INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on October 22, 2019 through October 23, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Alliance Medical 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:
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
During a licensing inspection conducted on October 22-23, 2019, the facility failed to provide documentation for the Clinical Supervisor to have at least two years supervisory experience or the core curriculum in clinical supervision.Employee # 7 was hired for the current position of Clinical Supervisor on July 16, 2018 and did not have two years supervisory experience or the core curriculum in clinical supervision.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
It was determined that one employee conducting clinical supervision failed to meet the 704.6 qualifications.
The Facility Director will be responsible for making sure that all employees providing clinical supervision will meet the qualification outlined under 704.6. The Facility Director will also make sure appropriate language and wording is utilized when promotion of staff occur that may not include clinical supervision of other employees.
If employees do not meet 704.6 qualifications and are providing clinical supervision that employee will attend PA clinical supervision training.
Company Human Resources department will regularly review employee HR files to make sure all staffing regulations are being met in regards to the jobs employees are conducting at the facility.
|
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
|
Observations
During a licensing inspection conducted on October 22-23, 2019, it was determined that two counselor assistants were not supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7. Employee #9 was hired as a counselor assistant on April 29, 2019. This employee was not under the direct supervision of a clinical supervisor or a counselor.Employee #10 was hired as a counselor assistant on August 26, 2019. This employee was not under the direct supervision of a clinical supervisor or a counselor.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
It was determined that not all counselor assistants were being supervised by a clinical supervisor or clinician who meets the 704.6 or 704.7 qualifications.
The Facility Director will be responsible for making sure that all counselor assistants are being supervised by a full-time clinical supervisor or clinician who meets the 704.6 or 704.7 qualifications.
During the supervision period of a counselor assistant all provided direct supervision and observation will be documented on a weekly basis.
Company Human Resources department will regularly review employee HR files to make sure all staffing regulations are being met in regards to the jobs employees are conducting at the facility.
|
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
During a licensing inspection conducted on October 22-23, 2019, it was determined that three counselor assistants with bachelor's degrees were not receiving close supervision to include one hour of direct observation from a trained counselor or clinical supervisor for the first 6-months of employment. Employee #8 was hired as a counselor assistant on November 12, 2018 and was still in this position at the time of the inspection. Employee # 8's record provided one documentation of supervision in December and May, twice in January, February, March and April with no documentation of one hour of direct observation. Employee #9 was hired as a counselor assistant on April 29, 2019 and was still in this position at the time of the inspection. Employee # 9's record provided no documentation of supervision in the month of May, Once in June and July, three times in August, and twice in September with no documentation of one hour of direct observation. Employee # 10 was hired as a counselor assistant on August 26, 2019 and was still in this position at the time of the inspection. Employee # 10's record provided one documentation of supervision in the month September and no documentation of one hour of direct observation. These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
It was determined that not all counselor assistants received one hour of direct observation from a trained counselor or clinical supervisor for the first 6-months of employment.
The Facility Director will be responsible for making sure that all counselor assistants are being supervised by a full-time clinical supervisor or clinician who meets the 704.6 or 704.7 qualifications.
During the supervision period of a counselor assistant all provided direct observation will be documented on a weekly basis for the first 6-moths of employment.
Company Human Resources department will regularly review employee HR files to make sure all staffing regulations are being met in regards to the jobs employees are conducting at the facility. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
During a licensing inspection and physical plant inspection conducted on October 22-23, 2019, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. A vent that connected two counseling areas was open and sessions were able to be heard through this vent. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to ensure privacy so that counseling sessions cannot be heard.
The facility will purchase and install a sound system/white noise machines to be utilized in facility hallways to provide external sound masking clinical sessions.
The facility will research ways to improve noise reduction for office interiors or ways to mitigate office crossing sounds. A consultation will occur with HVAC technician to discuss filtering that may be placed in ventilation to help mitigate sound transfer through the ventilation system.
Facility Director is responsible for oversight of installation and implementation of these changes. |
709.28 (c) (6) 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 must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
|
Observations
During a licensing inspection conducted on October 22-23, 2019, the project failed to document an informed and voluntary consent from the client for the disclosure to include the date, event or condition upon which the consent will expire in one of eight records reviewed.Patient # 3 was admitted on February 3, 207 and was still an active patient at the time of the inspection. An informed and voluntary consent form signed and dated on February 15, 2018 to "Any OTP" did not include the date, event or condition upon which the consent will expire.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to appropriately document one informed and voluntary consent in one record that was reviewed.
Incorrect releases from this patient record or others found during chart audits will be marked as void in the electronic record and redone if needed.
The facility will be changing electronic documentation system in 2020 and new system will improve the way informed and voluntary consent.
The facility will ensure that all clinical staff appropriately complete all aspects of the informed and voluntary consent for patients.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to informed and voluntary consent.
Supervisory staff will continue to conducted weekly chart reviews which does include this aspect of the patient file.
|
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
|
Observations
During a licensing inspection conducted on October 22-23, 2019, the program failed to provide documentation of a narcotic treatment physician providing narcotic treatment physician services at least 1 hour per week onsite for every ten patients for the months of August and September 2019.During the week of September 2-6, 2019, the patient census was 479. The program was required to provide at least 47.9 physician hours. The combined physician hours provided were 45.75.During the week of August 5-11, 2019, the patient census was 480. The program was required to provide at least 48 physician hours. The combined physician hours provided were 47.25.During the week of August 12-18, 2019, the patient census was 480. The program was required to provide at least 48 physician hours. The combined physician hours provided were 46.During the week of August 19-25, 2019, the patient census was 478. The program was required to provide at least 47.8 physician hours. The combined physician hours provided were 46.During the week of August 26-September 1, 2019, the patient census was 478. The program was required to provide at least 47.8 physician hours. The combined physician hours provided were 47.These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
The facility fail to provide the required physician hours for patient census. The physician is required to provide 1 hour of service for every 10 enrolled patients.
The Facility Director will be responsible to adjust the physicians schedule to meet the requirement of 1 hour of service for every 10 enrolled patients with the assistance of a Physician Assistant who can provide 2/3 of the required time. The physician and Physician Assistant will provide the necessary coverage.
The Facility Director will be responsible for ongoing compliance through regular review of the physician and physician assistant time-sheets.
|
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
|
Observations
During a licensing inspection conducted on October 22-23, 2019, the program failed to provide documentation of a dose review being conducted at least twice a year in one of eight records reviewed. Patient # 6 was admitted on December 4, 2018 and discharged on September 5, 2019. The only documentation of a dose review in the patient record occurred on June 17, 2019.The findings were reviewed with program staff during the licensing process.
|
Plan of Correction
Documentation of a dose review being conducted at least twice a year was unable to be located in one record reviewed.
Additional dose reviews were located in another area of the electronic record where medication orders are documented. During future audits the facility will advise the auditors of the secondary location were medication reviews may be located. |
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.
|
Observations
During a licensing inspection conducted on October 22-23, 2019, the program failed to provide documentation of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Patient # 1 was admitted on March 19, 2019 and was still an active patient at the time of the inspection. In October 2019 the patient had zero hours psychotherapy and in September 2019 the patient had one hour of individual therapy. Patient # 2 was admitted on September 19, 2019 and was still an active patient at the time of the inspection. There was only 30 minutes of psychotherapy hours documented in the patient record. Patient # 4 was admitted on February 5, 2019 and was still an active patient at the time of the inspection. In June 2019 the patient had one hour of psychotherapy and in July two hours of psychotherapy.Patient # 8 was admitted on June 6, 2019 and was discharged on September 23, 2019. In September and August 2019, the patient had .45 hours of psychotherapy and in June and July 2019 the patient had zero hours of psychotherapy.These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
The facility failed to provide 2.5 hours of psychotherapy services for all patient records that were reviewed.
The facility will ensure that all patients receive the required of monthly psychotherapy. Monitoring of ongoing compliance with this regulation will be the responsibility of the Supervisory Staff through regular record review, clinical supervision, and utilization for Electronic Record reports.
Open counseling positions will be filled to help ease the burden on current counseling staff and provide additional counseling staff to when other staff are out of the building.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to individualized psychotherapeutic needs.
Facility Staff will utilize Electronic Record reports to periodically check counseling compliance for their caseloads.
Supervisory staff will continue to conducted weekly chart reviews which does include this aspect of the patient file. |
709.93(a)(4) 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:
(4) Referral contact.
|
Observations
During a licensing inspection conducted on October 22-23, 2019, the facility failed to provide documentation of a complete client record to include referral contacts in six of eight client records reviewed.Client # 1 was admitted on March 19, 2019 and was still an active client at the time of the inspection. Client # 2 was admitted on September 19, 2019 and was still an active client at the time of the inspection. Client # 4 was admitted on February 5, 2019 and was still an active client at the time of the inspection. Client # 5 was admitted on June 27, 2019 and was still an active client at the time of the inspection. Client # 6 was admitted on December 4, 2018 and was discharged on September 5, 2019.Client # 7 was admitted on July 30, 2018 and was discharged on May 31, 2019.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to provide documentation of referral contact in all records reviewed.
Current and future referral contacts will be marked on a referral form or in a case management note to correct current patient records. If recognized in future chart audits the same actions will apply.
The facility will be changing electronic documentation system in 2020 and new system will capture referral contacts differently than current electronic documentation system.
During transition period between electronic documentation system change the facility will document referral contact/source in the patient record utilizing case management notes and incorporating information in the interpretive summary documentation.
|
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.
|
Observations
During a licensing inspection conducted on October 22-23, 2019, the facility failed to provide documentation of complete client record to include case consultations being provided with more than solely with the clinician and client in one of even patient records reviewed.Client # 7 was admitted on July 30, 2019 and was discharged on May 31, 2019. There was a case consultation conducted on January 30, 2019 and October 30, 2018 that only included the clinician and client.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to appropriately document case consultation in one record that was reviewed.
The facility will ensure that all clinical staff appropriately document all case consultations in the patient record including all staff who were present.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to case consultations.
Supervisory staff will continue to conducted weekly chart reviews which does include this aspect of the patient file. |