INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and NTP monitoring conducted on December 5-6, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Healing Way was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records on December 5, 2017, the facility failed to ensure that the project director met the educational qualifications for the position.Employee # 8 was appointed to the position of project director on 7/2/17. Employee #8 only has a high school diploma.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director was changed on December 8th 2017. The individual is an owner, as well as his Bachelor's Degree is in Psychology. He has been an owner since The Healing Way has been established and handled the business management for the Healing Way for almost four years. He will be having meetings with the Facility Director to go over all planing and changes in both staff and new projects starting 12/26/2017. The facility director will have the responsibility to see the meetings happen and prepare minutes of at least monthly meetings as of 12/26/2017. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records on December 5, 2017, the facility failed to ensure that supervision is being completed by a trained counselor or clinical supervisor. Currently the counselor assistants are being supervised by the facility director. Employee # 4 was hired as a counselor assistant with a high school diploma on 9/1/17.Employee #5 was hired as a counselor assistant with a high school diploma on 10/23/17.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Due to the changes of staff the counselor assistance's were under the direct supervision of the Clinical Program Director. As the counseling room has a window directly into the counseling room for small groups and individual sessions. As of 12/22/17 each counselor assistant will be assigned a separate counselor. One counselor assistant is a Certified Peer Recovery Specialist so she will be under the lead counselor with a BA degree and the other counselor assistant will be under a supervisor with a MS degree. The Program Director will be responsible to see that they are properly supervised and the weekly supervision notes reflect intervention was done. In the event either the lead counselor of the supervisor is absent the other lead counselor or supervisor will maintain the observations. |
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 on December 5, 2017, the facility failed to ensure that all staff received the required trainings, within the required time.Employee #1 was hired on 7/2/14. Employee #1 failed to show documentation that they completed the required HIV/AIDS training.Employee #9 was hired on 2/14/15. Employee #2 failed to show documentation that they completed the required HIV/AIDS training.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The mandatory HIV/Aids six hour training that was missed by the two executives is scheduled for January 4th 2018 and any other new staff will also be scheduled for that training. That is the earliest time we could get. All the new staff are mandated to take the six hour HIV/Aids training in January. It will be the Program Directors responsibility to see that this training is done and all mandated staff attend and complete the training. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on an observation that took place at around 9am on December 5, 2017, the facility failed to ensure privacy during counseling sessions.A group session was taken place in one room with the door open and this licensing specialist could see and overhear the group session. Additionally, later that day this licensing specialist, who was in the conference room located by the group room, could still hear a group session even with both doors closed. The group room is located across the hallway from the conference room. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The group rooms will have a sign on the inside and outside of the doors that state the door must be closed during a group or meeting. A noise protector devises as used on the counseling offices will be purchased and placed at the group room. The signs will be on the doors of the group rooms and Board/meeting room by December 22, 2017 and the noise protector will also be ordered by December 22, 2017. In the mean time only one group will be run at a time with the door closed and no meetings will be held in the board/meeting room at the same time a group is in session. The door to the hallway getting to the group rooms will also be closed until the sound protectors ordered arrives. The ordering of the sound protector will be done by the COO/Office manager and the signs on the doors will be the responsibility of the the Facility Director. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records on December 6, 2017, the facility failed to obtain an informed and voluntary consent in four of seven client records, #1, 2, 3 and 5.Client record #1 - The facility had a consent to obtain for a treatment provider dated 3/31/17, which is not a valid consent.Client record #2 - Consent to release to an agency dated 11/28/16 did not show documentation of the agency ' s name. Additionally, a letter dated 8/7/17 was addressed "To Whom It May Concern".Client record #3 - Consent to release to a hospital dated 12/2/17 did not have the date staff signed to consent. Additionally, a letter dated 9/28/17 was addressed "To Whom It May Concern".Client record #5 - Three consent to releases to a treatment facility, an agency and psych was all dated 5/11/17 for the client and 5/15/17 by staff. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Addendum: due to holiday and snow the therapist will correct the consent forms for patient 1,2,3 and 5 on Monday or Tuesday January 8th, or 9th when the patient comes in their counselor will have new forms filled out.
Due to the severity of this observation a training will be done on 12/22/2017 on the proper way to fill out a consent form. The main focus will be why you do not ever put on the form "to whom it may concern". The newly appointed masters level clinical supervisor will facilitate the group. The Program Director will be responsible to see that it is done. This training will address what must be on the consent form and who it will go to in the training, as well as general information on confidentiality. Another training on Confidentiality and HIPPA will be mandated in January for all staff.
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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 on December 6, 2017, the facility failed to document a follow-up attempt in record #7.Client record #7 was admitted on 1/24/17 and involuntarily terminated on 10/24/17. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
When a patient is involuntary terminated the therapist/counselor will send a letter to the address of the patient. The therapist/counselor will follow up with a phone call a week after the letter was sent to ask if the patient received the letter and if they are receiving services at another agency. If not receiving services do they need assistance to get referred to another provider? The lead therapist/counselor will be responsible to see that staff they supervise gives them a weekly list of all involuntary discharges and will check to see that a letter was generated and sent. They will also check that a follow up call in done in a week. If no answer on the phone another letter will be sent to the address listed in the Tower Computer system Patient #7 will have a letter sent and a follow up call, the letter will be sent on 1/9/2018.
A training will be done on how to present a notification of termination of treatment from The Healing Way. The notification may be verbal but must also be in writing and present it to a individual in treatment. A training will be done by December 27, 2017. The Program Director will facilitate this training and the New Project Director will be responsible to see this training is done. All clinical and executive staff are mandated to attend this training. |
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 a review of the physician hours, the facility failed to ensure that the physician worked at least 1 hour per week onsite for every ten patients. The physician works a total of 10 hours a week. ClientsJuly 31 - Aug 5114Aug 6 - Aug 12113Aug 13 - Aug 19115Aug 20 - Aug 26116Aug 27 - Sept 2113Sept 3 - Sept 9112Sept 10 - Sept 16112Sept 17 - Sept 23113Sept 24 - Sept 30115Oct 1 - Oct 7115Oct 8 - Oct 14116Oct 15 - Oct 21113Oct 22 - Oct 28113Oct 29 - Nov 4111Nov - 5 - Nov 11111Nov 12 - Nov 18 110Nov 19 - Nov 25108Nov 26 - Dec 2110The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A review of the Medical Directors hours are to calculated by the executive staff and revisions are to be made to be in compliance with the regulations on one hour per every ten patients.The hours will be adjusted by 12/29/2017 by the new Project Director. Both the Project Director and the President of The Healing Way will be responsible to see they the hours are within the limits of the regulations and the Program Director will be also responsible to see that this has been corrected. |
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.
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Observations
Based on a review of seven client records on December 6, 2017, the facility failed to show documentation that the physician reviewed their dosage levels in client records, #2, 3, 5, 6 and 7.Client #2 was admitted on 11/26/18Client #3 was admitted on 4/5/16Client #5 was admitted on 5/11/17Client #6 was admitted on 4/6/15Client #7 was admitted on 1/24/17The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Medication Dosage review is required twice a year. To adhere to the plan of correction the Healing Way's Project Director will first try to see if a list can be generated off the Tower Computer Program. The Medical Director will be made aware of the deficiency. A Microsoft Excel spread sheet will be designed to capture this information to prevent this for occurring. The Excel spread sheet or the Tower Computer program will be able to track this for the Medical Director by January 5, 2017. The Project Director assigned the Program Director to see this project is completed and the Project Director responsible to see it is done. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of seven client records on December 6, 2017, the facility failed to ensure that the patient was receiving on average 2.5 hours of psychotherapy per month, which included 1 hours of individual psychotherapy in client records, #1, 2, 3, 4 and 7.Client #1 was admitted on 4/3/17:For the month of October 2017 was seen for a total of 1 hour (individual sessions) For the month of September 2017 was seen for a total of 2 hours (individual sessions)For the month of August 2017 was seen for a total of 1 hour (individual session)For the month of July 2017 was seen for a total of 2 hours (individual sessions)For the month of June 2017 was seen for a total of 45 minutes (individual sessions)For the month of May 2017 was seen for a total of 1 1/2 hour (individual sessions)For the month of April 2017 was seen for a total of 1 hour and 15 minutes (individual sessions)Client #2 was admitted on 11/28/16:For the month of January 2017 was seen for a total of 2 hours (individual sessions)For the month of February 2017 was seen for a total of 1 1/2 hour (individual sessions)For the month of March 2017 was seen for a total of 1 hour and 40 minutes (individual sessions)For the month of April 2017 was seen for a total of 1 1/2 hour (individual sessions)For the month of May 2017 was seen for a total of 2 hours (individual sessions)For the month of June 2017 was seen for a total of 30 minutes (individual session)For the month of July2017 no services documented (individual or group sessions)For the month of August 2017 only 30 minutes documented (individual session)For the months of September 2017 and October 2017 no services documented (individual or group sessions)For the month of November 2017 was seen for 25 minutes (individual session)Client #3 was admitted on 4/5, 2016:For the month of July 2017 was seen for a total of 1 hour and 30 minutes (individual sessions)For the month of June 2017 was seen for a total of 60 minutes (individual session)Client #4 was admitted on 7/26/17:For the month of August 2017 was seen for a total of 3 hours (group sessions)For the month of September 2017 was seen for a total of 3 hours (group sessions)For the month of October 2017 was seen for a total of 1 1/2 hour (group session) and 30 minutes (individual session)For the month of November 2017 was seen for a total of 3 hours (group sessions) and 30 minutes (individual session)Client #7 was admitted on 1/24/17 and discharged on 10/24/17:For the month of February 2017 was seen for a total of 1 hour (individual sessions)For the month of March 2017 was seen for a total of 45 minutes (individual sessions)For the month of April 2017 was seen for a total of 30 minutes (individual session)For the month of May 2017 was seen for a total of 30 minutes (individual session)For the month of June 2017 was seen for a total of 1 hour (individual session)For the month of July 2017 was seen for a total of 1 hour (individual session)For the month of August 2017 was seen for a total of 68 minutes (individual sessions)The findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
A training on what the requirements are mandating 2 1/2 will be discussed in a mandatory training by January 5, 2018. The confusion of the staff on the regulations of the 2 1/2 hours per month that have to include both individual and group sessions. The training will be the responsibility of the Program Director to facilitated the mandatory training for all the clinical staff, as well as the executive staff per the order of the Project Director. The Project Director will oversee that the training was completed. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of one transferred client record on December 6, 2017, the facility failed to notify the transferring facility in writing the client's admission and the date of their initial dose.Client #4 was transferred to this facility on 7/26/17.The finding was discussed with facility staff during the licensing inspection.
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Plan of Correction
Transfer of a patient from Medication Assisted Treatment must notify the receiving agency of the transfer in both verbal, as well as written form and given the present dose of medication.
There will be a training by January 5,2018 of clinical, nursing staff and also including the Medical Director and executive staff on this regulation and our deficiency. A patient should not have been transferred from The Healing Way to another MAT program through a verbal transfer only. There needs to be paperwork faxed from the counselor, as well as from the nursing dept. showing the last dose and recent dosing patterns, as well as basic patient information on treatment and UDS results of the patient. The counselor will be responsible to put a note in the patents chart noting the transfer information the lead counselor/supervisor will be responsible to see it is done when reviewing the staff work during supervisions. This transfer will be investigated on both the transferring and receiving programs. The training on the proper procedure will be done and all staff mentioned above will sign a form letter to be added to their personal file that they understand the procedure. This training will be done in two parts one for the clinical team and the other for the Medical, nursing and executive staff. It will be facilitated by the Program Director as directed by the Project Director. |
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 on a review of seven client records on December 6, 2017, the facility failed to document psychosocial evaluations that included the counselor's clinical impressions in records, #1, 2, 4, 5 and 7.Client #1's psychosocial evaluation was completed on 4/3/17.Client #2's psychosocial evaluation was admitted on November 28, 2016. Their psychosocial evaluation was not completed as of the date of the licensing inspection.Client #4's psychosocial evaluation was completed on 7/26/17.Client #5's psychosocial evaluation was completed on 5/11/17.Client #7's psychosocial evaluation was completed on 1/24/17.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A Psychosocial training will be done by 1/5/2018, that includes an emphasize on the counselor's clinical impression section of the psychosocial in the psychosocial. This deficiency will be emphasized in the overall training of the psychosocial. This training will be the responsibility of the clinical supervisor to facilitate the training and the Program Director will see that this training was completed. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of seven client records on December 6, 2017, the facility failed to document a preliminary treatment plan during the intake process in client records, # 4 and 5.Client #4 was admitted on 7/26/17 and their preliminary treatment plan was signed and dated by the counselor on 9/29/17 and by the client on 9/28/17.Client #5 was admitted on 5/11/17 and their preliminary treatment plan was not signed or dated until 5/31/17.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The intake, therapist and counseling staff have been notified that the initial/preliminary treatment plan is to be done at time of admission. The trainer will discuss the omitting of the treatment plan, the date of signing of the treatment plan or late signing of the treatment plan will not be tolerated by any staff. This training was discussed briefly in a meeting 12/21 and will have a formal training on this subject on or before 1/5/2018. The Program Director will facilitate this training and the Project Director will see that this training is completed. |
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 seven client records on December 6, 2017, the facility failed to ensure that counseling services are provided according to their individual treatment plan in client records, #4 and 5.Client #4 was admitted on 7/26/17 and their comprehensive treatment plan dated 9/26/17 stated that the client will be seen 1x a week for individual and group sessions each.Individual sessions:7/26/1710/24/1711/301/7Group sessions:8/6/178/17/179/7/1710/17/1711/11/1711/20/1712/2/17Client #5 was admitted on 5/11/17 and their comprehensive treatment plan dated 6/12/17 stated that the client will be seen 1x a week for individual and group sessions each.Individual sessions:8/2/178/9/178/17/178/23/178/31/179/13/179/29/17Group sessions:5/15/175/22/176/21/177/17/177/24/177/31/178/7/178/9/178/14/178/21/178/28/179/18/179/21/1710/5/17The findings were reviewed with facility staff during the licensing inspections.
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Plan of Correction
When Individuals are not following there treatment plan it has to be addressed and an addendum to the plan must be made, as well as listed in the notes.
A training on the treatment plans will be done by 1/5/2018. The training will be done by the Program Director. The Project Director will see that the training is done. It will be the supervisors/lead counselors responsibility during supervision to check a few charts on the staffs case load to see the staff are adhering to the regulations.The Supervisor or lead counselor will be responsible to see that the staff under their supervision is adhering to the regulations. The Program Director responsibility will be to check that the supervisor/lead counselor is doing there job supervising staff under them. The Project Director will be responsible to see the Program Director is doing his job checking on the supervisor. |
709.93(a) 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:
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Observations
Based on a review of seven client records on December 6, 2017, the facility failed to provide a complete client record in six of seven client records, #1, 2, 3, 5 and 7.Client #1 - The following progress notes did not have the counselor's signature: 8/11/17, 9/6/17, 9/8/17, 9/29/17, 10/6/17 and 10/30/17.Client #2 - The following progress note did not have the counselor's signature: 8/8/17.Client #3 - The following progress notes did not have the counselor's signature: 6/26/17, 7/24/17 and 7/31/17.Client #4 - The following progress notes did not have the counselor's signature: 7/26/17 and 10/24/17. Additionally, the counselor put the time of the session at 2am for 30 minutes for progress note 11/30/17.Client #5 was discharged on 11/11/17. The facility failed to document in client's record a discharge summary.Client #7 was discharged on 10/24/17. The facility failed to document in client's record a discharge summary.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client record deficiencies in the notes. Identified deficiencies that many signatures were missing in from many, also session times were wrong, as well as missing discharge information.
A few training will be done the first training will start on or before 1/5/2018. The focus is on paying attention to signatures missing on the computer program, as well as the correct time of a sessions. Discharge information was not done. The training will be done by the Program Director and it will be the responsibility of the Project Director to see it is done. A follow up in the next few weekly meeting as a reminder will be noted. The clinical supervisor and/or lead counselor will also review charts before the weekly supervision on staff that they are responsible for supervising and check on the information in the patients charts. |