INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on December17-18, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Tadiso, Inc. 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 staff records, the facility failed to ensure that each counselor met the qualifications of the position at the time of hire in in two of nine applicable records reviewed.
Staff #5 was hired as a counselor on December 18, 2023 and did not meet the educational requirements to be a counselor.
Staff #14 was hired as a counselor on September 16, 2024 and did not meet the educational requirements to be a counselor.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
During our licensing inspection ending on 12/18/2024, Based on a review of staff records, the facility failed to ensure that each counselor met the qualifications of the position at the time of hire in in two of nine applicable records reviewed.
Staff #5 was hired as a counselor on December 18, 2023 and did not meet the educational requirements to be a counselor.
Staff #14 was hired as a counselor on September 16, 2024 and did not meet the educational requirements to be a counselor.
TADISO PLAN OF CORRECTION
Tadiso was unable to obtain official transcripts for staff #14 and therefore the staff member will be offered from the Human Resource department the choice to take a position she is qualified for within the agency or be discharged from employment.
Human Resource Director and Director of Behavioral Health services will follow licensing alert 03-2021 and 03-2024 for guidance on acceptable degrees for position of counselor effective 1/21/2025 for any new candidate. If a candidate is eligible for Act 66 of 2023, Tadiso will submit the request to Ra-licensure account for review.
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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 applicable staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in three of seven records.
Staff #15 was hired as a support staff on December 5, 2022. The HIV/AIDS and TB/STD trainings were to be completed by December 5, 2024. The HIV/AIDS training was completed on December 13, 2024. There was no documentation that the TB/STD training was completed at the time of the inspection.
Staff #16 was hired as a support staff on October 18, 2021. The TB/STD training was to be completed by October 18, 2023. The TB/STD training was completed on November 14, 2024.
Staff #17 was hired as a support staff on September 13, 2021. The TB/STD training was to be completed by September 13, 2023. There was no documentation that the TB/STD training was completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the annual licensing audit ending on 12/18/2024, based on a review of applicable staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in three of seven records.
Staff #15 was hired as a support staff on December 5, 2022. The HIV/AIDS and TB/STD trainings were to be completed by December 5, 2024. The HIV/AIDS training was completed on December 13, 2024. There was no documentation that the TB/STD training was completed at the time of the inspection. Staff #17 is scheduled/on waiting list for February 13. 2025 TB/STD.
Staff #17 was hired as a support staff on September 13, 2021. The TB/STD training was to be completed by September 13, 2023. There was no documentation that the TB/STD training was completed at the time of the inspection. Staff #17 is scheduled/ on waiting list for February 13, 2025 TB/STD.
TADISO PLAN OF CORRECTION
New hires will be scheduled for DDAP TB/STD as soon as an available time slot is open by the HR department.
Staff #15 and #17 have been scheduled for TB/STD training on 2/13/2025
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on applicable patient records reviewed, the facility failed to have a narcotic treatment physician determine the patient 's initial dose and schedule in two of four records.
Patient #3 was admitted to outpatient on October 21, 2024 and was still active at the time of the inspection. An initial dose order was documented and authenticated by a CRNP on October 21, 2024.
Patient #7 was admitted to outpatient on February 7, 2024 and was still active at the time of the inspection. An initial dose order was documented and authenticated by a CRNP on February 7, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This was an oversight on our part as we were under the impression that we were covered with our exception for mid-level practitioners to complete services as does the medical director/physician based on the collaboration agreement signed off by our SOTA on 9.14.2023. We were educated that this is not permissible by DDAP for mid-level practitioner on initial dose and schedule.
Tadiso put into effect 1/18/2025 that any mid-level practitioner with a SAMHSA exemption will receive a verbal order from an NTP physician for initial medication dose and schedule for patient.
Mid-Level Practitioner will complete MD Documentation of Addiction stating that a verbal order was received and specify in the note which doctor confirmed verbal order. The doctor that confirmed the verbal order of initial dose and schedule will then sign order within 24 hours.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document an annual evaluation of each patient 's status completed by the patient 's counselor and reviewed, dated and signed by the medical director. with all areas of regulation addressed within the regulatory timeframe in one of three records.
Patient #1 was admitted to outpatient on January 10, 2023 and was still active at the time of the inspection. The annual evaluation was due by January 10, 2024; however it was not completed until January 18, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 16-17, 2023 and November 28-30, 2022 annual licensing inspections.
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Plan of Correction
During our annual licensing audit ending on December 18,2024 the review of patient records, the facility failed to document an annual evaluation of each patient 's status completed by the patient 's counselor and reviewed, dated and signed by the medical director. with all areas of regulation addressed within the regulatory timeframe in one of three records. This is a repeat citation from the November 16-17, 2023 and November 28-30, 2022 annual licensing inspections.
TADISO PLAN OF CORRECTION
Annual Clinical Evaluations will populate in the EHR on month 11 to allow for adequate time for all required signatures to be obtained in the document by the annual due date. IT changed auto population date to begin occurring on 1/18/2025 in EHR.
Clinical Supervisors will review the services due report with their supervisees in clinical supervision, providing them a list of all Annual Clinical Evaluations that need to be completed that week to ensure they are completed by the required due date.
Medical Department will check annual clinical evaluation folder each day to maintain compliance for signature.
Currently Tadiso has an exception for Mid-Level Practitioner to conduct some duties that are assigned to the medical director. Plan Effective date 1/21/2025
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in four of nine applicable records.
Client #1 was admitted to outpatient on January 10, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on August 28, 2024 and the next update was due by October 28, 2024; however this was not completed until November 7, 2024.
Client #5 was admitted to outpatient on June 16, 2019 and was discharged on March 18, 2024. A treatment and rehabilitation plan update was completed on November 28, 2023 and the next update was due by January 28, 2024; however this was not completed until February 15, 2024.
Client #8 was admitted to outpatient on April 21, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on June 10, 2024 and the next update was due by August 10, 2024; however this was not completed until September 16, 2024.
Client #9 was admitted to outpatient on July 14, 2017 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on September 17, 2024 and the next update was due by November 17, 2024; however this was not completed until November 19, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 16-17, 2023 annual licensing inspection.
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Plan of Correction
Based on client records reviewed during annual licensing inspection ending on 12/18/2024, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in four of nine applicable records.
TADISO PLAN OF CORRECTION
Treatment Plan Progress Updates will populate in the EHR one week before the due date of the master treatment plan progress update.
Clinical supervisors will review services due reports in clinical supervision and ensure that treatment plan progress updates are completed on or before the treatment plan due date.
If the master treatment plan is updated on time, the treatment plan progress update can be omitted from the patient's file. Plan of correction effective 1/21/2025.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for annual evaluations was submitted and approved by the Department for the November 16-17, 2023 and November 28-30, 2022 annual licensing inspections. Annual evaluations were again found to be a deficiency in the December 17-18, 2024 annual licensing inspection.
This was reviewed with the facility staff during the licensing process.
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Plan of Correction
Tadiso PLAN OF CORRECTION UPDATE
Director of Accreditation and Licensing will review and re-distribute written Plans of correction with Department heads at least quarterly to continuously review the findings and ensure that the departments are consistently following what was stated in the POC's they submitted. Director of Accreditation will do random monthly spot checks of deficiencies and document the items checked. Effective 2.1.2025
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