INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 2-4, 2013 by staff from the Division of Drug and Alcohol 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:
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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 employee training records, the facility failed to provide documentation of STD/TB training in three of seven employee records.
The findings include:
Twelve employee records were reviewed on October 2, 2013. Seven of the employees reviewed were employed for a length of time to require completion of at least four hours of TB/STD training. The facility failed to provide documentation of at least four hours of TB/STD training in employee records # 10, 11 and 12.
Employee #10 was hired as a counselor on May 14, 2012 and was required to obtain at least 4 hours of TB/STD training by May 14, 2013. There was no documentation of the completion of TB/STD training at the time of the inspection.
Employee #11 was hired as a counselor on August 27, 2012 and was required to obtain 4 hours of TB/STD training by August 27, 2013. There was no documentation of the completion of TB/STD training at the time of the inspection.
Employee #12 was hired as a counselor on June 4, 2012 and was required to obtain 4 hours of TB/STD training by June 4, 2013. There was no documentation of the completion of TB/STD training at the time of the inspection.
An interview with the project / facility director took place on October 2, 2013 and the findings were discussed and confirmed.
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Plan of Correction
All staff will have the required STD/TB training within the first year of employment. Staff who have not completed the STD/TB training as of the date of the site visit will have the STD/TB training completed using the state approved curriculum. Training will be completed by December 31, 2013. The Director of Social Services will monitor compliance with the training requirement. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in three of three client records.
The findings include:
Sixteen client records were reviewed on October 2-4, 2013. Six of the client records reviewed were that of discharged clients. Three of the discharged clients were involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 11, 12 and 15.
Client # 11 was admitted into treatment on October 12, 2012 and was involuntarily terminated from the project on June 20, 2013. There was no documentation of written notification provided to the client as of the time of the on-site inspection.
Client # 12 was admitted into treatment on October 9, 2012 and was involuntarily terminated from the project on May 20, 2013. There was no documentation of written notification provided to the client as of the time of the on-site inspection.
Client # 15 was admitted into treatment on December 21, 2012 and was involuntarily terminated from the project on May 22, 2013. There was no documentation of written notification provided to the client as of the time of the on-site inspection.
An interview with the project / facility director and clinical supervisor took place on October 4, 2013 and the findings were discussed and confirmed.
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Plan of Correction
All patients will be notified in writing and the patient chart will document their notification of the decision to involuntarily terminate the patient from treatment. The Director of Social Services will monitor compliance. Effective date of compliance will be 11/1/2013. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on the review of patient records, the facility failed to restrict the reasons for involuntary termination to those allowed by regulation in one of three patient records.
The findings include:
Six patient records were reviewed October 2-4, 2013. Three patient records were reviewed for involuntary or therapeutic discharge. One patient record contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient # 15 was admitted December 21, 2012 and discharged on May 22, 2013. The discharge summary dated May 23, 2013, stated that the patient was given a 7-day detoxification due to "Failure to pay" which is not one of the reasons allowed by regulation for termination. There were no financial goals documented on the treatment plan or updates.
An interview with the project / facility director took place on October 4, 2013 at which time the findings were discussed and confirmed.
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Plan of Correction
All involuntary patient terminations will comply with the regulation for reasons for termination. The Director of Social Services will monitor compliance. Effective date for compliance will be 11/1/2013. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based upon a review of client records, the facility failed to document a psychosocial evaluation that included an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors and attitude toward treatment in seven of ten client records.
The findings include:
Sixteen client records were reviewed on October 2-4, 2013, ten of which were reviewed for psychosocial evaluations. Seven out of ten records lacked documentation of a psychosocial evaluation that included an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors and attitude toward treatment, specifically records # 1, 3, 5, 6, 7, 9 and 10.
Client #1 was admitted on May 8, 2013. The psychosocial evaluation, dated May 8, 2013, failed to include an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors and attitude toward treatment. The documentation included a repeat of the client reported information and did not include an assessment by the clinician for the required components.
Client #3 was admitted on August 5, 2013. The psychosocial evaluation, dated August 5, 2013, failed to include an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors and attitude toward treatment. The documentation included a repeat of the client reported information and did not include an assessment by the clinician for the required components.
Client #5 was admitted on May 20, 2013. The psychosocial evaluation, dated May 20, 2013, failed to include an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors and attitude toward treatment. The documentation included a repeat of the client reported information and did not include an assessment by the clinician for the required components.
Client #6 was admitted on June 18, 2013. The psychosocial evaluation, dated June 18, 2013, failed to include an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors and attitude toward treatment. The documentation included a repeat of the client reported information and did not include an assessment by the clinician for the required components.
Client #7 was admitted on September 3, 2013. The psychosocial evaluation, dated September 3, 2013, failed to include an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors and attitude toward treatment. The documentation included a repeat of the client reported information and did not include an assessment by the clinician for the required components.
Client #9 was admitted on July 9, 2013. The psychosocial evaluation, dated July 9, 2013, failed to include an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors and attitude toward treatment. The documentation included a repeat of the client reported information and did not include an assessment by the clinician for the required components.
Client #10 was admitted on August 6, 2013. The psychosocial evaluation, dated August 6, 2013, failed to include an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors and attitude toward treatment. The documentation included a repeat of the client reported information and did not include an assessment by the clinician for the required components.
An interview with the project / facility director and clinical supervisor took place on October 4, 2013 and the findings were discussed and confirmed.
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Plan of Correction
The interpretive summary for all patients enrolled in the program will include an assessment of the patients problems/needs, assets/strengths, support systems, coping mechanisms,negative factors and attitude toward treatment. Training will be conducted by the Director of Social Services to ensure that all clinical personnel adhere to the requirement and document in the patient chart the interpretive summary which conforms to the regulation. The Chief Operations Officer will monitor compliance with this documentation. Effective date 11/1/2013. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the type and/or frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five of ten client records.
The findings include:
The individual treatment and rehabilitation plans in 10 client records were reviewed on October 2-4, 2013. All ten client records contained individual treatment and rehabilitation plans which were required to include the type and frequency of treatment and rehabilitation services. The individual treatment and rehabilitation plans contained in client records # 1, 4, 5, 8 and 9 did not include the type and/or frequency of treatment and rehabilitation services
Client # 1 was admitted on May 8, 2013 and the individual treatment and rehabilitation plan was developed on June 11, 2013. The individual treatment and rehabilitation plan failed to include the type and frequency of treatment and rehabilitation services.
Client # 4 was admitted on June 18, 2013 and the individual treatment and rehabilitation plan was developed on July 2, 2013. The individual treatment and rehabilitation plan stated "weekly counseling" failed to include the type of counseling to be provided.
Client # 5 was admitted on May 20, 2013 and the individual treatment and rehabilitation plan was developed on June 11, 2013. The individual treatment and rehabilitation plan included documentation of "three sessions" but failed to include the type of counseling to be provided.
Client #8 was admitted on September 3, 2013 and the individual treatment and rehabilitation plan was developed on October 4, 2013. The individual treatment and rehabilitation plan included documentation of "three - five hours a month" but failed to include the type of counseling to be provided.
Client #9 was admitted on July 31, 2013 and the individual treatment and rehabilitation plan was developed on August 19, 2013. The individual treatment and rehabilitation plan failed to include they type and frequency of treatment and rehabilitation services.
An interview with the project / facility director and the clinical supervisor took place on October 4, 2013 at which time the findings were discussed and confirmed.
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Plan of Correction
All patient records will include documentation of the type and/or frequency of treatment and rehabilitation services on the individual treatment plan. The Director of Social Services will monitor compliance with this procedure.Effective date for compliance 11/1/2013. |