing a training on treatment planning on 03/28/2016.
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