INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 20, 2016 and October 21, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, ARS of Pennsylvania LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of eight records reviewed.Thirteen personnel records were reviewed on October 21, 2016, eight of which were identified as counselors. Employee #13 was hired as a counselor on 9/27/16. A review of the employee ' s resume indicated that she did not have the required two years of clinical experience needed for the counselor position. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will review all applicants to determine the appropriate qualifications are met.
Prior to sending applicant's resumes to HR for phone screens, Executive Director will review these resumes and will determine if candidates are meeting the group of qualifications for the position.
The Executive Director will ensure that all staff have an annual training plan, appropriate level of supervision and appropriate case load based on their credentials and experience, in accordance with state regulations.
The part time Counselor that was noted by the reviewers as not having the required two years of clinical experience needed for the counselor position has since left the company. Moving forward, new hires are being classified appropriately.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The fire drill record log was reviewed on October 20, 2016. The log was reviewed for the period of August 2015-August 2016. There was no documentation that a fire drill was conducted in April 2016. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director along with the safety officer will ensure that fire drills and other emergency drills are conducted on a monthly basis. These drills will be documented and stored in the safety binder in the Executive Director's office. This documentation will include a list of participants of each drill. Any notes following each drill will be communicated with staff during staff meetings.
One fire drill and one other emergency drill (bomb threat drill) have been conducted since the time of the review and both are documented.
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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
Twelve client records were reviewed on October 20 and 21, 2016. The facility failed to obtain an informed and voluntary consent in one of twelve client records reviewed. Additionally the facility exceeded 4 PA. Code in client record #3. 4 Pa. Code states:Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.(1) Whether the client is or is not in treatment.(2) Client's prognosis.(3) The nature of the project.(4) A brief description of the client's progress.(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.Client #3 was admitted March 9, 2016 and was still an active client at the time of the inspection. The consent to release information form to a prison exceeded 4 PA. Code by allowing the following information to be released: lab test results, discharge summary, urine drug screens, dosing history and the transitional care plan. Documentation in client record #3 indicated that the facility released information to the prison that exceeded 4 PA. Code on 8/10/16. Specifically, the date and milligram of the last dose. Client #11 was admitted into treatment on February 17, 2016 and discharged on July 24, 2016. The client record contained documentation indicating that the facility released patient identifying information to a treatment provider and failed to obtain an informed and voluntary consent. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On October 25, 2016, Executive Director met with primary counselor to review restrictions on code 255.5 / PA. Code. Primary Counselor met with Client #3 and updated the releases of information for the prison.
The Executive Director, the Director of Operations and the Compliance Officer met on November 18, 2016, to review consent and confidentiality processes.
The Executive Director and Clinical Supervisor will provide additional training to all staff on confidentiality and release of information in accordance with state and federal regulations and ARS Policy.
The Executive Director or Clinical Supervisor will review consents and information to be released prior to any information being provided to an external entity. In addition, a copy of the consent and the information being released will be sent to ARS' Corporate Compliance Officer for final review and approval prior to release. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of patient records, the facility failed to ensure that random urine drug screens were completed at least monthly in one of twelve patient records. Patient #3 was admitted on March 9, 2016 and was still an active client at the time of the inspection. Patient record #3 was missing a urine drug screen for September 2016. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Lead nurse will begin using Methasoft to monitor and track UDS to ensure that all patients are meeting the requirements of having at least one UDS prior to admission and each month throughout the course of treatment. The Lead nurse will provide the Executive Director with monthly reports confirming UDS were completed in accordance with State and Federal regulations |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in one of twelve records reviewed. Patient #2 was admitted on June 29, 2016 and was still an active client at the time of the inspection. The facility documented that patient #2 had not attended group sessions after the 8/17/16 session and missed an individual session scheduled for 10/19/16. The facility documented in progress notes that the patient did not show for counseling sessions but did not document any effort to engage the patient or do a behavioral contract even though the patient had been dosing daily at the facility. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The office manager will prepare daily reports identifying which patients did not attend group sessions, individual sessions, and/or receive daily medications. The Office Manager will send the daily reports to the Executive Director, Clinical Supervisor, and all counselors daily for follow up. The Clinical Supervisor will review these reports and address any deficits during regular supervision.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of twelve patient records on October 20 and 21, 2016, the narcotic treatment program failed to document that it notified the transferring narcotic treatment program of the admission of the patient and the initial dose given in one of one records, as required. Patient #2 was admitted on June 29, 2016 and was still an active patient at the time of the inspection. There was no documentation in patient record #2 that the narcotic treatment program notified the transferring narcotic treatment program of the patient ' s admission and initial dose. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All patients transferring to ARS from another narcotic treatment program, who are determined to be appropriate for continued maintenance, detoxification or another treatment modality, will be required to complete the Transfer Acknowledgement Form. ARS Staff who complete the Transfer Acknowledgement Form will send the form to the transferring narcotic treatment program via fax within 24 hours from admission.
In addition, medical staff will verify last dose and will document information received from the transferring program in a medical note in Methasoft.
Lastly, Clinical Supervisor will review all admission charts to ensure follow up was successful.
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