INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on October 24, 2019 through October 25, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Alliance Medical Services 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:
|
Plan of Correction
|
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on the review of eleven personnel records during an on-site licensing inspection on October 24-25, 2019, it was determined that the project failed to provide close supervision for the first 6 months, to a counselor assistant with a bachelor's degree.
Employee # 10 was hired as a counselor assistant on June 24, 2019 and was a current employee at the time of the inspection. Per the regulation, employee #10 was to be under close supervision, including one hour of direct observation per week for the first 6 months of employment. Direct observation of employee #10 ended on September 24, 2019. No direct observation was documented for the week of September 30- October 6, 2019, October 7-13, 2019 or October 14-20, 2019.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
ED reviewed with Clinical Supervisors that all counselor assistants must have documented observed sessions in our supervisions that we are currently completing weekly for the first six months. ED will review supervision files/notes monthly to ensure compliance. |
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.
|
Observations
Based on the review of eleven personnel records during an on-site licensing inspection on October 24-25, 2019, it was determined that one employee failed to complete the training requirements for counselors.
Employee #6 was hired on June 10, 2010 and was a current employee at the time of the inspection. Due to the employee being in the position of a counselor, 25 clock hours of training is required annually. This employee only completed 23.5 training hours for the 2018 training year.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
ED has ensured all clinical staff have been assigned enough clinical hours for 2019 due to an error in 2018. ED will monitor training hours completed monthly. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on the review of client records, it was determined that the project failed to obtain an informed and voluntary consent from clients that included documentation of the specific information to be disclosed in nine client records reviewed during an onsite annual renewal inspection on October 24-25, 2019.
Client #2 was admitted on June 10, 2019 and was a current client at the time of the inspection. An informed and voluntary consent dated June 10, 2019 did not document what specific information was to be disclosed.
Client #3 was admitted on April 8, 2019 and was a current client at the time of the inspection. An informed and voluntary consent dated April 8, 2019 did not document what specific information was to be disclosed.
Client # 4 was admitted on July 15, 2019 and discharged on September 11, 2019. An informed and voluntary consent dated July 15, 2019 did not document what specific information was to be disclosed.
Client # 8 was admitted on July 16, 2019 and was a current client at the time of the inspection. An informed and voluntary consent dated July 16, 2019 did not document what specific information was to be disclosed.
Client #11 was admitted on October 16, 2018 and discharged on August 1, 2019. An informed and voluntary consent dated 22, 2019 did not document what specific information was to be disclosed to another treatment facility. Additionally, an informed and voluntary consent dated July 22, 2019 did not document what specific information was to be disclosed.
Client # 12 was admitted on September 27, 2019 and was a current client at the time of the inspection. An informed and voluntary consent dated September 27, 2019 did not document what specific information was to be disclosed to another treatment facility. Additionally, an informed and voluntary consent dated on September 27, 2019 did not document what specific information was to be disclosed.
Client #14 was admitted on June 18, 2019 and was a current client at the time of the inspection. An informed and voluntary consent dated June 18, 2019 did not document what specific information was to be disclosed.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Client releases have the 5 pt criteria in them when print view options are selected. ED and Clinical supervisors reviewed releases with staff during staff meeting on 11-7-19. Clinical supervisors will create training tool for new hires and staff by 11-29-19. This will be checked weekly during chart audits by supervisors. |
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
|
Observations
Based on the review of the narcotic treatment physician's timesheets during an onsite licensure renewal inspection on October 24-25, 2019, it was determined that the program failed to ensure that a narcotic treatment physician provide services at least 1 hour per week onsite for every ten patients.
The census for the week of August 12, 2019 through August 19, 2019 was 538; therefore, the number of narcotic treatment physician hours required to meet regulation standards would be 53.8. The narcotic treatment physician only provided onsite services for 18-hours.
The census for the week of August 20, 2019 through August 26, 2019 was 540; therefore, the number of narcotic treatment physician hours required to meet regulation standards would be 54. The narcotic treatment physician only provided onsite services for 18-hours.
The census for the week of August 25, 2019 through September 1, 2019 was 535; therefore, the number of narcotic treatment physician hours required to meet regulation standards would be 53.5. The narcotic treatment physician only provided onsite services for 6-hours.
The census for the week of September 2, 2019 through September 8, 2019 was 534; therefore, the number of narcotic treatment physician hours required to meet regulation standards would be 53.4. The narcotic treatment physician only provided onsite services for 6-hours.
The census for the week of September 9, 2019 through September 15, 2019 was 527; therefore, the number of narcotic treatment physician hours required to meet regulation standards would be 52.7. The narcotic treatment physician only provided onsite services for 18-hours.
The census for the week of September 16, 2019 through September 22, 2019 was 528; therefore, the number of narcotic treatment physician hours required to meet regulation standards would be 52.8. The narcotic treatment physician only provided onsite services for 24-hours.
The census for the week of September 23, 2019 through September 29, 2019 was 527; therefore, the number of narcotic treatment physician hours required to meet regulation standards would be 52.7. The narcotic treatment physician only provided onsite services for 18-hours.
The census for the week of September 30, 2019 through October 6, 2019 was 527; therefore, the number of narcotic treatment physician hours required to meet regulation standards would be 52.7. The narcotic treatment physician only provided onsite services for 18-hours.
These findings were reviewed with the program during the licensing process.
|
Plan of Correction
Full-time PA has been hired. DOC has increased his availability to MMT each week starting 11-7-19. Temp agency for DOC hours has been established for the need of any gaps in DOC needs vs census. ED will monitor census vs hours needed weekly. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
|
Observations
Based on the review of twenty-one patient records during an on-site licensing inspection on October 24-25, 2019, it was determined that the program failed to obtain informed, voluntary and written consent before one patient was administered an agent for maintenance treatment.
Patient #12 was admitted on September 27, 2019 and was a current patient at the time of the inspection. There was no documentation that the program obtained informed, voluntary, written consent before the patient received the initial dose of methadone on September 30, 2019.
These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
ED reviewed with medical team and doctor on 11-15-19. The importance of ensuring all intake documents are completed on day of intake. ED added the consent on our intake flow sheet to ensure intake compliance. This will be checked on the flow sheet during intake days to ensure compliance by supervisors. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
|
Observations
Based on the review of twenty-one patient records during an on-site licensing inspection on October 24-25, 2019, it was determined that the program failed to complete an annual physical examination on one patient.
Patient # 18 was admitted on September 21, 2018 and was a current patient at the time of the inspection. The most recent annual physical examination was due no later than September 21, 2019; however, it was not documented as of the date of the inspection.
These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
ED reviewed the importance of documentation being completed by the due date. Counselors starting 11-12-19 must bring their services due list to supervisors daily to ensure compliance for the week. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
|
Observations
Based on the review of twenty-one patient records during an on-site licensing inspection on October 24-25, 2019, it was determined that the program failed to review, reevaluate, modify and update two patients' treatment plans as required by Chapter 157, 709 and 711.
Patient # 16 was admitted on August 17, 2018 and was a current patient at the time of the inspection. A treatment plan update occurred on December 19, 2018 and the next update was due no later than February 19, 2019; however, the next update was dated on March 4, 2019. Additionally, after the March 4, 2019 update, the next treatment plan update was due no later than May 4, 2019; however, the next treatment plan update was dated June 4, 2019.
Patient #21 was admitted on July 3, 2018 and was discharged on March 8, 2019. A treatment plan update occurred on August 31, 2018 and the next update was due no later than October 31, 2018; however, the next update was dated November 2, 2018.
These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
ED reviewed the importance of documentation being completed by the due date at staff meeting 11-7-19. Counselors started 11-12-19 that they must bring their services due list to supervisors daily to ensure compliance for the week. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on the review of twenty-one patient records during an on-site licensing inspection on October 24-25, 2019, the facility failed to document follow-up information in five of the twenty-one client records reviewed.
Client #4 was admitted on July 15, 2019 and discharged on September 11, 2019. There was no documentation of follow-up information in the client's record at the time of the licensing inspection.
Client # 5 was admitted on July 30, 2018 and discharged on May 31, 2019. There was no documentation of follow-up information in the client's record at the time of the licensing inspection.
Client #6 was admitted on August 19, 2019 and discharged on October 7, 2019. There was no documentation of follow-up information in the client's record at the time of the licensing inspection.
Client # 7 was admitted on April 15, 2019 and discharged on September 30, 2019. There was no documentation of follow-up information in the client's record at the time of the licensing inspection.
Client # 11 was admitted on October 16, 2018 and discharged on August 1, 2019. There was no documentation of follow-up information in the client's record at the time of the licensing inspection
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
ED reviewed the importance of documentation being completed by the due date at staff meeting 11-7-19. Counselors started 11-12-19 that they must bring their services due list to supervisors daily to ensure compliance for the week. |