INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection, and inspection conducted for the approval to use a narcotic agent, specifically methadone and buprenorphine in the treatment of narcotic addition. This inspection was conducted on June 21 - 22, 2016 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 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's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that all staff persons received at least 6 hours of HIV/AIDS and other health related topics within the regulatory timeframe in one of eleven personnel records reviewed.Employee #5 was hired as a counselor on November 26, 2014 and was due to complete the HIV/AIDS training no later than November 26, 2015. There was no documentation that Employee #5 completed the HIV/AIDS training at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #5 has been scheduled to take HIV/AIDS training on July 19, 2016.
As further corrective action the Executive Director will continue to reinforce the requirement to complete the trainings mandated by regulation. This will be done at full staff meetings on a quarterly basis and in supervision with the program managers on a quarterly basis as well. The office manager will continue to monitor compliance and will bring advise the executive director and the program manager of any potential issue at least three months prior to the deadline for meeting the requirements. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that each counselor completed at least 25 clock hours of annual training. Employee #11 was hired as a counselor on January 31, 2001. The facility's training year that was reviewed was from July 1, 2014 through June 30, 2015. Employee #11's employee record only documented 18 hours of annual training for the training year reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will continue to inform staff of their obligation to meet the minimum training hour requirements. This action will occur at full staff meetings not less than quarterly. The office manager will continue to keep a spreadsheet of staff training hours and will disseminate the information to the program coordinators. The program coordinators will monitor progress and will review the information with their direct reports in supervision not less than monthly. The policy and procedure will be revised to reflect the fact that any staff that is now compliant may face disciplinary action including the loss of paid time off. All of the above actions will commence as of July 1st and the policy will be revised as of July 31st. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill records, the facility failed to document the exit route used during fire drills.A review of the July 2015 through May 2016 fire drill record was reviewed during the annual licensing inspection. During the months of April 2016 and May 2016, the facility failed to document the exit route used during each fire drill. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director has discussed the matter with the office manager. Beginning with monthly supervision in July, 2016 the office manager will bring the fire drill log to the meeting for review. The executive director will continue to review the log during supervision on a quarterly basis. |
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 outpatient client records were reviewed during the renewal inspection on June 21-22, 2016. The facility failed to obtain an informed and voluntary consents in client records, #8 and 10. Client # 8 was admitted into treatment on 12/10/15 and was an active client at the time of the inspection. The client's record documented a consent to release information to a treatment program facility. This consent form did not document the dated signatures of the client and the witness. The client's record documented that the facility sent correspondence to the treatment program facility on 12/7/15, requesting the client's records. Client # 10 was admitted into treatment on 3/14/16 and was an active client at the time of the inspection. The client's record documented that the facility sent correspondence to a treatment program facility on 3/14/16, requesting the client's records, specifically PPD test results, discharge paperwork, and last dose verification. A consent to release information to the treatment program facility was not documented in the client's record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All release forms that are required will be reviewed for accuracy and completeness by the program coordinator for approval. The coordinator will reinforce this requirement with staff on a quarterly basis. All charts then will be randomly audited on a bi-monthly basis by coordinator or designee, to ensure that consent forms have client signature, witness signature and dates of both signatures.
With regard to inpatient facilities, it is protocol for them to send a consent for release of information when attempting to transfer a client to our facility. The coordinator will review this requirement with staff at team meeting on a quarterly basis to ensure that all documentation is received and then a confirmation fax or email will be sent to the transferring facility. As part of a bi-monthly chart audit process, a review of all transfers will be done by coordinator or designee to ensure that all documentation is complete and accurate.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Ten outpatient methadone maintenance client records were reviewed on June 21-22, 2016. The facility failed to obtain an informed, voluntary, written consent prior to the administration of a narcotic agent for maintenance treatment in client record # 10. Client # 10 was admitted into treatment 3/14/16 and was still an active client at the time of the inspection. The client received their initial dose of methadone on 3/14/16. The written consent documented in the client's record did not show documentation of the date of the client's signature. The informed consent was signed by physician on 3/14/16. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
It is current protocol that all consents to methadone and any other induction paperwork is dated and signed by both the physician and the client. The program coordinator will review intake paperwork following the admission will ensure that all paperwork is dated and signed.
As part of bi-monthly random chart audits the fiscal technician will review this information and indicate the results on a spreadsheet which will be reviewed by the executive director and program managers at management meetings on a bi-monthly basis. |
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
Four outpatient buprenorphine client records were reviewed on June 22, 2016. The facility failed to obtain a complete drug-screening urinalysis at least monthly for client records # 13 and 14. Client # 13 was admitted into outpatient treatment with buprenorphine on 9/10/14 and was discharged on 9/30/15. The last complete drug-screening urinalysis was obtained on 4/15/15. Client # 14 was admitted into outpatient treatment with buprenorphine on 10/21/15 and was still an active client at the time of the inspection. Complete drug-screening urinalysis was obtained on 10/21/15, 2/16/16, and 6/16/16.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program coordinator will review state urine testing requirements with all outpatient staff by July 15, 2016. Beginning on July 5, 2016 the Coordinator will conduct ongoing reviews to monitor compliance with this process and will re-enforce the requirement not less than monthly at team meetings and individual supervision. The executive director will review compliance with the Coordinator in monthly supervision beginning in July 2016 and quarterly thereafter. Clients receiving buprenorphine services will continue to receive warnings and be put on contracts when a pattern of noncompliance is established.A violation of the contract will result in termination from the program. The contracts will be on file in the client chart. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Four outpatient buprenorphine client records were reviewed on June 22, 2016. The facility failed to document that the client received an average of 2.5 hours of psychotherapy per month during the client's first 2 years, which included 1 hour of individual psychotherapy in client records # 12 and 14. Client # 12 was admitted on 12/21/15 and started buprenorphine treatment on 4/1/16. The client was still active at the time of the inspection. Documentation in the client's record showed less than 2.5 hours of psychotherapy per month for the months of April 2016 and May 2016 and less than 1 hour of individual psychotherapy for the months of April 2016 and May 2016. Client # 14 was admitted on 10/21/15 and was still an active client at the time of the inspection. The client's record documented less than 2.5 hours of psychotherapy per month for the months of April 2016 and May 2016 and less than 1 hour of individual psychotherapy for the month of May 2016. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program coordinator will review licensing requirements for psychotherapy services with all outpatient staff by July 15, 2016. Beginning in July, 2016 monthly reviews of case notes will continue to occur to monitor compliance with this process. The need for compliance with both individual and group therapy will be emphasized during the buprenorphine orientation process and clients receiving buprenorphine services will continue to receive warnings and be put on contracts when a pattern of noncompliance is established. The executive director will review progress with on this matter with the Coordinator in supervision in July, 2016 and bi-monthly thereafter. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Ten outpatient methadone maintenance client records were reviewed on June 21-22, 2016. The facility failed to document that it notified, in writing, the transferring narcotic treatment program of the initial dose given to the client by the receiving narcotic treatment program in client record # 8. Client # 8 transferred from a narcotic treatment program and was admitted into the facility on 12/10/15. The client was still an active client at the time of the renewal inspection. There was no documentation that the transferring program had been notified, in writing, of the date of the initial dose given to the client. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
It is current protocol that transfers in will be sent written notification and verification of dose and admission date. The program coordinator is responsible for reviewing and approving this information for each transferring client.
As part of the bi-monthly random chart audit the fiscal technician will review this information to ensure accuracy and completeness. This information will be reviewed by management at meetings on a bi-monthy basis. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of the outpatient methadone maintenance client records, the facility failed to document an annual evaluation of the patient in one of ten client records reviewed during the annual inspection conducted on June 21, 2016 through June 22, 2016.Client #3 was admitted into treatment on December 4, 2012 and was still an active client as of the date of the on-site inspection. There was an annual evaluation completed on 12/18/13 and 12/17/14; however an annual evaluation was due to be completed by 12/4/2015. There was no documentation of an annual evaluation in the client record as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program coordinator is responsible for maintaining a master spreadsheet of all clients in the program. As part of this information is the date when the initial medical exam is due and then maintaining oversight to ensure that an annual evaluation is performed. It is current protocol that all clients are ran through AMS (the dispensing system) to gather admission dates and thus annual dates. The report is then given to the front desk staff with a copy to the therapist and coordinator to schedule. AMS did not designate Client #3 as needing the annual evaluation. On June 27, 2016 a report was filed with the AMS technical department to correct the error. ensure that this does not happen in the future. The follow resolution was provided by Netsmart the copy which produces AMS:
Resolution: The Medical Exams Due report is recommended to identify clients with up coming tests within a date range. If the 'Include Past due Patients' box is selected, clients that missed a past test will continue to appear.
Update: None Required
Date Provided: 6/27/2016
As such the technical computer system error has now been resolved. The program coordinator will continue to monitor the situation to ensure that technical errors do not compromise the system. In addition, the master client spreadsheet list as kept by the coordinator serves as a crosscheck to ensure that annual evaluations are conducted.
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