INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25, 2017 through July 26, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation, Inc. 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(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
Ten personnel records were reviewed on July 25, 2017 through July 26, 2017. Nine personnel records were required to have documentation of HIV/AIDS and tuberculosis, sexually transmitted disease (TB/STD) training. The facility did not provide documentation of the HIV/AIDS and TB/STD trainings within the required time frame in six of nine personnel records reviewed.
Employee #4, a counselor, was hired on August 17, 2015. HIV/AIDS and TB/STD trainings were to be completed within one year of hire, by August 17, 2016. The personnel record contained no documentation of HIV/AIDS or TB/STD training.
Employee #5, a counselor, was hired on May 15, 2016. HIV/AIDS and TB/STD trainings were to be completed within one year of hire, by May 15, 2017. The personnel record contained no documentation of HIV/AIDS or TB/STD training.
Employee #6, a counselor, was hired on June 6, 2016. HIV/AIDS and TB/STD trainings were to be completed within one year of hire, by June 6, 2017. The personnel record contained no documentation of HIV/AIDS or TB/STD training.
Employee #7, a counselor, was hired on January 6, 2016. TB/STD training was to be completed within one year of hire, by January 6, 2017. The personnel record contained no documentation of TB/STD training.
Employee #9, a counselor, was hired on July 5, 2016. HIV/AIDS and TB/STD trainings were to be completed within one year of hire, by July 5, 2017. The personnel record contained no documentation of HIV/AIDS or TB/STD training.
Employee #10, a counselor, was hired on November 11, 2015. HIV/AIDS and TB/STD trainings were to be completed within one year of hire, by November 11, 2016. The personnel record contained no documentation of HIV/AIDS or TB/STD training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All of the staff that have not had the required trainings are registered for DDAP sponsored trainings. The trainings are scheduled for September 6th, October 3rd, and October 19th. The Program Director will ensure that all staff attend and complete the trainings. In the unforeseen event that an individual is not able to attend the scheduled training the Program Director will register them for the next available training.
As a longer term strategy the provider is starting the process of being able to offer the training in-house. A draft curriculum will be sent to DDAP for review and approval by October 31, 2017. |
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
Fifteen client records were reviewed from July 25, 2017 through July 26, 2017. The facility failed to obtain a consent to release information form in two of fifteen records reviewed. Additionally the facility exceeded 4 PA. Code in client record #1.
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 #1 was admitted into the outpatient drug free activity on April 13, 2017 and was still an active client at the time of the inspection. The client record contained a consent to release information form to a government agency, dated April 12, 2017 which allowed the following information to be released: precense in treatment, prognosis, nature of the project, progress and relapse. Documentation in client record #1 indicated that the facility released infromation that exceeded 4 PA. Code on May 16, 2017 by releasing the names and dosages of the clients prescribed medications.
Client #2 was admitted into the outpatient maintenance activity on March 7, 2017 and was still an active client at the time of the inspection. The client record contained documentation indicating that the facility released patient identifying information to an agency on March 1, 2017 and a labratory on March 2, 2017. The facility failed to obtain an informed and voluntary consent prior to the disclosures.
Client #5 was admitted into the outpatient drug free activity on December 23, 2016 and discharged on May 20, 2017. The client record contained documentation indicating that the facility released patient identifying information to an agency on November 7, 2016 and failed to obtain an informed and voluntary consent prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff training on confidentiality and 4 PA Code occurs annually. The Executive Director will schedule the next training to occur within 90 days. Program Directors will reinforce confidentiality requirements and protocol in group and individual supervision during the months of August and September and thereafter on a not less than bi-monthly basis.
In addition to the above, the Provider has a clinical chart auditing process whereby two charts per clinician are audited each month. The adherence to confidentiality regulations and the release of information are part of the chart audits. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Fifteen client records were reviewed for client rights on July 25, 2017 through July 26, 2017. The facility failed to include on the facility's Ackowledgement of Rights form the following verbiage: creed, color, national origin, marital status, handicap and religion.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Pharmaco Program Director has added the following verbiage: creed, color, national origin, marital status, handicap and religion, to the Acknowledgement of Rights form as of August 7, 2017.
The Pharmaco Program Director has informed all staff to discard the old form and to only use the new form. The use of the new form will be monitored by the Program Director during supervision and checked by the assessor during chart audits. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of unusual incidents, the facility failed to notify DDAP within 3 business days of the unusual incident.
Unusual incident reports were reviewed on July 25, 2017 through July 26, 2017. Three unusual incident reports dated October 11, 2016, May 2, 2017 and June 20, 2017 showed events occurred at the facility that required the presence of fire personnel.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Training on the reporting of Unusual Incidents takes place on a not less than annual basis. The executive director will arrange for the next training to be held within 90 days. In addition the executive director will reinforce the need to submit the unusual incident reports to DDAP within 3 business days and will highlight the importance of preparing and submitting the reports when the presence of fire personnel is required. This will be done at the August 9, 2017 staff meeting. The the matter will be reinforced by program directors in group and individual supervision on a not less than quarterly basis. In addition, the Office Manager will audit the unusual incident binder on a weekly basis to ensure the all applicable reports have been sent the Commonwealth. Finally, the missing reports were faxed to DDAP on August 18, 2017. |
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 a review of physician ' s hours, the facility failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients in two of three weeks reviewed.
During the week of March 12-18, 2017, the facility reported a census of 291. The facility was required to provide at least 29.1 physician hours. There was 10.25 physician hours documented. The amount of physician hours documented is less than the amount of hours required.
During the week of March 19-25, 2017, the facility reported a census of 289. The facility was required to provide at least 28.9 physician hours. There was 10.92 physician hours documented. The amount of physician hours documented is less than the amount of hours required.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency was the result of the medical director being on vacation. Several strategies are being pursued. First of all the Provider will be adding additional hours for the psychiatrist on a permanent basis, and in particular to ensure coverage to meet the regulatory requirement during the medical director's time off. In addition, the Provider is in the process of adding a part-time doctor to the staff to assist with patient census growth and to provide coverage during time-off. It is the goal of the Provider to have additional coverage in place by September 15, 2017. |
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 seven patient records.
Patient #8 was admitted on August 8, 2016 and was discharged on March 6, 2017. Patient #8 was identified as receiving buprenorphine as part of their treatment. Patient record #8 was missing urine drug screens for January 2017 and February 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will reinforce the requirement of UDS on at least monthly in group and individual supervision during the month of August, 2017. In addition, in monthly Suboxone meetings with staff and the medical director, a form has been created to identify the date of the last UDS and the deadline for the next UDS. This information will be checked separately during the chart audit process. Finally, the Executive Director will ensure compliance in monthly supervision with the responsible Program Director. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of the patient records, the facility failed to document the signature of the medical director on the annual evaluation in one of two records reviewed.
Five patient records were reviewed on July 25, 2017 through July 26, 2017. Two of the five patient records are required to include an annual evaluation. One of the two records failed to include the medical directors signature on the annual evaluation.
Patient #4 was admitted to treatment on June 11, 2014. The annual evaluation was completed on June 2, 2017. The evaluation was signed by the counselor, but was not reviewed, signed and dated by the medical director as required.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will reinforce in group and individual supervision during the month of August 2017 the requirement of having the medical director sign annual evaluation. The matter will also be reviewed in monthly clinical chart audits which are completed by an assessor and reviewed by the Director of Assessments. |