INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the July 10, 2012 licensure renewal inspection. The follow-up inspection was conducted on March 1, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Axiom Family Counseling 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.
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Plan of Correction
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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) 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 and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on the review of personnel records, the facility failed to document that the employee met the qualifications for the position of clinical supervisor in one of one personnel record.
The findings include:
Three personnel records were reviewed on March 1. 2013. One personnel record was reviewed for the position of clinical supervisor. The facility did not document the employee met the qualification for the position of clinical supervisor in personnel record # 2.
Employee # 2 was hired as the clinical supervisor on February 1, 2013. There was no documentation in the personnel record reviewed of the employee's qualification for the position of the clinical supervisor.
The Clinical Director was interviewed on March 1, 2013 and confirmed the findings.
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Plan of Correction
At the time of the site inspection, the personnel files was stored at the corporate location and were unavailable for inspection. All completed personnel files, detailing all education and experience, will be kept at treatment facility for review.
The project director and clinical director will ensure that all personnel records are kept on site at all times. Clinical Director and Project Director will be only staff members who will have access to locked filing cabinet with personnel records stored to ensure they remain onsite. |
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 the review of personnel records, the facility failed to document that the employee met the qualifications for the position of counselor in one of one personnel record.
The findings include:
Three personnel records were reviewed on March 1. 2013. One personnel record was reviewed for the position of counselor. The facility did not document the employee met the qualification for the position of counselor in personnel record # 3.
Employee # 3 was hired as a counselor in July, 2012. There was no documentation in the personnel record reviewed of the employee's qualification for the position of a counselor.
The Clinical Director was interviewed on March 1, 2013 and confirmed the findings.
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Plan of Correction
At the time of the site inspection, the personnel files was stored at the corporate location and were unavailable for inspection. All completed personnel files, detailing position necessary education and experience, will be kept at treatment facility for review.
The project director and clinical director will ensure that all personnel records are kept on site at all times. Clinical Director and Project Director will be only staff members who will have access to locked filing cabinet with personnel records stored to ensure they remain onsite.
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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
Compliance with this regulation could not be determined during the plan of correction follow up inspection. Compliance will be determined during the next scheduled inspection. The original deficiency is listed below:
Based on a review of personnel and training records, the facility failed to provide documentation of STD/TB training within one year of hire in one of one personnel records reviewed.
The findings include:
Two personnel records were reviewed on July 9-10, 2012. Per regulation, staff persons shall receive a minimum of four hours of TB/STD training and six hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first two years of employment.
Employee #1 was hired December 8, 2010 and was the sole employee at the facility, serving as the project/facility director and counselor until June 1, 2012. This employee was required to obtain four hours of TB/STD training by December 8, 2011. Employee # 1 completed the TB/STD training on May 1, 2012.
An interview with a facility representative / board member was conducted on July 10, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
The Project created an Employee Training Tracking Form to document the HIV and STD/TB trainings of each employee and ensure that each employee meets the requirement of completing HIV and STD/TB training within one year of hire.
The Clinical Director will complete and monitor the Employee Training Tracking Form to ensure that each employee meets the requirement of completing HIV and STD/TB training within one year of hire.
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the 2011 annual report, the governing body failed to make available to the public the 2011 annual report.
The findings include:
The 2011 annual report was reviewed on March 1, 2013. The facility is publicly funded and required to make available to the public an annual report. The 2011 fiscal year ended on December 31, 2011. The governing body failed to make the 2011 annual report available to the public, as required.
The Clinical Director was interviewed on March 1, 2013 and confirmed that the 2011 annual report had not been made available to the public as of March 1, 2013.
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Plan of Correction
Facility will publish newspaper supplement in local paper for 2011 and 2012 fiscal years stating that annual report can be requested and viewed at our treatment facility and is available for public to request and review.
A hard copy of activities and accomplishments of 2011 and 2012 will be available in the treatment facility, 2011 and 2012 statements of income and expenses and statement disclosing names of officers, directors, and principal shareholders.
In future, the CEO of Axiom who is responsible for the completion of all annual reports will contact local newspaper when report is completed to print ad stating that the annual report is available upon request. As part of ongoing quality assurance management, three months after fiscal year end, the clinical director will verify completion of report and printing of ad. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documents, the facility failed to complete an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The administrative documents were reviewed on March 1, 2013. The project's fiscal year is January - December. An annual audit of financial activities was due to be completed at the end of the project's fiscal year. There was no documentation of an annual audit for calendar year January 1, 2011 through to December 31, 2011.
An interview with the Clinical Director on March 1, 2013 confirmed that no annual audit for 2011 had been completed.
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Plan of Correction
A request for waiver of a financial audit was sent to the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Program Licensure in January 2012.
If the waiver is not approved, the facility will hire an independent public accountant to complete the annual audit of financial activities associated with the facility drug/alcohol abuse services once a response is generated from the Department.
In the future, the CEO and Project Manager will both ensure a timely audit is completed by scheduling an independent audit in January of each year following the close of the fiscal year. If the facility does not meet the criteria for an audit, the CEO and Project Manager will request waiver of audit in January each year.
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document an annual performance evaluation in one of one personnel records.
The findings include:
Three personnel records were reviewed on March 1, 2013. Two employees had not yet been employed for one year. One personnel record required the documentation of an annual evaluation. There was no annual performance evaluation documented in personnel record #1.
Employee #1 is the project/facility director and was hired on December 8, 2010. An annual performance evaluation was due to be completed by December 8, 2012. There was no performance evaluation documented for 2012 in personnel record #1.
An interview with the Clinical Director was conducted on March 1, 2013 at which time it was confirmed that no performance evaluation had been completed for employee #1.
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Plan of Correction
Annual performance reviews are tracked in personnel charts on the Employee Record Checklist. All employees will be reviewed one month before the anniversary of date of hire to assure that an annual performance evaluation is completed.
In regards to the inspection, the state representatives reviewed the employee record of the project manager. It was explained by the state inspection representatives that the Project Director needs an annual performance review completed by the Board of Directors or a self-review. The project director has completed a self-review for the calendar year of 2012. The review is detailed in her employee file. Her employee file will be included in the review process and she will be notified that she needs to complete a self-review one month before the anniversary of her date of hire.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in four of four client records.
The findings include:
Four client records were reviewed on March 1, 2013. Four client records were reviewed for the completion of informed and voluntary consents from the client for the disclosure of information contained in the client record. The facility did not document an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 1, 2, 3 and 4.
Client # 1 was admitted on September 23, 2012. Client information was released to a laboratory completing drug screen testing. There was no documentation of a consent from the client permitting the release of the information.
Client # 2 was admitted on October 17, 2012. Client information was released to a laboratory completing drug screen testing. There was no documentation of a consent from the client permitting the release of the information.
Client # 3 was admitted on August 3, 2012. Client information was released to a laboratory completing drug screen testing. There was no documentation of a consent from the client permitting the release of the information.
Client # 4 was admitted on October 21, 2012. Client information was released to a laboratory completing drug screen testing. There was no documentation of a consent from the client permitting the release of the information.
The Clinical Director was interviewed on March 1, 2013 and confirmed the findings.
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Plan of Correction
A consent for companies that provide drug screen testing was created to allow for the release of the results of the laboratory completed drug screen testing. A copy was signed by all active clients and entered into their individual case file. The consent was also added to the intake packet for all new clients entering the Drug and Alcohol program.
As part of our ongoing quality management program, the project director will complete monthly chart audits to ensure all required consents are in the chart and filled out correctly.
The clinical director will hold a training for staff specifically designed to address proper ways to utilize consent forms to ensure all consent forms are properly utilized and carried out appropriately. |
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.
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Observations
Based on the review of patient records, the facility failed to document the patient's emergency contact in four of four patient records.
The findings include:
Four client records were reviewed on March 1, 2013. Four client rewords reviewed required documentation of the patient's emergency contact. There was no documentation of the patient's emergency contact in patient records # 1, 2, 3 and 4.
Client # 1 was admitted on September 23, 2012. There was no documentation of the patient's emergency contact in the patient record.
Client # 2 was admitted on October 17, 2012. There was no documentation of the patient's emergency contact in the patient record.
Client # 3 was admitted on August 3, 2012. There was no documentation of the patient's emergency contact in the patient record.
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Client # 4 was admitted on October 21, 2012. There was no documentation of the patient's emergency contact in the patient record.
The Clinical Director was interviewed on March 1, 2013 and did not dispute the findings.
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Plan of Correction
An emergency contact release form was created. The form details the emergency contact, their contact information and the information that will be released to the contact when necessary. This information will be limited to type of emergency and location of client. This release was presented to all current clients and their signature was obtained. The release is kept in their client chart. A copy of the release was added to the intake process for all new clients entering the Drug and Alcohol Program.
As part of our ongoing quality management program, the project director will complete monthly chart audits to ensure all required consents are in the chart and filled out correctly.
The clinical director will hold a training for staff specifically designed to address proper ways to utilize consent forms to ensure all consent forms are properly utilized and carried out appropriately.
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715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility's physician failed to document in the patient's record a physical examination, the patient's current dependency and evidence of a one year history of addiction and the basis for the determination in four of four patient records.
The findings include:
Four patient records were reviewed on March 1, 2013. Four patients were prescribed Suboxone. Four patient records were reviewed for documentation that the physician made a face-to-face determination of whether the individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for this determination. The physician failed to document in the patient's record a face to face physical examination, the basis for determination of current dependency and evidence of a one year history of addiction in patient records # 1, 2, 3 and 4.
Patient # 1 was admitted into treatment on September 23, 2012. The physician prescribed 8 mg 1/2 sc bid of Suboxone on September 29, 2012. There was no documentation by the physician of a face to face physical examination or that the patient was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination prior to the patient's admission to treatment.
Patient # 2 was admitted into treatment on October 17, 2012. The physician prescribed 8 mg 1/2 sc bid of Suboxone on October 22, 2012. There was no documentation by the physician of a face to face physical examination or that the patient was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination prior to the patient's admission to treatment.
Patient # 3 was admitted into treatment on August 3, 2012. The physician prescribed 8 mg/2 mg BID Suboxone on August 5, 2012. There was no documentation by the physician of a face to face physical examination or that the patient was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination prior to the patient's admission to treatment.
Patient # 4 was admitted into treatment on October 21, 2012. The physician prescribed 8 mg/2 mg BID Suboxone on October 25, 2012. There was no documentation by the physician of a face to face physical examination or that the patient was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination prior to the patient's admission to treatment.
The Clinical Director was interviewed on March 1, 2013 and confirmed the findings.
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Plan of Correction
At the date of the onsite inspection, Axiom's prescribing physician was completing an Outpatient Psychiatric Evaluation that did not detail dependence upon a narcotic drug or that the prospective client had been dependent for one year.
The Outpatient Psychiatric Evaluation has been updated to include a section to include basis for determination of current dependency and evidence supporting the dependence for at least one year.
This section will be part of determination process for admission into the treatment program. All current and new treating physicians will be trained on the new process by the clinical director.
A physical form was created to meet physical requirements to be conducted by the narcotic treatment physician including vital signs, review of organ systems, general appearance, and physician's impressions.
The Project Director will conduct monthly chart audits to ensure every client has a physical examination completed by the narcotic treatment physician as well as required critera for admission including documentation that the client has been physiologally dependedent upon a narcotic drug for atleast one year prior to admission in the initial evaluation. |
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 complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter in four of four patient records.
The findings include:
Four patient records were reviewed on March 1, 2013. Four patient records reviewed required documentation of a completed initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter. The facility did not document a completed initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter in patient records # 1, 2, 3 and 4.
Patient # 1 was admitted on September 23, 2012. The patient was prescribed Suboxone on September 29, 2012. There was no documentation that an initial drug-screening urinalysis was completed prior to the prescribing of the Suboxone in the patient record. The first documented drug-screening urinalysis was completed on October 13, 2012.
Patient # 2 was admitted on October 17, 2012. The patient was prescribed Suboxone on October 22, 2012. There was no documentation that an initial drug-screening urinalysis was completed prior to the prescribing of the Suboxone, nor was there documentation of random urinalysis being completed at least monthly thereafter, in the patient record. The record documented only one urinalysis dated November 9, 2012.
Patient # 3 was admitted on August 3, 2012. The patient was prescribed Suboxone on August 5, 2012. The initial drug-screening urinalysis results were received on August 8, 2012.
Patient # 4 was admitted on October 21, 2012. The patient was prescribed Suboxone on October 22, 2012. The initial drug-screening urinalysis results were received on October 28, 2012.
The Clinical Director was interviewed on March 1. 2013 and confirmed the findings.
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Plan of Correction
As part of the initial assessment for treatment interview, an initial drug screening will be conducted in house by office staff. The collection of the urine screen will be documented on the current drug and alcohol tracking form already utilized by Axiom. The UDS will be sent to drug screening facility and the initial assessment appointment with doctor will be completed when the UDS is returned. Axiom's treating physician will utilize the drug and alcohol tracking form to verify UDS was completed and will review results. All current and new treating physicians of Axiom will be trained on the new procedure. Upon entrance into the program, the client will receive monthly random urinalysis, as monitored by the treating therapist. As part of ongoing quality management process, the clinical director will review drug and alcohol tracking forms in client's chart for compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation that included the client's assets/strengths, support systems, coping mechanisms and negative factors in four of four client records.
The findings include:
Four client record was reviewed on March 1, 2013. Four client rewords were reviewed required documentation of a psychosocial evaluation. The psychosocial evaluations did not include the client's assets/strengths, support systems, coping mechanisms and negative factors in client records # 1, 2, 3 and 4.
Client # 1 was admitted on September 23, 2012. The psychosocial evaluation completed on September 23, 2012 included client reported assets/strengths, coping mechanisms and negative factors and did not include a clinical impression of the information.
Client # 2 was admitted on October 17, 2012. The psychosocial evaluation completed on October 17, 2012 included client reported support systems and coping mechanisms and did not include a clinical impression of the information.
Client # 3 was admitted on August 3, 2012. The psychosocial evaluation completed on August 3, 2012 did not include documentation of the client's support systems or coping mechanisms.
Client # 4 was admitted on October 21, 2012. The psychosocial evaluation completed on October 21, 2012 did not include documentation of the client's support systems or coping mechanisms.
The Clinical Director was interviewed on March 1, 2013 and did not dispute the findings.
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Plan of Correction
Axiom's Psychosocial evaluation form has been modified to include the following components: composite picture, client problems/needs, assets and strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and counselor conclusions and clinical impressions. All staff involved in client assessment and treatment will be trained by Clinical Director on how to complete and utilize the new psychosocial evaluation form.
As part of our ongoing quality management process, project manager and clinical director will conduct monthly chart audits to ensure psychosocial evaluation reflects neccessary criteria and requirements as reported above. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultation notes in two of four client records.
The findings include:
Four client records were reviewed on March 1, 2013. Four client records reviewed required case consultation notes. The facility failed to document a policy for the completion of case consultation notes. Case consultation notes are required at least quarterly. The facility did not document case consultation notes at least quarterly in client records # 1 and 3.
Client # 1 was admitted on September 23, 2012. A case consultation note was due to be completed by December 31, 2012. There was no case consultation note documented.
Client # 3 was admitted on August 3, 2012. A case consultation note was due to be completed by December 31, 2012. There was no case consultation note documented.
The Clinical Director was interviewed and confirmed the findings.
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Plan of Correction
The primary therapist will meet individually with the clinical director to review all current cases.
Therapist and Clinical Director will consult on course of treatment and progress in current program.
As part of ongoing quality management process, the project manager will review charts on a monthly basis to ensure the case consultations have occurred.
All case consultations will be documented and tracked in the "consultation log" to ensure compliance is met. |
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 the review of client records, the facility failed to document a discharge summary that included the reason for treatment and services offered in one of one client record.
The findings include:
Four client records were reviewed on March 1. 2013. One client record was reviewed as a discharge record and required the completion of a discharge summary. The facility did not document a discharge summary that included the reason for treatment and services offered in client record # 3.
Client # 3 was admitted on August 3, 2012 and discharged on February 16, 2013. The discharge summary completed on February 16, 2013 did not include the client's reason for treatment or services offered to the client while in treatment.
The Clinical Director was interviewed on March 1, 2013 and did not dispute the findings.
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Plan of Correction
The clinical director will revise the discharge summary to state the reasons for treatment, services offered, response to treatment, and client status. All employees will be trained by the clinical director on the effective utilization of the corrected form including proper discharge procedures.
As part of ongoing quality management process, the project manager will review charts on a monthly basis to ensure that the discharge summary is completed correctly by all staff. Any deficiencies noted on the completion of the form will be addressed by the clinical director with each staff member. |