INITIAL COMMENTS
|
This report is a result of an onsite licensure renewal and methadone/buprenorphine monitoring inspection. The inspection was conducted on August 11-12, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Clear Choices, LLC 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 the inspection:
|
Plan of Correction
|
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.
|
Observations
The facility failed to ensure that each counselor met the qualifications for the position in one of two records.
The personnel records were reviewed on August 11, 2016. Two new counselors were hired in the last licensing year. Employee # 3 did not meet the qualifications for the position of counselor.
Employee #3 was hired on October 21, 2015 for the position of counselor. Employee #3 holds a Bachelors of Arts in Business Administration, which does not meet the educational requirements for the position of counselor.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director will obtain degree qualifications prior to offering employment and will compare the degree classification with the approved list of degrees to ensure that all hires are appropriately categorized as counselors or counselor assistants according to the regulations. Facility Director will refer not only to the regulations but also to the Alerts which added additional degree qualifications for the position of counselor. Facility Director will complete this prior to hire of each new employee and will make the information available for review during State Audits and as needed. Employee #3 will be moved to the position of Counselor Assistant until such time as they meet the qualifications for Counselor. All documentation related to obtaining the qualifications will be maintained on file for review as needed. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
The facility failed to document the completion of 12 clock hours of annual training required for project/facility directors in one of one personnel records.
The personnel records were reviewed on August 11, 2016. One personnel record pertained to the project/facility director. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the project/facility director since September 21, 2009. The facility training year is from January through December. Employee # 1 had documentation of 4.5 hours of training for the 2015 training year.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director will obtain and maintain appropriate training hours as required by regulation. Facility Director will document all trainings on Feed back form and will maintain documentation on site for review during Audits and as needed. Facility Director will monitor all training hours for all staff to ensure compliance through random checks of the Training Binder. |
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.
|
Observations
The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
The client records were reviewed on August 11-12, 2016. Two of the clients reviewed were receiving prescriptions for buprenorphine from the facility physician. The prescriptions were being faxed to the pharmacy and the prescription contains client identifying information. There were no consent to release information to the pharmacy in client records # 4 and 5.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director will hold in house training related to Consent and Releases by 9/30/16 to assist all staff in complete understanding of the regulations as related to Consent and will document this training for review as needed. All patients who will receive their medication at a pharmacy will be required to provide an appropriate release of information to this facility prior to any information being released to their pharmacy. All releases will be maintained on file for review. Facility Director will monitor staff obtaining appropriate releases through random chart audits and through peer review as needed. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
|
Observations
The facility failed to document verification that the individual has reached 18 years of age in two patient records.
Patient records were reviewed on August 11-12, 2016. Two of the patients reviewed were being prescibed buprenorphine by the facility physician and did not have any documention of age verification in their record.
Patient #4 was admitted on May 23, 2016 and was first given buprenorphine on May 23, 2016. There was no age verification in patient record #4.
Patient #5 was admitted on September 10, 2015 and was first given buprenorphine on September 10, 2015. There was no age verification in patient record #5.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director will provide an in house training related to verification of patient's identity including age and obtaining and maintaining documentation of that identity on file. All patient will be required to provide identification and proof of age prior to receiving medication to ensure that only individuals over the age of 18 are receiving medication. Facility Director will monitor compliance with this regulation through random chart audits and peer review as well. Training will be completed and documented by 9/30/16. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
|
Observations
The facility failed to document verification of the individual's identity, including name, address and date of birth in two patient records.
Patient records were reviewed on August 11-12, 2016. Two of the patients reviewed were being prescibed buprenorphine by the facility physician and did not have any documention of verification of their identity, including name, address and date of birth in their record.
Patient #4 was admitted on May 23, 2016 and was first given buprenorphine on May 23, 2016. There was no verification of identity, including name, address and date of birth in patient record #4.
Patient #5 was admitted on September 10, 2015 and was first given buprenorphine on September 10, 2015. There was no verification of identity, including name, address and date of birth in patient record #5.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director will provide an in house training related to verification of patient's identity including age and obtaining and maintaining documentation of that identity on file. All patient will be required to provide identification, proof of age and address prior to receiving medication to ensure that only individuals over the age of 18 are receiving medication. Facility Director will monitor compliance with this regulation through random chart audits and peer review as well. Training will be completed and documented by 9/30/16. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
|
Observations
The facility failed to physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22.
Patient dosing was observed by the Licensing Specialist on August 12, 2016. It was observed that when patients return their take home bottles, the bottles are thrown in the general trash with the patient identifying information still legible on the take home bottle.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director will provide training for staff related to Confidentiality and will maintain documentation of that training on site for review as needed. Each patient will be required to black out their identifying information on medication labels and staff will monitor to ensure that this occurs. Staff will complete this for patients who are unable to do so. Facility Director will monitor compliance with the regulation through random monitoring in the dispensary and through reporting from medical staff to clinical staff as needed to assist patients in maintaining confidentiality. |