INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Naaman Center. was found to be not 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(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" (SRFSR) for all of the facilities in the project, the project failed to ensure that there was one full-time clinical supervisor for eight full-time equivalent (FTE) counselors in the project.
The FTE for the project was calculated to be 12.2 which would require the project to employ one full-time clinical supervisor. As of July 1, 2017 the only full-time clinical supervisor was promoted to the position of project director and facility director.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Project Director has submitted an exception request for 704.6(a).
Upon receiving the results of the exception request, the Project will act in one of two ways.
1. If the exception is approved: Clinical supervision will continue as outlined in the exception request. Lead Counselors will continue to provide ongoing individual/and or group supervision weekly. Lead Counselors will provide quality assurance chart checks and review these chart checks with counselors during supervision. Lead Counselor caseloads will be adjusted down, as needed, at facilities with higher client loads. The Project Director/Facility Director is a qualified Clinical Supervisor and will continue to provide supervision to Lead Counselors and counselors on a regular basis and as needed. If, at any time, a facility would cross over the 8 counselor threshold, a full time Clinical Supervisor will be hired. If, at any time, the quality of our care appears to be negatively impacted by this structure, we will seek to hire a full-time clinical supervisor. In April 2018, a thorough internal review of the exception will be conducted by the Project Director. Parameters to be considered will include: client satisfaction and outcomes, charting compliance, staff satisfaction, and Project growth or decline. If these results are congruent with our standards, and the Project remains at or near its current size, an exception request will be submitted to extend the exception. If factors indicate a negative impact on the Project from the exception, the Project will begin a search for a full-time Clinical Supervisor, to be compliant with 704.6 prior to the end of the trial period on 6/30/18.
2. If the exception is denied: The project will conduct an internal and external search for a full-time Clinical Supervisor by the Project Director. The Clinical Supervisor will be hired in accordance to all provisions outlined in 704.6. The Project will be compliant by 1/1/18.
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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 staff records conducted on September 19, 2017, the facility failed to ensure that a lead counselor had the required number of training hours.
Employee #2 was hired as a counselor on 9/28/2012 and promoted to lead counselor on 6/26/17. Employee #2 had only 21 documented hours of training for the facility training year from July 1, 2017 thru June 30, 2017.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Project Director will regularly review training hour progress with Counselors at each monthly staff meeting and/or through quarterly reviews. Email prompts will be sent to Counselors that are deficient in accruing training hours. All Counselors will be compliant with their required number of training hours by the end of the next review period. |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on a review of facility policies and procedures conducted on September 19, 2017, the facility failed to adhere to program requirements regarding secure storage of Vivitrol.
Vivitrol was stored in a small, unlocked refrigerator in the second-floor break room. Since the second exit route from the second floor passes through this area the door from the hallway remains open during business hours.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The storage refrigerator for Vivitrol was immediately moved. It was moved from the staff break room to the Office Manager's office on the first floor. This is a locked area. The refrigerator is a small refrigerator only for the storage of Vivitrol. The refrigerator was also outfitted with a refrigerator lock. The Office Manager is in charge of locking and unlocking the supply. Staff with potential access to the Vivitrol includes the Office Manager, Medical Director, the person responsible for the injection, and the Project Director. The Office Manger maintains the key used for unlocking the Vivitrol supply. These improvements have been fully implemented as of 10/3/2017. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of facility policies and procedures conducted on September 19, 2017, the facility failed to submit a complete policy and procedure to The Department.
The facility Policy and Procedure manual contains the following under 709.32 (c)subsection (3):
"What is inspected....who inspects...how often....what manner recorded...outdated drugs are removed...copies of drug related regs are posted?"
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The office manager will inspect the medication storage refrigerator quarterly. This refrigerator is dedicated to the storage of Vivitrol only. The inspection will be recorded on a log sheet. The log will include the date of the inspection and the results. The inspection will review that the appliance is in working order and will review the contents of the appliance. Each stored Vivitrol product will be reviewed for an expiration date. Any outdated meds will be removed for disposal. A copy of this policy will be kept with the inspection log.
Updated policies must be reviewed and passed by the Board of Directors. This policy will be reviewed by the Project Director at our next Board meeting on 10/24/17. The policy will be fully approved and implemented by 11/1/17.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of facility policies and procedures conducted on September 19, 2017, the facility failed to submit a complete policy and procedure to The Department.
The facility Policy and Procedure manual contains the following under 709.32 (c)subsection (4):
"Who is authorized to remove drug?"
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Office Manager, Medical Director, Project Director, the Nurse are all authorized to remove Vivitrol from the refrigerator. A Vivitrol Medication Log is kept on top of the appliance. When a dose of Vivitrol is received it is placed in the refrigerator and marked on the log by the Office Manager. The date of receipt and the name of the identified recipient are logged. The date of the shot is given and the verification signature is then completed at the time of administration by the nurse administering the shot.
Updated policies must be reviewed and passed by the Board of Directors. This policy will be reviewed by the Project Director at our next Board meeting on 10/24/17. The policy will be fully approved and implemented by 11/1/17.
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709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
Based on a review of facility policies and procedures conducted on September 19, 2017, the facility failed to submit a complete policy and procedure to The Department.
The facility Policy and Procedure manual contains the following under 709.32 (c)subsection (5):
"Security regarding the loss, theft, or misuse of drug?"
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
This incomplete section was reviewed and rewritten. It is now written as follows:
709.32(c)(5)
The Project maintains a secure supply of Vivitrol. One dedicated refrigerator solely for the storage of Vivitrol is housed in the office of the Office Manager. Access to this space is limited. In addition, this refrigerator is equipped with a refrigerator lock. The Office Manager maintains the keys used to open this lock. The Project Director, Medical Director, Office Manager, and the nurse are the only staff with access to this supply. A Medication Log is kept which tracks every does of Vivitrol as it arrives and as it is injected. Vivitrol is not a controlled substance and has a low risk of misuse. Quarterly inspections will be conducted to verify the contents of the refrigerator. Any discrepancy between the log and medications present will be reported immediately by the Office Manager to the Project Director. The Project Director will then conduct an investigation to determine the possible cause of the discrepancy.
Updated policies must be reviewed and passed by the Board of Directors. This policy will be reviewed by the Project Director at our next Board meeting on 10/24/17. The policy will be fully approved and implemented by 11/1/17.
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