INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on June 22, 2022 through June 23, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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
Based on a review of personnel records and the facility-submitted Staffing Requirement Facility Summary Report, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training within the regulatory time frame in one of three applicable personnel records reviewed.
Employee #7 was hired as a counselor on August 31, 2020. The HIV/AIDS training was due to be completed no later than August 31, 2021. However, the training was not completed as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The subject employee is scheduled to take the required HIV/AIDS training on July 14th and 15th. The Human Resources Director will verify that the training has been completed and obtain documentation of the same.
The HR Director maintains a spreadsheet of all employees and training requirements. Compliance is reinforced individually in supervision as well as by the CEO in monthly staff meetings. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a release of information form in one of seven client records reviewed.
Client #2 was admitted April 12, 2022 and was active at the time of inspection. The release of information form to the funding source did not include the dated signature of the client on the form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO reviewed the citation with the Clinical Director and Director of Assessments. The matter was also discussed at the management meeting of July 12, 2022. The Clinical Director will reinforce with all assessment and clinical staff the requirement to obtain written client signatures on all consent forms. If the intake and assessment is performed via telehealth, the forms will be provided to the therapist to present to the client at the next in-person session. If all of the treatment sessions are conducted via telehealth the client will be asked to make arrangements to visit the facility in-person to sign the forms, or print the emailed forms and sign and return them to Aldie. Compliance will be ensured via supervision and regular chart audits. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the facility ' s decision to involuntarily terminate the client ' s treatment at the project in one of one applicable client record reviewed.
Client #4 was admitted on April 2, 2019 and was administratively discharged on April 15, 2022.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The CEO reviewed the matter individually with the Clinical Director and at a management meeting held on July 12, 2022. Instructions were provided that in the event of an involuntary termination, the Clinical Director or her designee will prepare a letter notifying the client of the decision to terminate treatment and the reason for the decision. The letter will also state that the client can request reconsideration. If the request is made it will be presented to the treatment team for consideration. Compliance will be monitored by the Clinical Director in each instance of involuntary termination. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to give the client an opportunity to request reconsideration of a decision to terminate treatment in one of one applicable client record reviewed.
Client #4 was admitted on April 2, 2019 and was administratively discharged on April 15, 2022.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The CEO reviewed the matter individually with the Clinical Director and with the management team at a meeting held on July 12, 2022. Instruction was provided that in the written letter to the client notifying them of the decision to terminate treatment, the letter must also state that the client has the opportunity to request reconsideration. If the request is presented it will be reviewed by the treatment team. The Clinical Director will ensure that the opportunity for reconsideration is made in writing to each client where treatment has been terminated. |
715.21(2) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(2) A patient terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, shall be afforded the opportunity to receive detoxification of at least 7 days. The detoxification may take place at the facility or the patient may be referred to another narcotic treatment program or hospital licensed and approved by the Department for detoxification.
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Observations
Based on a review of patient records, the facility failed to provide an involuntarily terminated patient the opportunity to receive detoxification of at least 7 days at the facility or refer the patient to another facility for detoxification in one of one applicable patient record reviewed.
Patient #4 was admitted on April 2, 2019 and was involuntarily discharged on April 15, 2022. There was no documentation, in the record, that the patient was offered detox services of at least 7 days or that the patient was referred to another facility for detox services.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The CEO discussed the matter with the Clinical Director and the Chief Nursing Officer. The issue was also discussed at the management meeting of July 12, 2022. Instruction was provided that any involuntarily terminated client (except in instances of physical violence) must be provided with the opportunity to receive detox services for at least seven days. The Chief Nursing Officer will reinforce this requirement with nursing staff and the Clinical Director with clinical staff. The Clinical Director will ensure that compliance with maintained as part of daily program management. |
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.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in one of two applicable client records reviewed.
Client #5 was admitted June 22, 2021 and was discharged December 28, 2021.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The CEO reviewed the matter with the Clinical Director and the Assessment Director, as well as with the management team at a meeting held on July 12, 2022. A procedure was established whereby all discharged clients will be contacted via telephone within 30 days post-discharge. The contact will be made by one of the case management staff. The phone contact will be documented in the client record. If after three (3) failed attempts to contact by telephone, the case management staff will send a letter via regular mail. The assessment supervisor will ensure compliance as part of individual supervision and team meetings. |