INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the licensure renewal and the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on April 14 - 15, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northeast Family Health Care, LLC was found not to be in compliance with the applicable chapters of 4 PA Code and 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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704.7(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
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of five personnel records reviewed.
The findings include:
Five clinical personnel records were reviewed on 4/14/2015. The facility failed to ensure that employee # 2 met the experiential requirements for the position of counselor.
Employee # 2 was hired as a bachelor's level counselor on 12/10/2014. Employee # 2 did not meet the qualifications for the position of counselor as the employee did not have one year of clinical experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will review and provide Employee #2 with an updated and corrected job description reflecting the requirements of a counselor assistant, upon completion placing it in the counselor assistant's employee personnel file.
Additionally, facility director will provide weekly supervision until Employee #2 has met the requirements of a Bachelor's level counselor according to 704.7 and is able to provide clinical services meeting the criterion. Counselor assistant will also complete all required trainings as outlined in the employee's training plan.
Facility Director will review all new hire applicants and qualifications as well as human service experience, and compare to the requirements of a counselor and/or counselor assistant to ensure that all criterion are met prior to hire. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all exits from the facility were unobstructed.
The findings include:
Physical plant inspections were conducted on 4/14/2015 at approximately 12:50 PM and 4/15/2015 at 1:35 PM.
The main entrance door into the front of the facility was locked via a key operated dead-bolt mechanism that restricted egress from the facility on the dates and times of the physical plant inspections. The main entrance door is labeled and utilized as an exit route from the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will have a push bar installed on the front door within 7 days (by 5/5/15) to ensure that the fire exit is accessible and able to be unlocked, at all times in case of an emergency.
Staff will periodically observe and monitor the push bar at the front door to ensure that it is not obstructed and that it is able to be utilized as a fire exit throughout the day and all hours of business. |
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 one of four client records.
The findings include:
Four client records requiring written notification to the client of the facility's decision to involuntarily terminate the client's treatment were reviewed on 4/14/2015 - 4/15/2015. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the facility in client record # 12.
Client # 12 was admitted into treatment on 11/5/2014 and was involuntarily terminated from the facility on 1/19/2015. There was no documentation of written notification of the facility's decision to involuntarily terminate the client's treatment as of the date of the on-site inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with 709.33, all clients who are involuntarily terminated from the program will be provided with a letter informing them of the date of discharge from the program.
Client#12 will be sent a letter of termination from treatment by 4/29/15 informing the client of the involuntary termination from the program.
Facility Director will review all discharged charts upon the client's discharge from the program, to ensure that the client has been provided with a termination letter, documenting date of termination, and information regarding returning to the program as well as local crisis information as part of the document. All discharged charts will be reviewed prior to closing charts, discharge reviews will be conducted monthly to ensure completion and that all involuntarily terminated clients receive a letter upon discharge. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to ensure that the consent to methadone treatment contained all of the informative content required by regulation in ten of ten patient records.
The findings include:
Ten patient records requiring documentation of the patient's consent to methadone treatment were reviewed on 4/14/2015 - 4/15/2015. The facility failed ensure that the consent to methadone treatment contained all of the informative content required by regulation in patient records 2, 3, 4, 6, 7, 8, 9, 10, 11 and 12.
Client # 2 was admitted to outpatient methadone treatment on 12/19/2014. Client # 2's consent to methadone treatment dated 12/24/2014 did not list that alternative methods of treatment exist.
Client # 3 was admitted to outpatient methadone treatment on 10/28/2014. Client # 3's consent to methadone treatment dated 11/3/2014 did not list that alternative methods of treatment exist.
Client # 4 was admitted to outpatient methadone treatment on 10/6/2014. Client # 4's consent to methadone treatment dated 10/15/2014 did not list that alternative methods of treatment exist.
Client # 6 was admitted to outpatient methadone treatment on 8/6/2014. Client # 6's consent to methadone treatment dated 8/6/2014 did not list that alternative methods of treatment exist.
Client # 7 was admitted to outpatient methadone treatment on 9/22/2014. Client # 7's consent to methadone treatment dated 9/24/2014 did not list that alternative methods of treatment exist.
Client # 8 was admitted to outpatient methadone treatment on 8/29/2014. Client # 8's consent to methadone treatment dated 8/29/2014 did not list that alternative methods of treatment exist.
Client # 9 was admitted to outpatient methadone treatment on 7/7/2014. Client # 9's consent to methadone treatment dated 7/9/2014 did not list that alternative methods of treatment exist.
Client # 10 was admitted to outpatient methadone treatment on 6/20/2014. Client # 10's consent to methadone treatment dated 6/20/2014 did not list that alternative methods of treatment exist.
Client # 11 was admitted to outpatient methadone treatment on 5/9/2014. Client # 11's consent to methadone treatment dated 5/12/2014 did not list that alternative methods of treatment exist.
Client # 12 was admitted to outpatient methadone treatment on 11/5/2014. Client # 12's consent to methadone treatment dated 11/12/2014 did not list that alternative methods of treatment exist.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Patients 2, 3, 4,6,7,8,9,10,11 & 12 will have updated medical charts which will be completed by Facility Director and nursing staff with a consent that meets the criterion of the consent to methadone treatment by 6/1/15. The corrected consent which was implemented on 4/29/15 for methadone treatment will include the following information including (1) that methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision. (2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results. (3) That alternative methods of treatment exist. (4) That the possible risks and complications of treatment have been explained to the patient. (5) That methadone is transmitted to the unborn child and will cause physical dependence. All charts will have updated consents that reflect the aforementioned information by 6/1/15. In order to ensure that all charts have the updated and correct consent, Facility Director will review the charts monthly. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in five of twelve client records reviewed.
The findings include:
Twelve client records were reviewed for counseling services on 4/14/2015 - 4/15/2015. The project failed to ensure that clients received counseling services according to the client's individual treatment and rehabilitation plan in client records # 5, 6, 9, 10 and 11.
Client record # 5 contained a treatment plan dated 12/22/2014 that identified the counseling services to be provided as group therapy sessions 2 times per month. The only group therapy sessions scheduled for the client in January 2015 through February 2015 were on 1/31/2015 and 2/24/2015.
Client record # 6 contained a treatment plan dated 9/24/2014 that identified the counseling services to be provided as individual therapy sessions 2 times per month and group therapy sessions 1 time per month. There were no individual therapy sessions scheduled for the client in November 2014.
Client record # 9 contained a treatment plan dated 10/7/2014 that identified the counseling services to be provided as individual therapy sessions 1 time per month. There were no individual therapy sessions scheduled for the client in November 2014.
Client record # 10 contained a treatment plan dated 10/23/2014 that identified the counseling services to be provided as group therapy sessions 1 time per month. There were no group therapy sessions scheduled for the client in November 2014 and December 2014.
Client record # 11 contained treatment plans dated 9/30/2014 and 11/28/2014 that identified the counseling services to be provided as individual therapy sessions 1 times per month and group therapy sessions 2 times per month. There were no individual therapy sessions scheduled for the client in November 2014 and no group therapy sessions scheduled for the client in December 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #5,6,9, 10 and 11 will have updated treatment plans reflective of the services provided.
Facility director will facilitate a staff training identifying treatment planning training within the next 30 days (by 5/28/15) to ensure that all therapists are documenting how the client will achieve treatment hours.
Additionally, facility director will conduct monthly chart reviews of all client charts, to ensure that the treatment plan reflects the service provided. |