INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on June 6, 2024, through June 7, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling Center 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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704.11(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 personnel records, the facility failed to ensure that one applicable employee received a minimum of 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum within the regulatory timeframe.
Employee # 9 was hired as a support staff member on April 15, 2022 and was due to have the communicable disease trainings no later than April 15, 2024. However, the personnel record contained no documentation of the completion of the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The subject employee completed the required training shortly after the required timeframe. To ensure ongoing compliance, the administrative assistant will maintain a staff training spreadsheet. Staff will be notified via e-mail, not less than quarterly, of unmet requirements. The supervisor will be copied on the email and will provide any assistance, including but not limited to, enrolling the staff person in the training to ensure compliance. |
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 personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of four applicable records reviewed.
Employee # 4 has been employed as a counselor since February 1, 2016. The facility's training year that was reviewed was from July 1, 2022 through June 30, 2023. Employee # 4's personnel record only documented 21.25 hours of training for the period reviewed.
This is a repeat citation from the June 8, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the start of the program year in July the Clinical supervisors will complete training plans with staff. The required hours as well as desired topics are included as part of the plan. Throughout the year the administrative assistant maintains a spreadsheet, and on not less than a quarterly basis sends emails to staff with their progress to date. Clinical supervisors are copied on the emails and address the matter in regular and group supervision. The CEO also stresses the importance of compliance and reiterates the various training options to achieve compliance, at staff meetings throughout the year. By June 1st of each year, all clinical staff are required to email the CEO certifying that the 25 hour requirement has been met, or specifying the trainings that will be completed prior to June 30th. The CEO and Clinical Supervisors will allow for adjustments in schedules to ensure adequate time is allotted to complete the trainings. Staff will then email the CEO prior to June 30th verifying that the 25-hour requirement has been met. |
709.28 (c) 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.
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Observations
Based on a review of eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client # 2 was admitted on July 5, 2022 and was discharged on January 26, 2024. The record contained documentation of a disclosure of information to another treatment provider on January 2, 2024, however, the record did not contain a client signed consent to release information form to the treatment provider.
Client # 4 was admitted on September 27, 2023 and was active at the time of the inspection. The record contained documentation of a disclosure of information to another treatment provider on September 28, 2023, however, the record did not contain a client signed consent to release information form to the treatment provider.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the observation with the Clinical Director and with other staff at the June 19th meeting. The importance of compliance was reiterated and counselors were instructed to focus on this area and to verify that a release of information exists prior to the dissemination of records. The clinical supervisors will reinforce the requirements in group and individual supervision. As part of the group supervision a refresher training will be provided on navigating the EHR to verify that a release of information is on 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
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Observations
Based on the review of seventeen weeks of physician and physician assistant timesheets, the facility failed to provide at least one hour of physician time a week on site for every ten patients in one week reviewed.
During the week of January 8, 2024 through January 14, 2024, the patient census was 295. The facility was required to provide at least 29.5 physician hours. There were 24 hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will seek to engage the services of a contracted physician to provide coverage during vacations or prolonged absences by the physician or physician assistant. Physicians that have worked previously with Aldie will be contacted by the CEO, and if needed resources from other facilities will be sought. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of seventeen physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census for two weeks reviewed. A physician must provide one-third of the required hours, with a certified registered nurse practitioner or physician's assistant providing the remaining two-thirds of the required hours.
During the week of January 8, 2024 through January 14, 2024, the patient census was 295. The physician was required to provide one-third of the 29.5 hours, which equals to 9.7 hours. The physician provided 0 hours.
During the week of April 1, 2024 through April 7, 2024, the patient census was 297. The physician was required to provide one-third of the 29.7 hours, which equals to 9.8 hours. The physician provided 9.5 hours.
Additionally, based on a review of patient records, the facility failed to ensure that documentation of duties performed by physician assistant or certified registered nurse practitioner (CRNP) were properly countersigned in five of seven applicable records reviewed. The written agreement between the physician assistant and the narcotic treatment physician indicates that orders written by the physician assistant will be countersigned within 72 hours.
Patient # 1 was admitted on July 21, 2023 and was active at the time of the inspection. The record contained documentation of an order by the physician assistant on May 5, 2024, which was not countersigned by the narcotic treatment physician until May 10, 2024. The record contained documentation of an order by the physician assistant on May 14, 2024, which was not countersigned by the narcotic treatment physician until May 20, 2024.
Patient # 2 was admitted on July 5, 2022 and was discharged on January 26, 2024. The record contained documentation of an order by the physician assistant on January 10, 2024, which was not countersigned by the narcotic treatment physician until January 16, 2024. The record contained documentation of an order by the physician assistant on August 4, 2023, which was not countersigned by the narcotic treatment physician until August 9, 2023.
Patient # 5 was admitted on July 5, 2023 and was discharged on April 29, 2024. The record contained documentation of an order by the physician assistant on November 8, 2023, which was not countersigned by the narcotic treatment physician until November 17, 2023.
Patient # 7 was admitted on August 8, 2017 and was active at the time of the inspection. The record contained documentation of an order by the physician assistant on February 28, 2024, which was not countersigned by the narcotic treatment physician until March 4, 2024.
Patient # 8 was admitted on October 19, 2023 and was active at the time of the inspection. The record contained documentation of an order by the physician assistant on December 7, 2023, which was not countersigned by the narcotic treatment physician until December 15, 2023. The record contained documentation of an order by the physician assistant on January 11, 2024, which was not countersigned by the narcotic treatment physician until January 16, 2024. The record contained documentation of an order by the physician assistant on February 27, 2024, which was not countersigned by the narcotic treatment physician until March 4, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Aldie will seek to engage the services of a contracted Physician to provided the required coverage during the time periods when the medical director is on vacation or otherwise not onsite for a week or more.
Regarding the observation of countersigning orders, the CEO has reviewed the matter with the medical director and PA. The Primary Supervising Physician Agreement has been updated to indicate that the supervising physician will countersign 100% of patient records completed by the PA within a reasonable amount of time. The existing agreement will be followed until such as time as the revised agreement is approved by the Pennsylvania Department of State.
The signing of the notes and compliance with the Supervising Agreement will be monitored as part of regular chart audits. |
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 a review of patient records, the facility failed to ensure that the narcotic treatment physician determined the initial dose and schedule. It was documented in the patient record that the facility's physician assistant (PA) rather than the narcotic treatment physician, determined the initial dose in one of three applicable patient records reviewed.
Patient # 8 was admitted on October 19, 2023 and was active at the time of the inspection. The initial medication order was written by the PA on October 26, 2023.
Additionally, during an observation of medication administration on June 7, 2024, the nurses in both medication windows were observed to be preparing take-home medications or looking at a computer monitor, instead of observing the patient when ingesting the agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO and Chief Nursing Officer have reviewed the matter with the medical director and the physician assistant. The medical director, or a narcotic treatment physician will determine the initial medication dose. The Chief Nursing Officer will ensure compliance.
Regarding the nursing observation error, the CEO has reviewed the matter with the Chief Nursing Officer and the Director of Nursing. Both individuals have provided instruction and training to the dispensing nurses. The supervising nurses will continue to observe compliance, and provide any further guidance, as part of regular supervisory duties. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to ensure an annual physical examination was given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician in one of three applicable records reviewed.
Patient # 7 was admitted on August 8, 2017 and was active at the time of the inspection. The annual physical examination was due no later than August 8, 2023; however, the annual physical was not completed until August 28, 2023.
This is a repeat citation from the June 8, 2023 and the June 30, 2022 annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the Chief Nursing Officer, the Director, of Nursing, and the Clinical Director. The Director of Nursing will oversee and implement a processes whereby annual examinations will be scheduled up to 90 days in advance of the due date. By allowing the additional time, appointments can be rescheduled if missed by the patient or canceled for unforeseen circumstances. Aldie believes that its internal tracking mechanism are sound, and that compliance can be obtained by adjusting the scheduling process. |
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 a review of patient records, the facility failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor in two of three applicable patient records reviewed.
Patient # 2 was admitted on July 5, 2022 and was discharged on January 26, 2024. The annual evaluation of the patient's status was due to be completed by the counselor by July 5, 2023; however, the record did not contain documentation of an annual evaluation.
Patient # 7 was admitted on August 8, 2017 and was active at the time of the inspection. The annual evaluation of the patient's status was due to be completed by the counselor by August 8, 2023; however, the record did not contain documentation of an annual evaluation.
This is a repeat citation from the June 8, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the matter with the Clinical Director, and subsequently with the staff at a meeting on June 19, 2024. The requirement was reiterated and the importance for compliance. The clinical supervisors will further address the issue in individual and group supervisor. Aldie is also exploring modifying the EHR to provide alerts as to the due date for the annual review. Absent this technological assistance, the counselors will track the due dates on a separate spreadsheet. Compliance will also be verified as part of regular chart audits. |
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 a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in five of eight applicable client records reviewed.
Client # 1 was admitted on July 21, 2023 and was active at the time of the inspection. A treatment plan update was completed on November 18, 2023, and the next treatment plan update was due no later than January 18, 2024; however, the next treatment plan update was not completed until February 18, 2024.
Client # 2 was admitted on July 5, 2022 and was discharged on January 26, 2024. A treatment plan update was completed on November 28, 2022, and the next treatment plan update was due no later than January 28, 2023; however, the next treatment plan update was not completed until August 23, 2023.
Client # 4 was admitted on September 27, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 11, 2023 and the treatment plan update was due no later than January 11, 2024; however, the treatment plan update was not completed until June 5, 2024.
Client # 7 was admitted on August 8, 2017 and was active at the time of the inspection. A treatment plan update was completed on September 30, 2023, and the next treatment plan update was due no later than November 30, 2023; however, no additional treatment plan updates were completed prior to the inspection.
Client # 8 was admitted on October 19, 2023 and was active at the time of the inspection. A treatment plan update was completed on January 19, 2024, and the next treatment plan update was due no later than March 19, 2024; however, the treatment plan update was not completed until April 2, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the matter with the Clinical Director, and subsequently with the staff at a meeting on June 19, 2024. The requirement was reiterated and the importance for compliance. The clinical supervisors will further address the issue in individual and group supervisor. Aldie is also exploring modifying the EHR to provide alerts as to the due date for the treatment plan updates. Absent this technological assistance, the counselors will track the due dates for treatment plan updates on a separate spreadsheet. Compliance will also be verified as part of regular chart audits. |
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.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information every 90 days during the first year and annually thereafter, per facility policy, in three of seven applicable records reviewed.
Client # 1 was admitted on July 21, 2023 and was active at the time of the inspection. There was no documentation of a case consultation in the record.
Client # 2 was admitted on July 5, 2022 and was discharged on January 26, 2024. The record contained case consultation information completed on November 2, 2022 and the next case consultation was due to be completed no later than November 2, 2023; however, the record contained no additional case consultation prior discharge.
Client # 8 was admitted on October 19, 2023 and was active at the time of the inspection. The first case consultation was due to be completed by January 19, 2024, however, the case consultation was not documented until April 19, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO reviewed the issue with the Clinical Director and with the staff at a meeting on June 19, 2024. The importance of compliance with reiterated. Aldie is exploring modifying the EHR to provide alters as to due dates for case consultation. Counselors currently tract the requirement on separate spreadsheet. Clinical supervisors will continue to reinforce compliance at group and individual supervision. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information within 30 days of discharge, per facility policy, in two of three applicable records reviewed.
Client # 2 was admitted on July 5, 2022 and was discharged on January 26, 2024. Follow-up information was not documented until March 29, 2024.
Client # 3 was admitted on June 11, 2020 and was discharged on September 15, 2023. The client record did not contain documentation of follow-up information.
This is a repeat citation from the June 8, 2023 and the June 30, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Aldie believes that the existing internal procedures for sending follow-up communications within 30-days occurs in the vast majority of incidents. However, the existing policy does not allow much room for human error or unforeseen circumstances. As such, the management team will review the existing policy at a meeting on July 9th. A revised policy will be in place by July 15th, extending the 30 day time period. Coupled with the revised policy will be an enhanced effort to audit all records of discharged clients within 45 days. If a follow-up communication is not found in the client record, the Clinical Director will arrange for such communication to be sent within 7 days of the finding and will verify that such action has occurred. |
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 patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing follow-up notes according to facility policy was submitted and approved by the Department for the June 8, 2023 and June 30, 2022 annual licensing inspections. Failing to complete follow-up notes was again found to be a deficiency in the June 6, 2024 through June 7, 2024 licensing inspection.
A plan of correction for completing annual physical evaluations was submitted and approved by the Department for the June 8, 2023 and June 30, 2022 annual licensing inspections. Failing to complete annual physical evaluations was again found to be a deficiency in the June 6, 2024 through June 7, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Aldie has made significant efforts to comply with prior plans of correction. Modifications and enhancements were made to both areas as outlined in the POC's. The CEO and management staff purposely and diligently implemented, monitored, and evaluated the changes throughout the year.
However, as revealed in the current licensing inspection, the full desired results of previous POC's have not been achieved. As such, Aldie has narrowed the focused to the areas that remain deficient. These actions are outlined in the observations on annual evaluations and follow-up communications with discharged clients. Enhanced monitoring and oversight of these areas will be done by the clinical directors and directors of nursing. Progress will be reviewed at monthly management meetings, and the CEO will direct any needed adjustments throughout the year. |