INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 25, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ARS of Epharta 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 a review of four personnel records, the facility failed to ensure one counselor had the educational and clinical experience prior to being hired.
Employee #4 was hired as a counselor on November 6, 2020 and is still current in that position. Employee #4 has a bachelor ' s degree in social work but does not have the documented one year of clinical experience to qualify as a counselor.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Executive Director reviewed this regulation with DDAP auditor to ensure thorough understanding of what qualifies as clinical/counseling experience versus case management experience. Effective immediately when reviewing resumes for an open clinical position, the Executive Director will differentiate between clinical/counseling and case management experience. Executive Director will ensure all future candidates have the appropriate required credentials and level of experience meeting regulation 704.7(b).
Employee number 4 officially has one year of clinical experience as of November 6, 2021 which is her 1 year anniversary in her current position which means that she now meets the requirements for her current position as a counselor. During her time of employment she has taken her ASAM certification and has worked on completing all required DDAP trainings. Her training plan includes working toward her CADC. She meets with CS for weekly individual supervision and participates in group clinical supervision and weekly treatment team meetings. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Based on a review of fire drills from October 2020 thru September 2021, the facility failed to ensure that the fire drill log included exit routes used and whether the fire alarm or smoke detector was operative for all fire drills.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Fire/Emergency drill log was updated on 11/3/2021 to include check boxes identifying whether the fire alarm was sounded, and a line was added to identify which exits were used during the drill. This log was disseminated to all PA locations for immediate implementation. Executive Director reviews the form each month to ensure completion and review the findings of the drill(s). |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of fire drills from October 2020 thru September 2021, the facility failed to document if the facility set off a fire alarm or smoke detector during each fire drill.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Fire/Emergency drill log was updated on 11/3/2021 to include check boxes identifying whether the fire alarm was sounded, and a line was added to identify which exits were used during the drill. This log was disseminated to all PA locations for immediate implementation. Health and safety officer is responsible for filling out this form each month during emergency/fire drills. Executive Director reviews the form each month to ensure completion and review the findings of the drill(s). |
715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
|
Observations
Based on a review of seven patient records, the facility failed to document what materials were sent to the receiving narcotic treatment program in one patient record reviewed.
Patient #5 was admitted on October 25, 2021 and was discharged on October 6, 2021. No documentation of material sent was in the patient record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The clinical supervisor will provide a training to all staff on which documentation needs to be sent to the new facility that a patient is transferring to, how to document this information in the patient's chart, and how to verify that the information was received by the patient's new clinic. This training will occur on 11/30/2021 in during group clinical supervision. Counselors will be responsible for sending all required paperwork to the facility that the patient is transferring to upon their discharge from our facility.
Quarterly peer review audits will be conducted on patient charts to ensure continued compliance with appropriately completing discharge paperwork including sending of appropriate transfer paperwork upon discharge. Peer review audits are conducted by the counselors are the charts initially and then reviewed by the CS and ED before being submitted to the Quality Assurance manager.
|
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.
|
Observations
Based on a review of three applicable client records, the facility failed to ensure that all closed client records contained follow up information in two records reviewed.
Client #3 was admitted on May 29, 2021 and discharged on Judy 7, 2021, the record contained no follow up documentation.
Client #7 was admitted on April 16, 2021 and was discharged on August 30, 2021, the record contained no follow up documentation.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
A training was conducted with the Clinical director on 9/28/2021 following our CARF survey in which the purpose of post-discharge follow-up calls were discussed including the process for these calls. Counselors were then trained on making these calls within 14 days of a patient's discharge from the program and documenting the call in a case management note with the intention of re-engaging the patient in treatment. Clinical supervisor reviews that these calls are made as discharges are entered into the monthly discharge report which has been being conducted since 10/1/2021. |