INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27-29, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, with the inspection also conducted for the approval to use Methadone and Buprenorphine in the treatment of narcotic addiction. Based on the findings of the on-site inspection, Dolminis 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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704.9(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
The facility failed to ensure that three out of four Counselor Assistants had close supervision during the first six months of employment. Staff # 8 was hired on January 21, 2019 as a Counselor Assistant. Staff # 8 was missing supervision for the weeks of March 3-9, 2019 and May 26-June 1, 2019. Staff #10 was hired on August 28, 2019 as a Counselor Assistant. Staff # 10 was missing supervision for the weeks of September 16-22, 2018, February 10-16, 2019 and February 17-23, 2019. Staff #11 was hired on March 4, 2019 as a Counselor Assistant. Staff #11 was missing supervision for the weeks of March 17-23, 2019, March 24-30, 2019, April 7-13, 2019, June 16-22, 2019 and July 11-17, 2019. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A facility grid has been developed and added to a Smartsheet to assist clinical directors with monitoring of clinical supervision dates and documentation of ongoing supervision sessions. Supervision notes will be uploaded to the Smartsheet where they can be easily reviewed and monitored monthly by the clinical directors. |
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
The facility failed to ensure that all counselors and counselor assistants had 6 hours of HIV/AIDS and 4 hours of TB/STD training within the first year of employment. Staff #10 was hired on August 28, 2018 as a Counselor Assistant. At the time of the inspection Staff #10 did not have documentation of TB/STD training. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff are responsible to monitor and attend needed trainings by due dates and ensure documentation of completed trainings is presented to Human Resources to be recorded in Personnel File.
In an effort to assist staff with monitoring of required trainings, timelines and submission of completed documentation a facility training grid has been developed. Executive and director will review training grid bi-monthly to assure that counselor is signed up for and attends mandated trainings on or before due date.
Human Resource Coordinator will monitor employee files annually to ensure compliance.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct unannounced fire drills at least once a month. There were no fire drills documented for January 2019 and March 2019. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Risk Leader is trained on Fire Drill procedures and protocols. Effective 9/12/19, Facility Risk Leader will be responsible for conducting fire drills when maintenance staff is unavailable.
All fire drill documentation will be completed at time of drill and filed in the facility Risk Binder. Executive director will review and monitor fire drill logs on the 3rd week of every month to ensure completion. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
The facility failed to conduct fire drills during normal staffing conditions. There were seven out of ten fire drills that were conducted after operational hours for dosing times. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Risk Leader is trained on Fire Drill procedures and protocols. Effective 9/12/19, Facility Risk Leader will be responsible for conducting monthly fire drills during dosing hours when maintenance staff is unavailable.
All fire drill documentation will be completed and monitored monthly by the facility risk leaders and reviewed by the facility management team.
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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.
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Observations
The facility failed to document whether a fire alarm or smoke detector were set off during each fire drill. In twelve out of twelve fire drills, the facility staff failed to indicate whether a fire alarm or smoke detector were set off during the fire drill. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from August 30, 2018.
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Plan of Correction
Effective 9/12/19, A line indicating that the fire/smoke alarm was utilized at the time of the drill has been added to the Fire Drill Evacuation Form. A "Yes" or "No" will be documented in the column space at the time of the monthly fire drill.
All fire drill documentation will be completed and monitored monthly by the facility risk leaders and reviewed by the facility management team.
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709.1-709.5 LICENSURE Subchapter A. General Provisions
Chapter 709. Standards for Licensure of Freestanding Treatment Activities
709.1. Scope.
(a) This chapter establishes the procedures for the issuance of a license by activity to freestanding drug and alcohol treatment facilities. The term, facility, applies to the physical location from which drug and alcohol services are provided. A facility may provide more than one service.
(b) This chapter provides standards by activity for the licensure of freestanding drug and alcohol treatment facilities, under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059).
709.2. Policy.
(a) Persons, partnerships and corporations, or other legal entities intending to provide drug and alcohol treatment services, shall first be licensed by the Department.
(b) No drug or alcohol freestanding treatment facilities may receive funds from the Department without a license issued under this chapter.
709.3. Legal base.
The authority of the Department to license drug and alcohol treatment activities is established under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059) as transferred to the Department by Reorganization Plan No. 2 of 1977 (P.L. 372) (71 P. S. subsection 751-25) and No. 4 of 1981 (P. L. 610) (71 P. S. subsection 751-31).
709.4. Exceptions.
(a) The Department may, within its discretion, and for good reasons, grant exceptions or extensions of time to this chapter when the policy objectives of this chapter are met, but no exception may be granted which contravenes the authorizing statute.
(b) The project director shall submit a written request for an exception which shall include the approval of the governing body.
(c) Exceptions will not be granted for a situation in which a provisional license would be appropriate.
709.5. Revocation of exceptions.
(a) An exception granted under this chapter may be revoked by the Department. Notice of revocation will be in writing and include the reason for the action of the Department and a specific date upon which the exception will be terminated.
(b) In revoking an exception, the Department will provide for a reasonable time between the date of written notice of revocation and the date of termination of an exception for the project to come into compliance with this part.
(c) If a project wishes to request a reconsideration of a denial or revocation of an exception, it must do so in writing to the Department within 30 days of receipt of the adverse notification.
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Observations
During a Project Wide review of the Policy and Procedures, the project failed to include sex and marital status in the Client Rights policy 709.30 (2), and also the project failed to include documentation of the reasons for removing sections from the record, 709.30 (3). These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedures manual will be updated by the Policy and procedure committee to include sex and marital status in section 709.30. Chief Compliance Officer will ensure completion of policy by Sept 1, 2019. The program director will be responsible to ensure that the new policy is shared with all staff by Sept 15, 2019. |
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
The narcotic treatment program failed to 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. Patient #7 was admitted on October 23, 2018 for Methadone treatment. Patient #7 received 1 hour of psychotherapy in November 2018, 0 hours of psychotherapy in December 2018 and 1 hour and 45 minutes of psychotherapy in January 2019. Patient #9 was admitted on November 20, 2018 for treatment with Buprenorphine. Patient #9 received 10 hours of group therapy and 30 minutes of individual psychotherapy in March 2019, 10 hours of group therapy and 30 minutes of individual psychotherapy in April 2019, 8 hours of group therapy and 45 minutes of individual psychotherapy in May 2019, 6 hours of group therapy and 0 hours of individual psychotherapy in June 2019 and 8 hours of group therapy and 30 minutes of individual psychotherapy in July 2019. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/16/19 and 9/17/19 executive director will review regulations regarding individualized psychotherapy service hours with clinical team and reinforce expectation that clients must receive at least 2.5 hours of psychotherapy per month which includes 1 hour of individual therapy during the first 2 years of treatment.
Clinical director will monitor individual psychotherapy hours monthly during clinical supervision and through random chart monitoring. Discrepancies in hours will be reported to executive director.
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