INITIAL COMMENTS
|
This report is a result of an on-site methadone monitoring and licensure renewal inspection conducted on November 22-23, 2021 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:
|
Plan of Correction
|
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.
|
Observations
Based on the review of personnel records, the facility failed to ensure that each counselor met the experience requirements for their position in two of fourteen records.
Employee # 19 was hired as a counselor on November 5, 2020. The employee had a bachelor's degree, but did not have documentation of 1 year of clinical experience at the time of hire.
Employee # 21 was hired as a counselor on December 7, 2020. The employee had a master's degree, but did not have documentation of a practicum. The employee had a bachelor degree, but did not have documentation of 1 year of clinical experience at the time of hire.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
POC For 704.7(b)
Tadiso will create a hiring checklist for qualifications for the position of counselor for verification from Human Resources and Social Service Director for employee's placement based on educational experience and to designate employees job placement following DDAP criteria for standard 704.7(b).
Social Service Director and Human Resource Director will collaborate using the hiring checklist when interviewing and onboarding potential/new employees and then place into employees' personnel file. Policy Specialist will collaborate with Social Service Director and Human Resource Director to create the hiring checklist, and checklist will be effective January 1, 2022, for all new social service employees.
Effective November 29, 2021, Employee #21 was reclassified as a counselor assistant by Human Resource Director. Social Service Director will ensure that Employee #21 will receive clinical supervision and training hours since hiring date meet that of a counselor assistant. Upon one year of working at Tadiso, Inc. individual will meet the one year of clinical service and be promoted to counselor position on November 29, 2022.
Employee #19 was no longer employed with Tadiso at time of audit on November 22 and 23, 2021.
|
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
Based on the review of patient records, the facility failed to document that the narcotic treatment physician reviewed the dosage levels at least twice a year in one of two records.
Patient # 5 was admitted on March 14, 2018 and was still an active patient at the time of the inspection. Dose reviews, completed on March 18 and September 14, 2021 were completed by the CRNP.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
POC 715.15(a)
The Medical Director or the staff physician will provide a dosage review 2 times per year. The Medical Director or staff physician will document in patient's electronic health record the dosage review. The Director of Medical Services will ensure compliance with this standard, effective immediately from review of findings on November 22 & 23, 2021.
|
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
|
Observations
Based on the review of patient records, the facility failed to document the narcotic treatment physician, who determined the patient's initial dose, consulted with the Certified Nurse Practioner that performed the physical examination in seven of seven records.
Client # 1 was admitted on June 30, 2021 and was still an active client at the time of the inspection.
Client # 2 was admitted on July 21, 2021 and was still an active client at the time of the inspection.
Client # 3 was admitted on July 7, 2021 and was still an active client at the time of the inspection.
Client # 4 was admitted on March 2, 2021 and was still an active client at the time of the inspection.
Client # 7 was admitted on December 8, 2020 and was discharged on July 7, 2021.
Client # 8 was admitted on March 23, 2021 and was discharged on September 16, 2021.
Client # 9 was admitted on February 18, 2021 and was discharged on April 30, 2021.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
POC 715.15(b)
On November 22 & 23,2021 during Tadiso DDAP audit, it was determined that the physician ordering the patient's initial dose did not consult with the CRNP who completed the physical exam, prior to the patient's initial dosage in seven of the seven records reviewed.
Effective immediately November 23, 2021, it is necessary to document a consult in patient's electronic health record that the CRNP and the physician consulted prior to the patient receiving their initial dose only if the doctor is not the one completing the initial physical.
The Director of Medical Services will be responsible for making sure that files accurately reflect the CRNP and the medical doctor have met for the initial dose consultation.
|
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.
|
Observations
Based on the review of client records, the facility failed to review and update the treatment and rehabilitation plans at least every 60 days in three of seven records.
Client # 4 was admitted on March 2, 2021 and was still an open client at the time of the inspection. A treatment plan update, due to be completed by July 13, 2021, was completed on August 3, 2021.
Client # 5 was admitted on March 14, 2018 and was still an open client at the time of the inspection. A treatment plan update, due to be completed by November 9, 2021, was completed on November 19, 2021.
Client # 7 was admitted on December 8, 2020 and discharged on July 7, 2021. A treatment plan update, due to be completed by April 19, 2021, was completed on April 30, 2021.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
POC for 709.92(b)
During the DDAP review on November 22 and 23, 2021 there were seven records reviewed three of the records failed to review and update the treatment and rehabilitation plans at least every 60 days.
Treatment Plans for all patients will be updated every sixty days based on the patient admit date and documented in the patient record. The Director of Social Services or one of the Social Services Coordinators will be responsible for ensuring that the treatment plans are completed in a timely manner by checking the service due reports each week. All treatment plans completed by counselors will be signed off by a supervisor and reviewed by the Medical Director. Effective immediately November 23, 2021.
A Quality Assurance Coordinator will pull a service due report each week to check for any outstanding treatment plans from previous week. Coordinator will email list to Social Service Director and Policy Specialist, individual counselors will receive an email from the coordinator about outstanding issues from their caseload. This process became effective December 11, 2021.
|