INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection conducted on November 29, 2016 through November 30, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, The Consortium 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 the 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 and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #1 and #2 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe.
Employee #1 was hired as a counselor on 11/02/2015 and was due to have both communicable disease trainings no later than 11/02/16. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #2 was hired as a counselor 4/29/2015 and was due to have both communicable disease trainings no later than 4/29/16. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employees #1 and #2 will have the required HIV/AIDS and TB/STD training by 3/15/16.
Responsible Party(s):
The Supervisors are responsible for ensuring that all direct reports receive a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe.
Ongoing Monitoring: The Supervisors will schedule all new staff for the HIV/AIDS and TB/STD required training within 90 days of hire. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the physical plant inspection that was conducted on November 30, 2016 at approximately 11:00 am, the facility failed to ensure that the grounds of the facility was maintained in a clean, safe, and sanitary manner as evidenced by the following:
1. Vestibule located near room 136 (child care area)-the tile floor was cracked and chipping
2. The women's restroom by the waiting area-the door hinge was removed and the door would not close without assistance. If a person did not close the door behind them, it would remain open.
3. Room 151 had stained ceiling tiles and the wall was stained and cracked.
4. Room 162 had cracked floor tiles.
5. The dosing room's (nursing station) floor tiles were worn, cracked, and peeling.
6. The entire hallway on the 2nd floor had tiles that were either cracked, chipped, broken, or peeling.
7. The chair rail between in the hallway between Rooms 245 and 205 was broken and hanging off the wall.
8. Room 226 (storage room) had a wall that was crumbling from water damage.
9. Carpets were stained in the following rooms: 202, 204, 206, 207, unmarked room by 207, 213, 214, 215, 217, 227, 239, 241, 242, 243, 244, and 249.
10. Floor tiles were cracked/broken in the following rooms: 205, 209, 210, 226, 229, 231, 231, 2 unmarked room by 232, 233, 234, 237, and 238
This is a repeat citation (although the rooms are different) from the prior licensing renewal inspection conducted on 08/03/2016 through 08/04/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Vestibule located near room 136 (child care area)where the tile floor was cracked and chipping will be repaired by 1/20/17.
2. The women's restroom by the waiting area, where the door hinge was removed and the door would not close, was repaired as of 12/1/16.
3. Stained ceiling tiles, as well as the cracked and stained wall in room 151 will all be repaired/replace by 1/20/17.
4.Cracked floor tiles in room 162 will be repaired by 1/20/17.
5. The dosing room's (nursing station) floor tiles, that were worn, cracked, and peeling will be repaired/replaced by 1/20/17.
6. The entire hallway on the 2nd floor, which had tiles that were either cracked, chipped, broken, or peeling will be repaired by 2/17/17.
7. The chair rail in the hallway between Rooms 245 and 205, which was broken and hanging off the wall will be repaired by 12/30/16.
8. Room 226, which (storage room) had a wall that was crumbling from water damage, will be repaired by 1/27/17.
9. Carpets that were stained in rooms: 202, 204, 206, 207, unmarked room by 207, 213, 214, 215, 217, 227, 239, 241, 242, 243, 244, and 249, will be thoroughly cleaned/replaced by 1/17/17.
10. Floor tiles that were cracked/broken in rooms: 205, 209, 210, 226, 229, 231, 231, 2 unmarked room by 232, 233, 234, 237, and 238 will be replaced by 1/17/17.
Responsible Party(s): The Facilities Dept is responsible for ensuring that the grounds of the facility are maintained in a clean, safe, and sanitary manner.
Ongoing Monitoring:Facilities Staff will monitor grounds and document daily rounds to ensure all issues are addressed in a timely manner.
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705.23 (2) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on the physical plant inspection that was conducted on November 30, 2016 at approximately 11:00 am, it was observed that there were multiple stained/dirty chairs in Room 249.
This is a repeat citation (although the rooms are different) from the prior licensing renewal inspection conducted on 08/03/2016 through 08/04/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The stained/dirty chairs in room 249 will be removed and replaced with non cloth or non stained, clean chairs by 1/20/17.
Responsible Party: The Facilities Dept is responsible for maintaining counseling areas with furnishings which are in good repair.
Ongoing Monitoring: The Facilities Dept will ensure that all furniture in the building is assessed during daily rounds and if necessary, furniture removed within 48 hours if not in good repair. |
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 the physical plant inspection that was conducted on November 30, 2016 at approximately 11:00 am, the facility failed to ensure that counseling sessions could not be heard outside of the peer specialist office-Room 218, as the Licensing Specialists were able to clearly hear the content of a session with a client.
This is a repeat citation (although the room is different) from the prior licensing renewal inspection conducted on 08/03/2016 through 08/04/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Additional sound machines will be ordered for the rooms where sessions can be heard outside of the counseling office,including room 218. To allow time for ordering and receipt of machines, all sound machines will be in use by 1/31/17. Until machines arrive, and are in place staff will be reminded to ensure sessions keep noise minimal, as to not be heard outside of the group and counseling session offices.
Counselors will also ensure that doors are closed during individual and group sessions.
Responsible Party: All staff is responsible for ensuring that noise cannot be heard outside of the counseling office.
Ongoing Monitoring: Facilities and Security staff will conduct walk throughs of the hallways outside of the counseling areas daily to ensure noise cannot be heard outside of the session.
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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant inspection that was conducted on November 30, 2016 at approximately 11:00am, the facility failed to maintain every bathroom in a sanitary manner as evidenced by graffiti being found on the walls and stalls of three first floor bathrooms: the men's room near the chart room, the ladies room near the chart room, and the men's room near room 157.
This is a repeat citation from the prior licensing renewal inspection conducted on 08/03/2016 through 08/04/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Bathrooms identified to have graffiti on the walls and stalls, will have all graffiti removed by 12/31/16.
Thereafter, bathrooms will be checked 1-2 times daily as part of the Facilities' staff daily rounds. Any graffiti noted, will be removed within 48 hours of identification.
Responsible Party:
The Facilities Dept is responsible for maintaining each bathroom in a functional, clean and sanitary manner at all times.
Ongoing Monitoring:
Facilities Staff will ensure bathrooms are thoroughly cleaned and graffiti free as part of their daily rounds.
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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 the physical plant inspection that was conducted on November 30, 2016 at approximately 11:00 am, the facility failed to ensure that the basement's 2nd exit door (to outside the facility) was not obstructed in any way. The door was very difficult to open initially and once it was opened it was just as difficult to close. The top hinge of the door did not have a hinge pin inserted, which resulted in the door not being attached to the door jamb securely.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The door identified as being deficient will be repaired by 1/20/17.
Responsible Party: The Facilities Dept is responsible for ensuring that all exit doors are operable and unobstructed at all times.
Ongoing Monitoring: The Facilities Dept will check all exit doors as part of their daily rounds and will place a work order request within 48 hours of identification of the issue. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection conducted on November 30, 2016 at approximately 11:30 am, the facility failed to ensure that all hard copy patient records were kept in locked storage containers and that there was no ability of unauthorized persons to gain access to such records in Rooms 134 and 140. These two rooms were being utilized to store discharged patient charts that were going to be stored/destroyed by an outside agency; however, there were maintenance supplies also located in the rooms, which would allow unauthorized persons access to the records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Rooms 134 and 140 will have all files placed in locked storage containers where unauthorized persons cannot have access,or files will be removed and archived off site by 12/29/16. Process to archive has changed, and takes more time to archive records in order to be in compliance for the pickup.
The Medical Records and Facilities Staff are responsible for ensuring that all records are stored in locked containers with no access to unauthorized persons.
Ongoing Monitoring: The Medical Records staff will ensure that all files are secured as required or archived off site as documented in the agency policy.
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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 the review of patient records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in patient record #'s 1, 3, 7, 18, and 20. Additionally, patient record #'s 6 and 17 had consent to release forms that were missing either the the specific information to be released or the name of the person or organization to whom the disclosure was made to.
Patient #1 was admitted on 10/10/2014 and was still active at the time of the inspection.
There were six consent to release information forms (urinalysis lab, transportation company, significant other, government agency, primary physician, and funding source) signed and dated on 9/30/15 that expired on 9/30/16 and there was no documentation that any of the release of information forms were updated. Additionally, there was a consent to release information form to a case manager, signed and dated on 11/3/15 and was not updated after it expired on 11/3/16.
Patient #3 was admitted on 8/25/2014 and was still active at the time of the inspection. There were seven consent to release information forms (urinalysis lab, transportation company, a family member, government agency, primary physician, and 2 funding sources), all signed and dated on 8/5/15, that expired on 8/5/16. There was no documentation that any of the release of information forms were updated.
Patient #6 was admitted on 9/08/2014 and was still active at the time of the inspection. There were two consent to release information forms (a transportation company and a hospital) signed and dated on 9/23/16. The specific information to be released was not identified on neither consent form.
Patient #7 was admitted on 3/18/2014 and was still active at the time of the inspection. There were four consent to release information forms (urinalysis lab, a family member, government agency, and primary physician), all signed and dated on 11/18/15, (urinalysis lab, transportation company, significant other, government agency, primary physician, and funding source) that expired on 11/18/16. There was no documentation that any of the release of information forms were updated.
Patient #17 was admitted on 5/27/2016 and was still active at the time of the inspection. There was a consent to release information form signed and dated on 5/25/16 with no purpose of disclosure documented and no name of the person or organization to whom the disclosure would be made to.
Patient #18 was admitted on 8/19/2013 and was still active at the time of the inspection. There was a consent to release information form to the funding source, signed by the client and a witness; however, the dated signatures of the client and witness was 8/26/2018, thus making the consent invalid.
Patient #20 was admitted on 5/16/2012 and was discharged on 9/16/2016. There was a consent to release information form to the urinalysis lab signed and dated on 6/16/15 and expired on 6/16/16 and there was no documentation that the consent form was updated at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff will be retrained on the documentation of informed and voluntary consent to release information form prior to the disclosure of information by 1/20/17.
Consents for chart #1,3,6,7,17,18 and 20 will be updated by 12/19/16.
Responsible Party(s): Counselors are responsible for ensuring that all consents are updated within the required time frames. Supervisors are responsible for ensuring that all consents are completely and accurately filled out.
Ongoing Monitoring: Supervisors will increase monitoring of deadlines for all releases of information. Additionally supervisors will increase review of all consents submitted to them to ensure all elements are completely filled out. |
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 timesheets presented during the presubmission process and re-reviewed on November 29, 2016, the facility failed to ensure that the narcotic treatment physician provided at least 1 hour per week onsite for every ten patients during the weeks of 8/26/16, 9/02/16, and 9/09/16.
During the week of 8/26/16, the facility's weekly census was 313, which results in the physicians requiring to provide at least 31.3 hours for the week. The timesheets for the narcotic treatment physicians employed by the facility have a total of 16.5 hours for the week.
During the week of 9/02/16, the facility's weekly census was 316, which results in the physicians requiring to provide at least 31.6 hours for the week. The timesheets for the narcotic treatment physicians employed by the facility have a total of 10.0 hours for the week.
During the week of 9/09/16, the facility's weekly census was 302, which results in the physicians requiring to provide at least 30.2 hours for the week. The timesheets for the narcotic treatment physicians employed by the facility have a total of 23.0 hours for the week.
This is a repeat citation (although the weeks are different) from the prior licensing renewal inspection conducted on 08/03/2016 through 08/04/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director will ensure that time scheduled off or out, is covered by another physician.
Responsible Party: The Medical Director is responsible for ensuring that there are sufficient physician hours to maintain at least 1 hour per week onsite for every ten patients in relation to the weekly census.
Ongoing Monitoring: The Chief Medical Officer will supply a schedule monthly to account for absences and scheduled off time to maintain adequate coverage. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of client records, client record # 7 did not receive individual counseling sessions in accordance with regulatory timeframe for an individual with 3 to 4 years of treatment at a narcotic treatment program.
Client #7 was admitted on 03/18/2014 and was still active at the time of the inspection. The client's chart did not have any documented psychotherapy sessions for the months of August 2016 and November 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be retrained to ensure that individual counseling sessions are occurring in accordance with regulatory time frames by 1/20/17.
Responsible party(s): Counselors are responsible for ensuring that they provide individual counseling sessions in accordance to regulatory time frames.
Supervisors are responsible for monitoring that counselors schedule and provide individual sessions as required.
Ongoing Monitoring: Weekly reports will be run to monitor individual session completion. |
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 client records, the facility failed to provide documentation of a completed counselor's annual evaluation in client record #'s 1, 3, 7, 18, 20, and 22.
Client #1 was admitted on 10/10/2014 and was still active at the time of the inspection. The last annual evaluation was completed on 9/30/15 and the next one was due no later than 9/30/16. There was no documentation of the evaluation in the client record at the time of the inspection.
Client #3 was admitted on 08/25/2014 and was still active at the time of the inspection. There was no documentation of any annual evaluations in the client record at the time of the inspection.
Client #7 was admitted on 03/18/2014 and was still active at the time of the inspection. The last annual evaluation was completed on 11/18/15 and the next one was due no later than 11/18/16. There was no documentation of the evaluation in the client record at the time of the inspection.
Client #18 was admitted on 08/19/2013 and was still active at the time of the inspection. The last annual evaluation was completed on 08/26/15 and the next one was due no later than 08/26/16. There was no documentation of the evaluation in the client record at the time of the inspection.
Client #20 was admitted on 5/16/2012 and was discharged on 09/16/2016. The last annual evaluation was completed on 07/07/15 and the next one was due no later than 07/07/16. There was no documentation of the evaluation in the client record at the time of the inspection.
Client #22 was admitted on 10/15/2012 and was discharged on 11/01/2016. The last annual evaluation was completed on 10/19/15 and the next one was due no later than 10/19/16. There was no documentation of the evaluation in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Record #'s 1, 3, 7, and 18 will have outstanding annual evaluations completed by 12/31/16.
Responsible Party(s): The Counselors are responsible for ensuring that all annual evaluations are fully documented at the anniversary date of the client's admission date each year.
The Supervisors are responsible for monitoring the submission of annual evaluations by the anniversary dates.
Ongoing Monitoring: Supervisors will increase monitoring of the due dates of all annual evaluations and will request submission one week prior to due date.
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715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
Based on a review of client records, client record # 21, who was admitted on 07/11/2016 and was discharged on 11/10/2016, did not have a comprehensive treatment plan documented in the client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be trained on the timelines and importance of completing comprehensive treatment plans within the required time frames by 1/20/17.
The Clinical Supervisors will increase monitoring of comprehensive treatment plan submission to ensure they are being completed as required.
Responsible Party: The Counselor is responsible for completing comprehensive treatment plans as required.
Ongoing Monitoring: The Clinical Supervisor will track and monitor completion of comprehensive treatment plans to ensure they are being done within 30 days of admission.
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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 the review of patient records, the facility failed to document treatment plan updates within the regulatory timeframe in patient record #'s 7, 9, 11, 16, 18, 19, and 20.
Patient #7 was admitted on 03/08/2014 and was still an active patient at the time of the inspection. An updated treatment plan was completed on 09/12/16 and the next treatment plan update was due no later than 11/12/16; however, the update was not documented at the time of the inspection.
Patient #9 was admitted on 02/24/2016 and was still an active patient at the time of the inspection. An updated treatment plan was completed on 05/31/16 and the next treatment plan update was due no later than 07/31/16; however, there has been no update documented at the time of the inspection.
Patient #11 was admitted on 08/18/2016 and was still an active patient at the time of the inspection. An updated treatment plan was completed on 08/18/15 and the next treatment plan update was due no later than 10/08/16; however, it was not completed until 11/10/16.
Patient #16 was admitted on 08/24/2016 and was still an active patient at the time of the inspection. The comprehensive treatment plan was completed on 09/22/16 and the next treatment plan update was due no later than 11/22/16; however, the update was not documented at the time of the inspection.
Patient #18 was admitted on 08/19/2013 and was still an active patient at the time of the inspection. An updated treatment plan was completed on 10/26/16 and the next treatment plan update was due no later than 10/08/16; however, it was not completed until 11/09/16.
Patient #19 was admitted on 03/16/2015 and was still an active patient at the time of the inspection. An updated treatment plan was completed on 09/01/16 and the next treatment plan update was due no later than 11/01/16; however, it was not completed until 11/18/16.
Patient #20 was admitted on 05/16/2016 and was discharged on 09/16/2016. An updated treatment plan was completed on 05/24/16 and the next treatment plan update was due no later than 07/24/16; however, it was not completed until 08/26/16.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Records #'s 7, 9, 11, 16, 18, and 19 will have updated treatment plans completed by 12/23/16 if not done so.
Responsible Party(s):Counselors are responsible for updating treatment plans every 60 days as required.
Supervisors are responsible for ensuring that counselors submit the updates on a timely basis as required.
Ongoing Monitoring: Clinical Supervisors will track and monitor completion of treatment plans to ensure they are being done as required.
Clinical Supervisors will review sampling of charts quarterly to ensure all treatment plans completed are in the client record as required.
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