INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on June 13, 2023 through June 15, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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 this inspection:
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Plan of Correction
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project director completed at least 12 clock hours of annual training during the facility's January 2022 through December 2022 training year in one of one applicable personnel record reviewed.
Employee #1 was hired as the Project Director on December 3, 2001. The personnel record documented 0 hours of annual training during the training year reviewed.
This is a repeat citation from the June 15, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 shall complete at least 12 clock hours of training annually in areas such as: (i) Fiscal policy. (ii) Administration. (iii)Program planning. (iv) Quality assurance. (v) Grantsmanship. (vi)Program licensure. (vii) Personnel management. (viii) Confidentiality.(ix) Ethics. (x) Substance abuse trends. (xi) Developmental psychology. (xii) Interaction of addiction and mental illness. (xiii)Cultural awareness. (xiv) Sexual harassment. (xv) Relapse prevention. (xvi) Disease of addiction. (xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous. The Special Assistant to Employee #1 and Training Director are responsible to monitor Employee #1's compliance with this plan monthly.
Effective 7/17/2023
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training during the facility's January 2022 through December 2022 training year in two of six applicable personnel records reviewed.
Employee #12 was hired as a counselor on September 13, 2021. The personnel record documented 7 hours of annual training during the training year reviewed.
Employee #13 was hired as a counselor on January 14, 2019. The personnel record documented 15.75 hours of annual training during the training year reviewed.
This is a repeat citation from the June 15, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisors will assist counselors with scheduling required annual trainings, according to the specific required trainings and the specific required training hours for each position. The Clinical Program manager will meet with each counselor monthly to monitor progress of completion, along with assessing and addressing any barriers to complete trainings. The Division Director is responsible to monitor this activity.
Effective 7/17/2023
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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 a physical plant inspection, the facility failed to 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. At the time of the inspection, there was a glass windowpane in the main exit door that was broken.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has engaged the services of a National Door Inc to replace the glass windowpane in the main exit door. The COO and CFO are responsible to monitor for the completion of this task.
Effective 7/31/2023
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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 a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. At the time of the inspection, the first floor handicap women's bathroom had a toilet that did not flush.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The first floor's handicapped woman's bathroom toilet flushing system has been replaced and is now operational in use. The Custodians are responsible to report any facilities issues to the Facilities Director at the end of each shift. The Facilities Director is responsible for weekly monitoring of the facility and arranging for any needed repairs. The Division Director and COO are responsible to monitor this activity.
Effective 7/17/2023.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year July 1, 2021 through June 30, 2022.
This is a repeat citation from the June 15, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Fiscal Department has engaged the services of an independent public accountant who completed our past annual audits of financial activities associated with our drug/alcohol abuse services. Although they have fallen behind in completing the past-due audits, as of 7/03/2023 we have established a plan to get them caught up and completed with a target of year-end for full completion and compliance. The associated reports will be provided as soon as available. The Fiscal Director is responsible for monitoring this activity,
Expected full completion date: 12/31/2023
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of a physical or sexual assault by staff or a client.
On May 11, 2023, there was an act of physical aggression from a client towards staff that was not reported to the Department within 3 business days. The incident was reported to the Department on May 17, 2023.
This is a repeat citation from the June 15, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Each employee completing an incident report is responsible to immediately notify a clinical manager of the incident and forward the report to the clinical manager within 24 hours of the incident. The clinical manager is responsible to review the Unusual Incident Reporting Policy and submit an Unusual Incident Report to DDAP within 3 business days if the incident meets the submission criteria outlined in the Unusual Incident Report Policy. If the clinical manager is unsure after referring to the policy, the clinical manager is required to immediately contact the Administrative Supervisor or the Division Director for clarity. The Administrative Supervisor is responsible to ensure all Unusual Incidents are submitted to DDAP within 3 business days of the incident. The Division Director is responsible for monitoring this activity.
Effective 7/17/2023
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of an incident involving the presence of police, fire, or ambulance personnel.
On September 21, 2022, there was an incident involving the presence of ambulance personnel that was not reported to the Department within 3 business days. The incident was reported to the Department on September 27, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Each employee completing an incident report is responsible to immediately notify a clinical manager of the incident and forward the report to the clinical manager within 24 hours of the incident. The clinical manager is responsible to review the Unusual Incident Reporting Policy and submit an Unusual Incident Report to DDAP within 3 business days if the incident meets the submission criteria outlined in the Unusual Incident Report Policy. If the clinical manager is unsure after referring to the policy, the clinical manager is required to immediately contact the Administrative Supervisor or the Division Director for clarity. The Administrative Supervisor is responsible to ensure all Unusual Incidents are submitted to DDAP within 3 business days of the incident. The Division Director is responsible for monitoring this activity.
Effective 7/17/2023
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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 patient records, the facility failed to document the narcotic treatment physician's review of dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient's therapeutic dosage in three of five applicable patient records.
Patient #2 was admitted on June 24, 2021 and was active at the time of inspection. The dosage level reviews completed on August 12, 2022 and December 1, 2022 were completed by the certified registered nurse practitioner instead of the narcotic treatment physician.
Patient #5 was admitted on December 23, 2021 and was discharged on January 20, 2023. The dosage level reviews completed on July 27, 2022 and September 27, 2022 were completed by the certified registered nurse practitioner instead of the narcotic treatment physician.
Patient #6 was admitted on January 27, 2022 and was discharged on January 21, 2023. The dosage level review completed on December 1, 2022 was completed by the certified registered nurse practitioner instead of the narcotic treatment physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Nurse Supervisor will schedule all Annual and 180 day med checks for the Narcotic Treatment physician to ensure that all patient's dosage levels are reviewed and documented at least twice a year with each review occurring at least 2 months apart. The Medical Director is responsible to ensure that his appointments are scheduled in this manner.
Effective 7/17/2023
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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 patient records, the facility 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, in two of seven patient records reviewed.
Patient #3 was admitted on December 1, 2021 and was active at the time of inspection. The patient record documented an average of 1.125 hours of psychotherapy during each of the months of February 2023, March 2023, April 2023, and May 2023.
Patient #4 was admitted on January 23, 2023 and was discharged on April 18, 2023. The patient record documented an average of 1 hour of psychotherapy during the month of February 2023 and 30 minutes of psychotherapy during the month of March 2023.
This is a repeat citation from the June 15, 2022 annual licensing renewal inspection.
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Plan of Correction
The facility will ensure that every month each patient is scheduled for the correct number of service hours aligning with their number of years in treatment. The patient's names on the case list trackers will be updated with a color key code to identify each patient's phase of treatment. Each color will indicate either Phase 1, 2, or 3. During each patient's first 2 years in treatment they will be scheduled for an average of 2.5 hours of psychotherapy with at least 1 hour of individual psychotherapy. The facility will provide additional psychotherapy services as indicated by ongoing assessment of the patient.
The patient's Counselors and Clinical Supervisors are responsible to ensure that patients are scheduled for the appropriate number of service hours according to their number of years in treatment. The Patient's are responsible for attending their scheduled services. The Clinical Program Manager is responsible for weekly monitoring of this activity.
Effective Date: 7/17/2023
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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 patient records, the facility failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and reviewed, dated, and signed by the medical director in one of five applicable patient records reviewed.
Patient #1 was admitted on November 1, 2021 and was active at the time of inspection. The last annual evaluation was completed on May 4, 2022 and the next one was due by May 4, 2023; however, there was no 2023 annual evaluation of the patient's status documented in the client record at the time of inspection.
This is a repeat citation from the June 15, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Nurse Manager will email a list of the patient's who have Annual Physical appointments for the following month. The Clinical Supervisors will utilize the monthly list to remind and monitor the counselors to complete the Annual Evaluations prior to the patient's annual appointments with the physician. The clinical supervisors will utilize the list to confirm, review, and sign the Annual Evaluations in the EMR. The clinical supervisors will inform the physician that the Annual Evaluation is open in the EMR for the physician's review and signature. The clinical supervisor's will be accountable for reviewing the chart, completing, and submitting any missing Annual Evaluations prior to the patient's Annual Physical appointment. The clinical supervisor will also document supervision with the counselor who did not complete the Annual Evaluation timely. The medical record for Patient #1 was made whole. The Annual Evaluation was completed on June 17, 2023. Moving forward, the clinical Program Manager will be responsible to monitor and ensure completion of this requirement.
Effective Date: 7/17/2023
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include follow-up information, in two of three applicable client records reviewed.
Client #4 was admitted on January 1, 2023 and was discharged on April 18, 2023. There was no follow-up documentation in the record as of the date of the inspection.
Client #7 was admitted on October 13, 2022 and was discharged on December 5, 2022. There was no follow-up documentation in the record as of the date of the inspection.
This is a repeat citation from the June 15, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Counselor completing the Discharge Packet will ensure that a 30 Day Follow-Up Letter is completed for the patient. The Clinical Supervisor will review the Discharge Packet for completion and submit the 30 Day Follow-Up Letter to the Administrative Supervisor. The Administrative Supervisor will make a copy of the letter and place it in a folder corresponding with the 30 Day Follow-Up month. The Care Manager will mail out the 30 Day Follow-Up Letters each month and document completion of the assignment.
The Administrative Supervisor will ensure that a copy is included in the patient's EMR and document completion of this assignment on the Discharge Tracker. The Counselor and Clinical Supervisor are responsible to ensure the 30 Day Follow-Up Letter is prepared and submitted with the Discharge Packet. The Care Manager is responsible to ensure the letters are mailed each month. The Administrative Supervisor is responsible to monitor and report on this activity.
Effective 7/17/2023
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