INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19, 20, 23 and 24, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A.R.S. of Lancaster, LP 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 personnel records, the facility failed to verify that each counselor met the educational and experiential qualifications for the position.
The findings include:
Four personnel records requiring verification of educational and experiential qualifications were reviewed on September 19, 2013. The facility failed to verify the educational and experiential qualifications in one out of four records reviewed, record # 4.
Employee # 4 was hired on September 13, 2013 as a counselor. At the time of the inspection, the only documentation in employee #4's record was a degree from a foreign university and documentation that the employee obtained a Master's degree from that country. There was no verification that the completed degree met the requirements as outlined in the standard.
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Plan of Correction
The facility director and human resource will verify that each counselor meets the educational and experiential qualifications for the position, including being from an accredited college and approved major. This will be done prior to the commencement of employment. Compliance will be monitored through ongoing personnel record audits by the facility director.
Employee #4's record will be verified through the completion of a documentation to documentation evaluation through World Education Services. This has been submitted to WES and a response in pending. |
709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
Based on the review of personnel records, the facility failed to verify the employee's training experience and professional licensure or registration, where applicable.
The findings include:
Four personnel records were reviewed for verification of the employee's training experience and professional licensure. Employee # 4 received their degree from a foreign university.
The staffing regulations require that counselors have degrees from an accredited university or college. The United States is the only country which has an accreditation system, therefore, universities/colleges in other countries cannot be accredited unless they have a satellite site in the United States. The facility failed to determine if the foreign degree that employee # 4 received was equivalent to the United States accreditation system.
This finding was confirmed by the facility director.
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Plan of Correction
The facility director and human resource will verify that each counselor meets the educational and experiential qualifications for the position, including being from an accredited college and approved major. If the degree is not from an accredited college, the facility director will complete a credential evaluation through World Education Services. This will be done prior to the commencement of employment. Compliance will be monitored through ongoing personnel record audits by the facility director.
Employee #4's record has been submitted to the World Education Services for a documentation to documentation evaluation of her foreign degree to the United States accreditation system. The results are pending and should be sent to the facility within 7 days. |
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 patient records, the facility failed to inform the patient, in writing, of a decision to involuntarily terminate the patient's treatment in one of three patient records.
The findings include:
Twenty-eight patient records were reviewed on September 20, 23, and 24, 2013. Three records reviewed were discharged patient records that required written notification to the client informing him/her of the decision to terminate the patient's treatment. The facility failed to document notification to patient # 28. Patient # 28 was discharged from the program on April 4, 2013. The notification of termination was documented in the patient record on April 18, 2013. This was after the patient was discharged from the program.
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Plan of Correction
The Clinical Supervisor reviewed in Clinical Meeting the Involuntary Discharge policy on 9/30/13. Specifically, the clinical supervisor reviewed that a patient must be notified in writing of the decision to involuntarily terminate prior to the patient terminating. Patients are informed of involuntary discharges through an official involuntary discharge form that they sign. Continued compliance will be monitored by the facility director. |
715.17(a) LICENSURE Medication control
(a) A narcotic treatment program shall comply with applicable Federal and State statutes and regulations regarding the storing, compounding, administering and dispensing of medication.
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Observations
Based on the review of patient records, the facility failed to ensure the narcotic treatment physician complied with applicable Federal and State statues and regulations regarding the storing, compounding, administering and dispensing of medication. The findings include:
Twenty-eight patient records were reviewed on September 20, 23, and 24, 2013. Four records reviewed were receiving Suboxone services at the facility. Documentation in patient record #3 revealed the narcotic treatment physician wrote an order that allowed for the patient to cut a suboxone strip in half. The order read: 4 mg stat then 1/2 tab qhs 5/14/2013: 1.5 fil in am and 1/2 in p.m. thereafter two 4 mg. The suboxone packaging states that each strip is a dose. There are no score lines on the strip that allow for this medication to be cut into half doses.
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Plan of Correction
The Facility Director reviewed with the program physicians on September 23rd and 24th that the Suboxone package indicates that each strip is a dose and cannot be cut. Moving forward, the physicians will write prescriptions applicable with Federal and State regulations. Compliance will be monitored through random chart audits for the next six months by the DON. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of patient records, the facility failed to document the provision of treatment services consistent with the type and frequency specified in the treatment plan in ten of fifteen records reviewed.
The findings included;
Twenty-eight patient records were reviewed on September 20, 23, and 24, 2013. Fifteen records were reviewed for the assurance that counseling services were provided as according to the treatment and rehabilitation plan. Services were not documented as stated in the treatment plans in records # 1, 2, 6, 12, 13, 15, 17, 18 and 25.
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Plan of Correction
The counselors were trained by the clinical supervisor on 9/30/13 to place hard stops on patients the last two weeks of the month using the methasoft system to ensure all patients who are noncompliant with counseling hours are met with and complete their requirements for the month. All missed counseling appointments will be documented within the patient record.
To ensure compliance for the next 6 months, the clinical supervisor will review with each counselor monthly that each patient received the minimum 2.5 hours of psychotherapy per month for the first 2 years of treatment.
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709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on the review of patient record documentation, counseling services were not provided to a client on a regular and scheduled basis in ten of fifteen records reviewed.
The findings include:
Twenty-eight patient records were reviewed on September 20, 23, and 24, 2013. Fifteen records were reviewed for the assurance that counseling services were provided on a regular and scheduled basis.. Services were not provided on a regular and scheduled basis in records # 1, 2, 6, 12, 13, 15, 17, 18 and 25. Review of documentation in the patient records revealed that due to the loss of clinical staff some patients did not have their regular and scheduled individual counseling sessions.
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Plan of Correction
When the clinical staff is under staffed due to a loss of a counselor, the clinical supervisor will reassign that caseload to ensure that all patients have a counselor who is able to complete their monthly counseling requirements. The clinical supervisor will monitor these reassignments to ensure compliance. |