INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 18, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ARS of Pennsylvania 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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704.7(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 a review of seven personnel records, it was discovered that that one employee had the required clinical experience to qualify as a counselor.Employee #5 was hired as a counselor on June 29, 2020 and was still current in that position. Employee #5 had a bachelor ' s degree in Human Services but did not have the one year of clinical experience. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director reviewed this regulation with DDAP auditor to ensure thorough understanding of what qualifies as clinical/counseling experience versus case management experience. Effective immediately when reviewing resumes for an open clinical position, the Executive Director will differentiate between clinical/counseling and case management experience. Executive Director will ensure all future candidates have the appropriate required credentials and level of experience meeting regulation 704.7(b)
The Employee #5 that was cited in this area is no longer employed with the company.. |
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 seven personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.Employee #5 was hired as a counselor on June 29, 2020 and was current in that position at the time of the inspection. Employee #5 was due to have the communicable disease trainings no later than June 29, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Employee #5 that was cited in this area is no longer employed with the company.
The Executive Director will be responsible for reviewing all clinical staff training compliance monthly. The Executive Director will review the training requirements and training plan with dates with all staff upon hire.
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
The Staffing Requirements Facility Summary Report was completed and reviewed on October 18, 2021. Employee #6 was hired as a counselor on May 26, 2021 and was still acting in that position. Employee #6 was reported to have 40 hours per week devoted to their 45 clients on their caseload.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by 40. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.The FTE counselor ' s caseload calculation is as follows: 40/40= 1(FTE); 45/1= 45/1, which equals to a client/counselor ratio of 45:1.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will review all counselor's caseloads in weekly supervisions to determine counselor to patient ratios. Clinical supervisor will identify the number of patients with exempt status versus non-exempt status in order to ensure that counselor to patient ratio is remaining within the 1:35 ratio that is required. Caseloads will be adjusted as needed based on incoming admissions and patients moving to exempt status. |
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
Based on a review of fire drills from September 2020 thru September 2021, the facility failed to ensure that the fire drill log included exit routes used and whether the fire alarm or smoke detector was operative for the fire drills for September 2021, August 2021 and July 2021. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Fire/Emergency drill log was updated on 11/3/2021 to include check boxes identifying whether the fire alarm was sounded, and a line was added to identify which exits were used during the drill. This log was disseminated to all PA locations for immediate implementation. Health and safety officer is responsible for filling out this form each month during emergency/fire drills. Executive Director reviews the form each month to ensure completion and review the findings of the drill(s). |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drills from September 2020 thru September 2021, the facility failed to document if the facility set off a fire alarm or smoke detector during each fire drill.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Fire/Emergency drill log was updated on 11/3/2021 to include check boxes identifying whether the fire alarm was sounded, and a line was added to identify which exits were used during the drill. This log was disseminated to all PA locations for immediate implementation. Health and safety officer is responsible for filling out this form each month during emergency/fire drills. Executive Director reviews the form each month to ensure completion and review the findings of the drill(s). |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of the physician timesheets for the months of June, July, August and September 2021, the facility failed to provide at least one hour of physician time a week, on site for every ten patients during the month of June 2021.During the week of June 13-19th, 2021, the patient census was 262. The facility was required to provide at least 26.2 physician hours. There were only eight physician hours documented. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To address the deficiency with Physician hours the Executive Director will be responsible to complete supervision with the Physician to review onsite hours requirement by 12/3/2021. Moving forward The Executive Director and Physician will develop a calendar schedule to review weekly to ensure proper on-site hour compared to census are completed. Executive Director will ensure appropriate coverage is identified for when the doctor and/or PA are on vacation in order to fulfill all required hours. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of the physician timesheets for the months of June, July, August and September 2021, the facility failed to ensure that one-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. During the week of June 13-19, 2021, the patient census was 262. The facility was required to provide at least 26.2 physician hours with at least 8.7 hours provided by a narcotic treatment physician. The facility only provided 8 hours. During the week of July 18-24, 2021, the patient census was 270. The facility was required to provide at least 27 physician hours with at least 9 hours provided by a narcotic treatment physician. The facility only provided 8 hours. During the week of August 1-7, 2021, the patient census was 262. The facility was required to provide at least 26.2 physician hours with at least 8.7 hours provided by a narcotic treatment physician. The facility only provided 8 hours. During the week of September 12-18, 2021, the patient census was 257. The facility was required to provide at least 25.7 physician hours with at least 8.5 hours provided by a narcotic treatment physician. The facility only provided 8 hours. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To address the deficiency with Physician hours the Executive Director will be responsible to complete supervision with the Physician to review onsite hours requirement by 12/3/2021. Moving forward The Executive Director and Physician will develop a calendar schedule to review weekly to ensure proper on-site hour compared to census are completed. Executive Director will ensure appropriate coverage is identified for when the doctor and/or PA are on vacation in order to fulfill all required hours. |