INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 13-14, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Freedom Healthcare Services, LLC 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(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
The project failed to ensure there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
The onsite inspection was held on June 13-14, 2016. At the time of the inspection, the project has two licensed facilities; however, one of them does not have any staff and has not yet admitted any clients. At the operational facility, there are 600 clinical hours worked by 17.14 FTE (Full time equivalent) counselors and one full time clinical supervisor. With 17.14 FTE counselors, at least two full time clinical supervisors would be required to be in compliance.
The findings were reviewed with facility staff.
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Plan of Correction
704.6 (A) Clinical Supervisor Qualifications:
In order to come into compliance with this deficiency the Clinical Director will be responsible for selecting and hiring two (2) additional Clinical Supervisors. Freedom Healthcare Services will add two (2) additional clinical supervisors by July 31, 2016. In the future when FHS meets the equivalent of 8 FTEs we will add an additional Clinical Supervisor.
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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
The facility failed to document all counselors met the qualifications for the position.
Staff qualifications were reviewed on June 14, 2016. Employee #10 was hired as a counselor on June 1, 2016. Employee #10 was found to meet the experience piece of the qualifications; however, did not meet the educational requirement. The personnel record for employee #10 contained an unofficial transcript for a degree in Community Ministry. This degree does not meet the educational requirement for the position of counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.7 (b) Licensure Counselor Qualifications:
In response to Freedom Healthcare Services deficiency listing 704.7 (b) Licensure Counselor Qualifications , employee #10 current patient's will be reassigned by the Clinical Supervisor to a qualified counselor by 7/10/16. Employee identified as # 10 in the deficiency listing was reassigned to perform Intake responsibilities only and all of his assigned patients were reassigned to fully qualified Counselors. The Clinical Director will ensure new Counselors meet the required qualifications for the position prior to hire.
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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
The facility failed to have a narcotic treatment physician make a face-to-face determination of current and one year narcotic dependency in three of the eight buprenorphine patient records reviewed on June 13-14, 2016.
Patient #2 was admitted on 2/23/16. There was no documentation by a narcotic treatment physician of a one year history of physiological dependence.
Patient #4 was admitted on 3/18/16. There was no documentation by a narcotic treatment physician of current physiological dependence on a narcotic and a one year history of physiological dependence.
Patient #6 was admitted on 4/1/16. There was no documentation by a narcotic treatment physician of current physiological dependence on a narcotic and a one year history of physiological dependence.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. By July 15, 2015, Medical Director will review with all physicians the process for determining and documenting the face to face determination of physiological dependency of at least one year.
2. By July 15, 2015 Lead Nurse will train all nurses to review intake paperwork to assure that physician has completed documentation of dependency prior to making a determination of narcotic dependency.
3. Immediately the Clinical Director will randomly check intakes for documentation of dependency.
4. Immediately the Clinical Director revised the Physician's Documentation of Addiction form in order to ensure that the administering Physician will correctly document the dependency and evidence of a 1 year history of addiction.
5. By July 15, 2016, the medical records of Patients #2, #4, and #6 will be reviewed by the administering Physician and Lead Nurse to document the addiction as originally stated using the revised form.
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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
The facility failed to obtain a complete, random monthly urinalysis in all eight buprenorphine patient records reviewed on June 13 - 14, 2016. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
Patient #2 was admitted on 2/23/16. Patient record #2 did not include documentation of complete monthly urinalysis for the months of March, April and May 2016.
Patient #3 was admitted on 11/5/15. Patient record #3 did not include documentation of complete monthly urinalysis for the months of December 2015 and January, February, March, April and May 2016.
Patient #4 was admitted on 3/18/16. Patient record #4 did not include documentation of complete monthly urinalysis for the months of April and May 2016.
Patient #5 was admitted on 3/9/16. Patient record #5 did not include documentation of complete monthly urinalysis for the months of April and May 2016.
Patient #6 was admitted on 4/1/16. Patient record #6 did not include documentation of complete monthly urinalysis for the month of May 2016.
Patient #7 was admitted on 6/29/15 and discharged 10/22/15. Patient record #7 did not include documentation of complete monthly urinalysis for the months of July, August and September 2015.
Patient #8 was admitted on 6/16/15 and discharged 11/19/15. Patient record #8 did not include documentation of complete monthly urinalysis for the months of July, August, September and October 2015.
Patient #9 was admitted on 1/13/16 and discharged 5/16/16. Patient record #9 did not include documentation of complete monthly urinalysis for the months of February, March and April 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.14 Licensure (a) Urine testing:
On 6/22/16
Freedom Healthcare Services will obtain a complete, random monthly urinalysis from an outside lab at least once per month.
FHS patient management software (Falcon) will use an algorithm to generate a random monthly drug screen to be sent to an outside lab. The Clinical Director shall monitor the process to make sure all patients are screened at least monthly. The Nursing Department shall be responsible for packaging the samples and preparing them for samples by the outside lab.
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